Testicular
Cancer.
The association between cryptorchdism and testicular
cancer was initially reported by LeConte in 1851 (6). It has been
well documented that men with a history of undescended testes have
a higher than expected incidence of testicular cancer developing between
the ages 20 and 40 years (1 in 2500 versus 1 in 100,000 in normal
population). Ninety six percent of the cancers are of germ cell origin,
mostly seminomas. Actually, 10% of all germ cell tumours are associated
with cryptorchidism (13). The progressive degeneration of germ cells
and dysplasia seen in cryptorchid testes are thought to be related
to the increased risk of malignancy. It should be mentioned here that
20% of tumors occur on the side of the normally descended testis (1,10),
a fact which indicates that factors other than maldescent may be responsible
for the increased rate of malignancy. Furthermore, orchiopexy, even
if done early in life, does not lower the incidence of cancer. It
is still not very well known whether testicular cancer is related
to maldescent itself, or is due to a DNA defect, which causes both
maldescent and cancer (10).
The increased risk of malignancy drive some to
recommend testicular biopsy for young men with history of cryptorchidism
to detect carcinoma-in-situ, precursor of invasive cancer, early and
thus perform prophylactic orchiectomy before further development to
malignant neoplasms (1). One should note that although the relative
risk for testicular cancer increases anywhere between 35 and 50 fold
in cases of undescended testes, this must be tempered with the reality
that testicular cancer is very rare. The overall lifetime risk is
very low inspite of maldescent (14).
Inguinal Hernia.
Most cases of undescended testes are associated with a patent processus
vaginalis because the processus vaginalis does not obliterate unless
the testis reaches the scrotum. This will predispose to indirect
inguinal hernia with possible subsequent incarceration and strangulation
(5,10). Detecting an inguinal hernia is an indication for immediate
surgical intervention to perform both hernioraphy and orchiopexy
(1,5,10,15).
Testicular Torsion.
The
incidence of torsion is known to be higher in undescended testes
than in normal testes. It may reach up to 20% of all undescended
testes (1). This is because the testicle is not in its normal anatomic
place, which will amplify any force or strain to an undesirable
stress for the testicle. It is also believed that torsion occurs
more frequently in the presence of testis tumor because of the increased
weight and distorted dimensions of
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the testis. Torsion may lead to atrophy of the testis and may even
present as an acute abdomen if the testis is intra-abdominal (10).
Testicular-Epididymal Fusion
Abnormality.
Abnormal connection between the testis and the epididymis is common
in cryptorchidism. The risk of abnormal fusion is greater with testes
inside the canal or abdomen than in inguinal testes or those lying
at the neck of the scrotum. These abnormalities are related to the
underlying androgen deficiency in-utero. In a percentage of these,
the abnormalities may be sufficient to interfere with fertility
(1).
Trauma.
Inguinal testes are at a slightly increased risk of direct trauma.
The most common cause of trauma is the car seatbelt or the straps
of the wheelchair in disabled patients (1).
Psychological Factors.
Cryptorchidism
may be a major psychological problem because the obvious physical
abnormality of the genitalia promotes patient and parental anxiety
about subsequent fertility (1). Moreover, after going to school,
a lot of patients experience ridicule and embarrassment from their
classmates in the changing rooms. "Single Dingle" and
"One Ball" are two examples of the expressions used to
make fun of these patients (5).
Evaluation of the
Patient with Cryptorchidism
History and Physical Examination.
It is important to distinguish between retractile (migratory) testis
and undescended testis. The retractile testis is a normal variant
whereby the testicle is retracted to the superficial inguinal pouch
most of the time (5). In order to diagnose "retractile testis"
we must be able to bring the testis fully to the lower one third
of the scrotum, it should remain in the scrotum after manipulation
without immediate retraction. The testis is usually normal in size
and there is a history that the testis resides spontaneously in
the scrotum some of the time (1). A true undescended testicle may
be felt in the superficial inguinal pouch or possibly in the inguinal
canal but cannot be manipulated into scrotum. It is also important
to distinguish between unilateral and bilateral undescended testes
in order to advise the parents with regards to issues of fertility.
With or without treatment, unilateral maldescent usually have better
prognosis...
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