Male patients with pain, swelling or erythema please refer to the Acute Painful Scrotum pathway Female patients

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1 UNDESCENDED TESTICLE ALGORITHM Unilateral undescended testicle OR Bilateral palpable undescended testicle Inclusin Criteria: Male patients w/ unilateral r bilateral undescended testicle(s) Exclusin Criteria: Male patients with testicular pain, swelling, r erythema (Refer t Acute Painful Scrtum clinical care guideline) Female patients N Is the patient ver 6 mnths f age? Yes! Radilgic Studies are NOT necessary r helpful Re-examine at 6 mnths f age Refer t Urlgy/ Pediatric Surgery Bilateral nn-palpable undescended testicle - regardless f age Refer t Urlgy Page 1 f 8

2 TABLE OF CONTENTS Algrithm Target Ppulatin Backgrund Definitins Initial Evaluatin Clinical Management Labratry Studies Imaging Therapeutics Patient Caregiver Educatin Fllw-up References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria: Male patients with unilateral r bilateral nn-palpable testicle(s) Exclusin Criteria: Male patients with pain, swelling r erythema please refer t the Acute Painful Scrtum pathway Female patients BACKGROUND DEFINITIONS Epidemilgy Undescended testicle ccurs in apprximately 1% f term bys and up t 5% f premature r small fr gestatinal age (SGA) bys (1). Up t 25% f testicles will descend spntaneusly by 4 mnths f age. It is very rare t see spntaneus descent after 6 mnths f age (2). Apprximately 2% f bys in the first 10 years f life will develp an ascending testicle (3). Knwledge Base Undescended testicle (Cryptrchidism) is defined as the failure f the testicle t descend int the scrtal psitin. The mst cmmn frm is cngenital. Hwever, it can be acquired and is referred t as an ascending testicle. A retractile testicle is ne where the testicle is initially extrascrtal but can be manually placed int the scrtum where it stays at least temprarily withut tensin. Risk Factrs Prematurity Small fr gestatinal age Preventin There is n knwn methd f preventin. Page 2 f 8

3 Cnsequences f Undescended Testicles Testicular Malignancy - Men with a histry f an undescended testicle have an increased risk f malignancy. This is mst cmmn in the undescended testicle, but the cntralateral testicle als has a slight increase in risk. With up t 1% f men getting malignancy, this is rughly twice the risk f men withut an undescended testicle. Fertility - Patients with bilateral undescended testicle have an infertility rate f 38% cmpared with 6-8% f men with bth testicles descended, where as thse with a histry f unilateral undescended testicle have an infertility rate f 10% (6). Differential Diagnsis Undescended Testicle Retractile Testicle Vanished r absent Testicle Disrder f Sexual Develpment (DSD) Value f Treatment Reduces malignancy risk if the testicle is brught int the scrtum befre 10 years f age Enables easier self-examinatin f testicle Ptentially imprves fertility Nrmal appearing male genitalia INITIAL EVALUATION Telephne Triage Patients with pain, swelling r erythema f the scrtum shuld be referred immediately t the Emergency Department r n-call Urlgist (r Pediatric Surgery if in Clrad Springs) fr emergent evaluatin. Patients ver 6 mnths f age shuld be referred t Pediatric Urlgy / Pediatric Surgery with the aim f having a successful surgery by 12 mnths f age. Histry Has the testicle been seen/felt in the scrtum, (especially when bathing as this may indicate a retractile testicle)? Were the testicles nted at birth? Des the testicle g up r dwn? Is a hernia ever nticed? Hw many gestatinal weeks was the patient when brn? Is there a family histry f undescended testicles, hernia r hydrcele? Whm t refer Patients ver 6 mnths f age (crrected fr gestatinal age) with a testicle that cannt be brught int the scrtum withut tensin. Patients under 6 mnths f age with bilateral nn palpable testicles. Patients ver 6 mnths f age with bilateral nn palpable testicles - t evaluate fr Disrder f Sexual Develpment (DSD). Patients with an undescended testicle and hypspadias t evaluate fr a DSD. Page 3 f 8

4 Patients under 6 mnths f age with a testicle that cannt be brught int the scrtum withut tensin, where there is an early request t see an Urlgist r Pediatric Surgen. CLINICAL MANAGEMENT A thrugh histry and physical examinatin are essential t the making the crrect diagnsis. Examinatin - Cnditin Specific Is the scrtum symmetrical and full? Can a testicle be seen in bth sides f the scrtum? If nt, Can the testicle be felt at any pint frm the internal ring f the inguinal canal t the scrtum? Can the testicle be felt in an ectpic lcatin, (femral canal, lateral t the scrtum, perineum, clse t the penis, n the cntralateral side)? Are the tw testicles equal in size and cnsistency? Is there a hernia r hydrcele? If bilateral nn palpable testicles, refer immediately t the SOAR team fr evaluatin fr ptential DSD. Is the penis nrmal r is there hypspadias? If s, cnsider DSD in the differential diagnsis. Treatment If a retractile testicle is diagnsed, a prvider shuld reexamine the patient annually, as there is a risk f an ascending testicle develping. If an undescended testicle is diagnsed, then surgical interventin is warranted, as hrmnal therapy has lw success, and lng term efficacy has nt been dcumented. Surgery In prepubertal bys with palpable, undescended testicles a qualified surgical specialist shuld perfrm a scrtal r inguinal rchidpexy. Ideally this shuld be perfrmed within a year f making the diagnsis (4). Bys with a nn-palpable undescended testicle shuld underg an examinatin under anesthetic, if palpable, then an rchidpexy is perfrmed, and if nt, then the testicle r the absence f a testicle shuld be ascertained either by laparscpy r surgical explratin. In pst pubertal bys with a nrmal descended cntralateral testicle, an rchiectmy is a reasnable surgical ptin because f the increased risk f cancer. LABORATORY STUDIES IMAGING N labratry r radilgical investigatins are necessary. Fr bys with bilateral nn palpable undescended testicles, cnsider measuring Mullerian Inhibiting substance t evaluate fr anrchia, where bth testicles have nt develped. THERAPEUTICS N pharmaclgic interventins are necessary. PATIENT CAREGIVER EDUCATION Patients and families shuld be taught testicular self-examinatin by PCP r specialist at fllw-up, s that malignancy can be detected. Page 4 f 8

5 FOLLOW UP Patients shuld be reevaluated 3 mnths after surgery t assess: If the testicle is crrectly placed, (surgery results in a 3-5% failure rate, usually due t the testicle slwly being pulled up ut f the scrtum). If the testicles are equal in size, as testicular damage can ccur. T ensure adequate healing frm surgery. Page 5 f 8

6 References 1. Sijstermans K, Hack WW, Meijer RW et al. The frequency f undescended testis frm birth t adulthd: a review. Int J Andrl : Wenzler DL, Blm DA, Park JM. What is the rate f spntaneus testicular in infants with cryptrchidism: J Url 2004; 171: Acerini CL, Miles HL, Dunger DB et al. The descriptive epidemilgy f cngenital and acquired cryptrchidism in a UK infant chrt. Arch Dis Child American Urlgical Assciatin Guideline: Evaluatin and treatment f cryptrchidism: AUA Guideline 5. Swerdlw A, Higgins C, Pike M. Risk f testicular cancer in a chrt f bys with cryptrchidism. BMJ 1997; Gilhly PE, Meyers F, Lattimer JK. Fertility prspects fr children with cryptrchidism. Am J Dis Child 1984; 138: 940. Page 6 f 8

7 CLINICAL IMPROVEMENT TEAM MEMBERS Duncan Wilcx, MD Urlgy Ann Kulungwski, MD Pediatric Surgery Lalit Bajaj, MD, MPH Emergency Medicine Leigh Anne Bakel, MD Hspitalist Angela Stwe, MS Clinical Effectiveness APPROVED BY Clinical Care Guideline and Measures Review Cmmittee Octber 11, 2016 Pharmacy & Therapeutics Cmmittee n/a MANUAL/DEPARTMENT Clinical Care Guidelines/Quality ORIGINATION DATE Octber 11, 2016 LAST DATE OF REVIEW OR REVISION Octber 11, 2016 APPROVED BY Lalit Bajaj, MD, MPH Medical Directr, Clinical Effectiveness REVIEW REVISION SCHEDULE Scheduled fr full review n Octber 11, Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 7 f 8

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