GPAtlas🧭 When to suspect
An undescended testis (cryptorchidism) is the absence of one or both testes from the scrotum, identified when the scrotum is empty on examination – usually at the newborn check or the 6–8 week infant check. It is the commonest congenital genital abnormality in boys, affecting around 3–4% of term and up to 30% of preterm infants at birth, falling to about 1% by 6–12 months as late descent completes. Roughly 80% of undescended testes are palpable in the groin and 20% are impalpable.
Two clinical tasks dominate primary care: distinguish a true undescended testis from a retractile testis (a normal variant that needs no surgery), and recognise the small group who need urgent assessment – principally a baby with bilateral impalpable testes or associated genital anomaly, in whom a disorder of sex development must be excluded. The long-term importance lies in a modestly increased risk of subfertility and testicular cancer, both reduced by early orchidopexy; the acute importance lies in torsion. Because spontaneous descent is unlikely after the first few months, the window for action is short and the priority is timely referral, not prolonged observation.
| Finding | Key feature | Action |
|---|---|---|
| True undescended (cryptorchid) | Absent from scrotum, lies along the normal line of descent; cannot be milked into the scrotum, or springs back under tension | Refer to paediatric surgery / urology |
| Retractile testis | Can be brought into the scrotum and stays there without tension; brisk cremasteric reflex (a normal variant) | Annual review to puberty (risk of later ascent) |
| Ectopic testis | Lies outside the normal line of descent (superficial inguinal pouch, perineum, femoral or penile) | Refer – will not descend spontaneously |
| Ascending (acquired) | Previously documented in the scrotum, now absent in an older boy | Refer – orchidopexy as for an undescended testis |
| Absent / atrophic | No testis found (e.g. perinatal “vanishing” testis from antenatal torsion); impalpable | Specialist – diagnostic laparoscopy is the gold standard |
Raise suspicion particularly in infants born prematurely or with low birth weight (the strongest associations), those with a family history of undescended testes, and any boy with an empty hemiscrotum at a routine check. In England the NIPE programme examines the testes within 72 hours of birth and again at 6–8 weeks, so most cases are picked up through these structured checks.
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🧠 Clinical pearl – “it was down before” does not exclude it A testis confidently documented in the scrotum during infancy can later ascend, as a relatively short spermatic cord fails to elongate with the child’s growth. So a normal newborn examination does not rule out an undescended testis in an older boy, and a retractile testis is not always benign – it is the reason these children are reviewed annually until puberty. |
Source: NHS NIPE Screening Programme · BAUS
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