Luke Harper: Pre-referral imaging for an undescended testis can be a hindrance

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


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  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.