Paediatric urologists see many boys with cryptorchidism–approximately 2-5% of boys have cryptorchidism at birth and 1-1.5% of three month olds present with it.[1] In my own practice I estimate that I see around 100-150 cases of cryptorchidism a year.

The term cryptorchidism is most commonly used to refer to an isolated unilateral undescended testis but also applies to children with bilateral non-palpable testes associated with ambiguous genitalia.

When children are referred to us with cryptorchidism, 20-50% of them have already undergone at least one form of imaging (ultrasound, CT scan, or MRI.) [2,3]

The results of a survey to determine the factors that influence referring clinicians to obtain imaging for suspected undescended testes suggest that many believe that imaging serves to identify nonpalpable testes, reassure families, and assist surgeons with operative planning. [4]

However, several systematic reviews–the results of which are reflected in guidelines from the American Urological Association, the European Association of Urology, and the European Society for Paediatric Urology–have shown that imaging does not reliably identify nonpalpable testis, that it is not warranted, and that it is very costly. [5,6,7]

Additionally, pre-referral imaging does not assist surgeons with operative planning, and in some cases it can actually be more of a hindrance. For example, wrongly diagnosing monorchidism when an intra-abdominal testis is present, but not clinically examinable and not identified by imaging, could mean that a cryptorchid testis is not diagnosed until a more advanced stage, which puts the patient at higher risk for seminoma. [8,9] And explaining that no viable testis was present after surgical exploration, when imaging suggested there was one, can be particularly distressing to families.

With regards to bilateral non-palpable testes or ambiguous genitalia, these patients are usually identified at birth, and the required imaging is typically done as part of the work-up performed at that point. However, if bilateral non-palpable testes, or a degree of ambiguity, is suspected once the child is in the community, patients would ideally be referred for specialist assessment to determine whether imaging is necessary.

More precise communication on how radiology for undescended testis affects paediatric urologists’ practice is important so that a greater number of referring clinicians understand the reasons why, for instance, an ultrasound for an undescended testis has the potential to create problems along the line. Educational updates, local education programmes, and national campaigns have been helpful in disseminating this message. [10,11] Hopefully, by working closer with our colleagues and sharing our own experiences, together we can improve practice as well as patient/family experience.

Luke Harper is a paediatric urologist at the Department of Paediatric Surgery, Hôpital Pellegrin-Enfants, CHU Bordeaux, France.

Competing interests: none declared

Provenance: unsolicited, peer reviewed

References:

1. Berkowitz GS, Lapinski RH, Dolgin SE, Gazella JG, Bodian CA, Holzman IR. Prevalence and natural history of cryptorchidism. Pediatrics. 1993 Jul; 92(1):44-9.
2. Kanaroglou N, To T, Zhu J, et al. Inappropriate use of ultrasound in the management of pediatric cryptorchidism. Pediatrics 2015 Sep;136:479-86.
3. Tasian GE1, Copp HL, Baskin LS. Diagnostic imaging in cryptorchidism: utility, indications, and effectiveness. J Pediatr Surg 2011 Dec;46(12):2406-13.
4. Tasian GE, Yiee JH, Copp HL. Imaging use and cryptorchidism: determinants of practice patterns. J Urol 2011 May;185(5):1882-7.
5. Kolon TF, Herndon CDA, Baker LA, et al. T Evaluation and Treatment of Cryptorchidism: AUA Guideline. J Urol 2014 Aug;192(2):337-45
6. Radmayr C , Doganb HS, Hoebeke P, et al. Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines. J Ped Urol. 2016 dec;12(6): 335–343
7. Tasian GE, Copp HL. Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-analysis. Pediatrics 2011;127(1):119-28.
8. Cho A, Thomas J, Nathan A, et al. Pre-referral radiological imaging for undescended testis. Wasteful and potentially harmful. ESPU meeting Barcelona, 2017.
9. Wood HM1, Elder JS. Cryptorchidism and testicular cancer: separating fact from fiction. J Urol. 2009 Feb;181(2):452-61. doi: 10.1016/j.juro.2008.10.074. Epub 2008 Dec 13.
10. Aggarwal H, Rehfuss A, Hollowell JG. Management of undescended testis may be improved with educational updates for referring providers. J Pediatr Urol 2014 Aug;10(4):707-11
11. Bryce Wyatt*, Anne Andrews, Andrew Stec, et al; The Impact of the Choosing Wisely © Campaign on Rates of Scrotal Ultrasound for Children Born with Cryptorchidism before and after Guideline Implementation. AUA Meeting Boston, 2017.