Delayed diagnosis of undescended testes is a major problem. A retrospective review of 298 testes units was performed to assess the age at referral, age at operation, complications and final outcome. The mean age at referral was 57 months. Only 24% of cases were operated below 2 years. A similar pattern of delayed orchidopexy has been reported by many other centres. As orchidopexy is recommended soon after 6-7 months of age, there is an urgent need for increased awareness of undescended testes and it’s consequences at all levels of child health care.

Keywords: Cryptorchidism, Orchidopexy, Undescended testes.

Undescended testis (UDT) is the most common endocrine disorder in male children(1). The incidence in prematures is 33%, full-terms is 3-5% and by the age of one year it comes down to 0.8-1%(2). In a recent study, it was found that surgical treatment at 9 months resulted in better catch-up of testicular growth compared to surgery at 3 years(3). Orchidopexy is recommended soon after 6-7 months of age (corrected for term) to maximise the future fertility potential(4).

A retrospective case note review of 250 patients (298 testis units) operated upon under the same surgeon over a period of six years was performed. Data were collected from the hospital database using the procedure code for orchiopexy for age at referral, age at operation, complications including need of re-operation and the final outcome.

Of the 250 cases under study, 202 (80.8%) were unilateral [right 110 (54.5%) and left 92 (45.5%)] and 48 (19.2%) were bilateral. The mean age at referral was 57 months (range 1-185 months) and the mean age at operation was 66 months (range 6-186 months). Only 60 (24%) cases were operated on before the age of 2 years. The number of cases operated between 2-6 years was 84 (33.6%). In 106 (42.4%) cases, orchidopexies were performed after 6 years of age. The follow up period ranged from 3 months to 3 years (mean 1.6 year).

At follow up, 254 (85.3%) testes units were found to be in the scrotum and were of normal size. In 25 (8.3%) cases, the testes were slightly smaller in size compared to the other side. In 6 (2%) cases, the testes were very small at operation and did not catch up in size during follow up period. Five (1.7%) cases did not turn up for follow up. Re-do orchiopexy was required in 8 (2.7%) cases, one of which presented in emergency as a strangulated inguinal hernia. This testis was smaller in size at the first operation and remained small during follow up. In the other 7 cases of re-do orchidopexies, the testes were found to be in the scrotum and of normal size. There was no incidence of postoperative testicular loss.

While concerns about the age at orchiopexy have been raised several times in the past, delayed orchiopexy is still a universal problem. Many centres from all over the world are still reporting the mean age of orchidopexy beyond the recommended age (5-10). The mean age at referral in our study was 57 months and only 24% of the patients could undergo an operation before the age of 2 years. Delayed referral is one of the major factors accounting for this delay. Other possible reasons for delay are diagnosis missed at screening and also late ascent of a testis previously sited in the scrotum(5-10). Some studies have shown an improved outcome, following a multifaceted approach to the implementation of guidelines for early referrals. Using this approach, the median age at surgery was reduced from 7.8 to 5.2 years in one study and from 4 to 2 yeas in another study(9,10).

It is vital to diagnose this condition early by pediatricians and health visitors at birth or by general practitioners at the six weeks’ check up. A further check up at 6-9 months of age would reveal the final position of the testis, thus ensuring a timely referral. A pilot study at our centre showed lack of communication between Health Visitors and General Practitioners (Personal Communication). One of our recommendations in the pilot study was to ensure that Health Visitors took the responsibility to write to the General Practitioner and/or Surgeons about it themselves, so that appropriate action could be taken at the earliest opportunity.

We conclude that there are ample opportunities to detect this problem under the child health care system. A coordinated campaign between surgeons, pediatricians, general practitioners and community workers is mandatory. Implementing on locally agreed guidelines and reinforcing them, periodic appraisals and auditing would ensure the timely intervention.

Contributors: The project was conceived by SV, CS and SN. SV, RK and CS collected the data. CS and SN wrote up the paper and jointly stand guarantors for the study.

Funding: None.

Competing interests: None stated.

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