Synopsis
Examine testes and penile anatomy accurately, refer persistent cryptorchidism and hypospadias at the right age, protect foreskin needed for repair, recognise differences of sex development, and treat suspected torsion as a surgical emergency.
- Undescended testis is absent from the bottom of the scrotum and cannot be manipulated to remain there. A retractile testis can be brought down without tension and stays transiently after cremaster fatigue.
- Examine every newborn and again at the 6–8-week physical examination in warmth, with relaxed hips, sweeping from groin towards scrotum and documenting each side separately.
- Spontaneous descent occurs mainly in the first 12 weeks. Refer bilateral undescended testes earlier, usually after the 6–8-week review, and unilateral persistence by about 4–5 months.
- Orchidopexy is usually performed around age 1 year; early treatment supports germ-cell development, permits surveillance and reduces but does not abolish later malignancy risk.
- Do not routinely order ultrasound for an impalpable testis before surgical referral; examination and operative assessment determine location and management more reliably.
- Hypospadias combines a ventral urethral opening, dorsal hooded foreskin and possible ventral curvature or chordee. Describe meatal site, stream, curvature, glans and both testes.
- Do not circumcise a child with hypospadias because foreskin can be required for repair. Refer to paediatric urology; many repairs are planned between about 12 and 18 months depending on anatomy and centre.
- Proximal hypospadias plus one or both undescended testes is not merely two common anomalies: involve endocrinology and a multidisciplinary differences-of-sex-development team promptly.
- The acute scrotum differential includes testicular torsion, torsion of an appendix testis, epididymitis, incarcerated hernia, trauma, IgA vasculitis, idiopathic oedema and tumour.
- Torsion peaks in neonates and adolescents but can occur at any age. Abdominal pain may dominate and the scrotum must be examined in a boy with unexplained lower abdominal pain.
- The reference-standard diagnostic and therapeutic step when torsion remains possible is urgent scrotal exploration. Doppler can assist genuinely low or equivocal pathways only when it does not delay surgery.
- At exploration, a viable torsed testis is untwisted and fixed and the contralateral testis is usually fixed; non-viable tissue may require orchidectomy after consent discussion.
Key red flags
Sudden severe testicular, scrotal, groin or lower abdominal pain with nausea or vomiting is torsion until urgently excluded by a surgeon.
A high-riding or horizontal testis, absent cremasteric reflex or rapidly increasing tenderness supports torsion, but no single sign safely excludes it.
A painful irreducible groin or scrotal swelling with vomiting suggests an incarcerated hernia and requires emergency surgical assessment.
Bilateral impalpable testes in a newborn, proximal hypospadias, bifid scrotum, micropenis or genital ambiguity requires urgent specialist differences-of-sex-development assessment.
Hypospadias with poor urinary stream or inability to void requires urgent assessment; do not circumcise because foreskin may be needed for reconstruction.
A previously scrotal testis that becomes persistently non-scrotal may be acquired ascent and needs referral rather than reassurance as a retractile testis.
Investigation priorities
Classify testicular position, hypospadias anatomy and acute torsion probability.
Diagnose torsion definitively and restore blood supply during the same procedure.
Management branches
One or both testes are not at the scrotal bottom in a newborn.
- Document palpability and position at newborn examination and recheck at 6–8 weeks, considering corrected age in prematurity.
- Refer bilateral persistence promptly after the early review and unilateral persistence by about 4–5 months; do not delay referral for ultrasound.
- Paediatric surgery plans orchidopexy, commonly around age 1 year, and explains fertility, tumour and follow-up implications.