This is often a very distressing condition, that is noted by either the parents or the pediatrician of a newborn child. Immediately concerns about lack of potency or fertility start plaguing the parent’s mind.
Causes of an empty scrotum
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Undescended testis
A testis that has not come down completely to the bottom of the scrotum. When the child is in the mother’s womb, the testes are intra-abdominal. As the fetus matures, the testes start descending and at birth about 97% of all children have their testes in the scrotum.
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Ectopic testis
A testis that has taken an abnormal route while descending and is now lying at a place other than its normal position. This testis can be found at various places and are usually picked up with proper examination technique.
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Testicular aplasia
Or non-development of the testis – This is very rare.
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Destroyed testis
The testis may have undergone a twist during development(thereby depriving it of blood supply) and such a testis subsequently shrinks.
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Surgical removal
The testis may have been removed due to some underlying disease.
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Intersex conditions
This is very, very rare. Genetically, the sex of the child may be quite different from what the child looks externally.
Doctor, I have heard that testis can descend spontaneously and I have been advised to wait till he turns five years of age before getting it corrected. Is that right?
Both right and wrong! The testis continues to descend after birth in a significant number of patients. At birth about 2% – 5% of boys will have undescended testes and if they are followed up then only just less than 1% of boys will have undescended testes at one year of age which is the incidence in adults. Spontaneous descent is extremely unlikely after six months and this is the right time for surgical intervention.
But why do undescended testes need to be brought down?
There are many reasons to bring down the testis at the appropriate time(around 6-9 months of age):
- Decreased Fertility: It has been found that the number of germ cells: starts diminishing at one year of age and the results of surgery are very different depending on the timing of surgery. There is a small decrease in the fertility in children with unilateral undescended testis even when the testis has been brought down at the appropriate time (six to nine months of age) and this is due to the fact that both testes are slightly abnormal since birth. If there is delay in bringing down the testis, there is a further, proportionate decrease in fertility.
Children with bilateral undescended testes have significantly reduced fertility in any case (60% vs 93% in normals) but this too comes down if there is any delay in bringing the testes down. - Malignancy: Normal men have a 1:100,000 chance of developing testicular malinancy. Boys with undescended testes have a higher risk of 6:100000. This risk is higher, the higher the position of the undescended testis and the longer the testis remains in an undescended state. Additionally, once the testis is brought down it can be examined more easily and any malignancy that develops can be detected early.
- Testicular torsion: Undescended testes are ten times more likely than normally descended testes to undergo torsion. When the testis undergoes torsion, its blood supply also undergoes a twist resulting in damage to the testis because of poor blood flow. Once fixed in position, it cannot undergo torsion.
- Incarceration of Associated Hernia: Almost all children with undescended testis have associated hernias and like any other hernia can undergo incarceration of the hernia
Doctor, I have been advised an ultrasound to locate the testis – When should I get it done?
Despite the advances in both the ultrasound machine and in the expertise of the ultrasonographer, it is not advised in localizing the undescended testis as there are many fallacious results, both false-positive, and false-negative. However there are two situations in which I would advise it:
- When the child has bilateral impalpable testes to evaluate the internal organs.
- To localize the testes in obese patients that may alter the surgical approach.
What should we do next?
Your child needs to undergo simple blood tests and can then be taken up for surgery.
Is there no other option apart from surgery?
Hormonal therapy in the form of a course of injections or spray is available but practiced in only a few centers in the world. The reasons are two-fold. Firstly, the results are very poor(less than 20% success rate) and secondly the child can develop side-effects from the therapy.
The Operation
After the child is anesthetized, if the testis has already been felt pre-operatively, then we go ahead with a standard open orchiopexy. If the testis has not been felt to be in a higher position before the operation, then under anesthesia with the muscles relaxed, we feel for the testis. If it is felt, then again a standard open orchiopexy, otherwise we put in a laparoscope through the umbilicus, confirm that the testis is present and confirm its location before proceeding with surgery. Depending on the operation pursued, the child will have a small groin incision, a very small scrotal incision and may have very small 1-3 incisions in the abdomen.
Care After Surgery
- In the immediate postoperative period please follow the General postperative instructions.
- The child will have dressings on his wounds(number depends on the type of surgery performed).
- This operation is relatively painless and most children are very comfortable and are able to carry out their routine activities with the usual painkillers. However, if your child is still uncomfortable, please do not hesitate to contact me.
- The child may have some difficulty in passing urine in the first 24-48 hours after surgery. Even if the child does not pass urine until the morning after surgery it is OK. If the child does not pass urine beyond this then please contact me.
- Give sponge baths to the child till it is time to remove the sutures. You can come in for a follow-up visit to me after 48 hours. I will inspect the wound(confirming that it is healing well) and then dress it up again.
- Your son will have to come in on the seventh postoperative day, for suture removal. I use unabsorbable sutures as in my opinion, it results in the best scar.
- I will also be calling in the child annually for an follow-up to monitor the growth of his testis, till he attains full testicular size. After this, I will teach the child self-examination that will help us detect early any unusual growth that may be an indicator of a malignancy so that, appropriate therapeutic intervention can be done.