What happens if your child’s testicles don’t drop?

Marilyn Kabasiita and her husband where over the moon when they held their baby boy, Shylock for the first time. However, one day, while bathing him, his mother noticed that something was amiss with his genitals. “We took him to see a paediatrician, who, after tests, confirmed that he had an undescended testicle and referred us to a paediatric urologist who affirmed the earlier report.”

Dr John Sekabira, a paediatric surgeon at Mulago National Referral Hospital, says during the last few months of normal foetal development, the testicles gradually descend from the abdomen through a tube-like passageway in the groin (inguinal canal) into the scrotum. However, he says, a percentage of boys are born when the testis are still up and this is called cryptorchidism (or undescended testes).

Risk factors
According to the conversation.com, an online portal, undescended testis or cryptorchidism is commonly seen in premature males because the testes do not descend from the abdomen to the scrotal sac until the seventh month of foetal development. “We give between six months and a year for the descent to be complete in such cases,” Dr Sekabira says.

Other factors that increase chances of undescended testis include a low birth weight, which may double or triple the risk, Down’s syndrome, other conditions that slow foetal growth and a family history of issues with genital development.

Dr Frank Asiimwe, a urologist at Mulago, advises that parents check their sons while bathing them. “They should feel for two testis because that is what is normal regardless of what other men in the family may have,” he says.

Causes
If they do not come down, Dr Asiimwe says, there will not be a firm ball-like feel since the scrotum will be empty. After confirming the diagnosis, the urologist assured Shylock’s parents that an undescended testicle is a common problem and could easily be fixed seeing that everything else with him was normal.

Undescended testes may occur due to several reasons although prematurity is a leading cause. To descend, Dr Sekabira says, a number of hormones come into play, some of which are produced by the testis themselves such as testosterone. “Therefore, if there are some abnormalities, such as insufficiency, they will not descend,” he explains.
However, there are also mechanical factors that aid dissension.

As the testis descend, Dr Sekabira says, there is a sac (processus vaginalis) that is supposed to pinch off as well as empty itself of water. If it does not seal off, it becomes patent. There are instances when it pinches off but retains water, “In this case, the boy develops hydrocele,” he says.

A hydrocele is a collection of fluid around the testicle. In children, this fluid comes down from the normal fluid that is present in the abdomen into a balloon-like structure around the testicle, called the tunica vaginalis.

The neck of this balloon runs along the spermatic cord and opens into the abdomen. Normally, this neck closes off by itself within the first year of life. If it is wide open, Dr Sekabira says, not only does fluid sip through but also the intestine can go into the sac and cause hernia.

“Complications worsen when an obstructed hernia develops. This is when the intestine dips in and some food goes into it hence gets stuck,” Dr Asiimwe adds.

Signs
A parent can notice a hydrocele or hernia by seeing a bulge or swelling in the scrotum or in the groin. “If this bulge contracts and expands, it suggests that the opening is big enough to permit free flow of fluid in and out of the tunica vaginalis,” he says.

Prune belly syndrome
According to Dr Asiimwe, this is a rare disorder characterised by partial absence of some or most abdominal muscles, giving rise to a wrinkled or prune-like appearance.

Notably, enlargement of the bladder is present in almost all cases alongside obstruction of the neck of the bladder resulting in bladder distention and urine retention.

“Undescended testes (cryptorchidism) often occur in males with prune belly syndrome due to reduced or on abdominal pressure as the muscles are not there or are weak,” Dr Asiimwe explains.
Disruption
Dr Asiimwe says the hormone may be strong enough but what the mother consumes, especially during the first trimester of pregnancy disrupts the arrival of the hormone to the testis.

“Therefore, intake of substances such alcohol, smoking are deadly to unborn children,” he warns.
Retractile testes
These are descended testes that easily move back and forth between the scrotum and the inguinal canal. The testes retract as a reflex response to touch, temperature, fear or laughter. Such a response is common, particularly in infants and children. Retractile testes do not lead to cancer or other complications.

“The testes usually stop retracting into the groin by puberty because they grow larger and do not require surgery or any other treatment,” Dr Asiimwe advises.

Treatment
For most babies, the hydrocele will go away in at most a year hence no need for surgery. Dr Sekabira explains that if the hydrocele has a big enough opening to let fluid flow freely in and out (as noted by the swelling-getting bigger and smaller) it is unlikely to close on its own and surgery is indicated.

Even for undescended testis, surgery is ideal and the child should undergo this surgery when they are between six and 18 months old. It is important to perform the procedure before the child is two years old since delays may increase the long-term risk of infertility, Dr Asiimwe says.

Similarly, in Shylock’s case, after discussion and counselling, the urologist recommended surgery. “It was successful and he is growing up without any issues. We were nervous that he may not be able to have children or have other concerns, but the urologist told us everything should be fine,” Kabasiita says.

Note
If cryptorchidism is not repaired, the consultants say the following complications may occur as your child grows and matures:
• Infertility (most common in bilateral cases, where both testes are affected).
• Risk of testicular cancer increases considerably by age 30 or 40.
• Inguinal hernia (a weakened area in the lower abdominal wall or inguinal canal where intestines may protrude).
• Testicular torsion (a painful twisting of the testes that can decrease blood supply to the testes).
• Psychological consequences of an empty scrotum as the child does not feel man enough hence insecure.

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