One notable omission of the study by Shah, et al.(1) is the
failure to mention the length/volume of normally descended contralateral
testis in their study cohort. This easy-to-obtain clinical information
will aid in differentiating monorchism from cryptorchid testis-an issue
of critical concern in preoperative counseling. In a study by Koff in 37
boys three-year old or younger with an impalpable testis, the length and
volume of the contralateral normally descended testis showed significant
compensatory enlargement exceeding 2 cm (mean 2.22) and 2 mL
respectively in 12 boys who had surgically proved monorchism as compared
to the descended testis in 19 boys with normal sized (mean 1.51 cm)
testes(2). In another study by Hurwitz and Kaptein(3), hypertrophy of
contralateral normal testis 1.8 cm. or greater predicted monorchia with
an accuracy of about 90% in patients with a nonpalpable testis. This
finding bears emphasis for preoperative counseling of parents that the
non palpable testis is most likely absent. One more issue that is less
emphatically mentioned but worthy of being explored is the detection of
palpable testes in 48.8% (22 out of 45 nonpalpable testes) cases by
appropriate clinical re-evaluation by the author. Implicit here is the
premise that good clinical examination in this "missing-ball mystery"
deserves its own mountain top and must be diligently pursued by every
pediatrician in a child with crytporchidism before further referral or
investigations.
Though offering useful insights into pitfalls of
imaging in cryptorchidism, the study failed to elaborate what entails
good clinical examination. To redress this deficiency, it is imperative
to examine a calm and comfortably lying affected child in an
appropriately warm room with gentle warm two-handed technique(4).
Additional clinical inputs from squatting position, pressure on femoral
artery and even examination under sedation or general anesthesia (prior
to surgery) in equivocal cases along with shape and size of empty
scrotum are essential(4-5).
Bhavneet Bharti,
Assistant Professor,
Health Education Unit,
Department of Pediatrics,
Advanced Pediatric Center,
Post Graduate Institute of Medical
Education and Research,
Chandigarh 160 012, India.
E-mail: [email protected]
References
1. Shah A, Shah A. Impalpable testes-is imaging really helpful? Indian
Pediatr 2006; 43: 720-723.
2. Koff SA. Does compensatory testicular enlargement
predict monorchism? J Uro1 1991; 146: 632-633.
3. Hurwitz RS, Kaptein JS. How well does
contralateral testis hypertrophy predict the absence of the nonpalpable
testis? J Urol 2001; 165: 588-592.
4. DCruz AJ, Das K. Symposium on common pediatric
surgical problems-I. Undescended testes. Indian J Pediatr 2004; 71:
1111-1115.
5. Docimo SG, Silver RI, Cromie W. The undescended testicle:
Diagnosis and management. Am Fam Physician 2000; 62: 2037-2044.
We thank Dr. Bharti for her valuable comments. We agree that
the size of the contralateral testis is helpful in predicting the status
of the opposite impalpable undescended testis. However, it is only a
prediction and the results cannot be quoted as an explanation for not
exploring and hence risking malignancy in an impalpable testis.
Moreover, even the testicular nubbin needs to be excised. To conclude,
no one can refute the importance of a good clinical examination for a
child with undescended testis.
Amar Shah,
Anirudh Shah,
Neonatal and Pediatric Surgery,
Amardeep Multispeciality,
Children’s Hospital and Research Center,
65, Pritamnagar Society, Gujarat College Road,
Ellisbridge, Ahmedabad 380 006, India.
E-mail: [email protected]
