Page 140 - Remedial Andrology

10.4 Special Conditions and Relevant Clinical Entities
10.4.1 Cryptorchidism
Cryptorchidism is the most common congenital abnormality of the male genitalia; at 1 year of age nearly 1%
of all full-term male infants have cryptorchidism [1620]. Approximately 30% of undescended testes are non-
palpable and may be located within the abdominal cavity. These guidelines will only deal with management of
cryptorchidism in adults.

10.4.1.1 Classification
The classification of cryptorchidism is based on the duration of the condition and the anatomical position of
the testes. If the undescended testis has been identified from birth then it is termed congenital while diagnosis
of acquired cryptorchidism refers to men that have been previously noted to have testes situated within the
scrotum. Cryptorchidism is categorised on whether it is bilateral or unilateral and the location of the testes
(inguinal, intra-abdominal or ectopic).

Studies have shown that treatment of congenital and acquired cryptorchidism results in similar hormonal profiles,
semen analysis and testicular volumes [1621, 1622]. However, testicular volume and hormonal function are
reduced in adults treated for congenital bilateral cryptorchidism compared to unilateral cryptorchidism [1623].

10.4.1.1.1 Aetiology and pathophysiology
It has been postulated that cryptorchidism may be a part of the so-called testicular dysgenesis syndrome
(TDS), which is a developmental disorder of the gonads caused by environmental and/or genetic influences
early in pregnancy, including exposure to endocrine disrupting chemicals. Besides cryptorchidism, TDS
includes hypospadias, reduced fertility, increased risk of malignancy, and Leydig/Sertoli cell dysfunction [1624].
Cryptorchidism has also been linked with maternal gestational smoking [1625] and premature birth [1626].

10.4.1.1.2 Pathophysiological effects in maldescended testes
10.4.1.1.2.1 Degeneration of germ cells
The degeneration of germ cells in maldescended testes is apparent even after the first year of life and varies,
depending on the position of the testes [1627]. During the second year, the number of germ cells declines.
Early treatment is therefore recommended (surgery should be performed within the subsequent year) to
conserve spermatogenesis and hormone production, as well as to decrease the risk for tumours [1628]. Surgical
treatment is the most effective. Meta-analyses on the use of medical treatment with GnRH and hCG have
demonstrated poor success rates [1629, 1630]. It has been reported that hCG treatment may be harmful to future
spermatogenesis; therefore, the Nordic Consensus Statement on treatment of undescended testes does not
recommend it use on a routine basis [1631]. See also the EAU Guidelines on Paediatric Urology [1632].

There is increasing evidence to suggest that in unilateral undescended testis, the contralateral normal
descended testis may also have structural abnormalities, including smaller volume, softer consistency and
reduced markers of future fertility potential (spermatogonia/tubule ratio and dark spermatogonia) [1621, 1633].
This implies that unilateral cryptorchidism may affect the contralateral testis and patients and parents should
be counselled appropriately.

10.4.1.1.2.2 Relationship with fertility
Semen parameters are often impaired in men with a history of cryptorchidism [1634]. Early surgical treatment
may have a positive effect on subsequent fertility [1635]. In men with a history of unilateral cryptorchidism,
paternity is almost equal (89.7%) to that in men without cryptorchidism (93.7%). In men with bilateral
cryptorchidism, oligozoospermia can be found in 31% and azoospermia in 42%. In cases of bilateral
cryptorchidism, the rate of paternity falls to 35-53% [1636]. It is also important to screen for hypogonadism, as
this is a potential long-term sequelae of cryptorchidism and could contribute to impaired fertility and potential
problems such as testosterone deficiency and MetS [1637].

10.4.1.1.2.3 Germ cell tumours
As a component of the TDS, cryptorchidism is a risk factor for testicular cancer and is associated with
testicular microcalcifications and intratubular germ cell neoplasia in situ (GCNIS), formerly known as carcinoma
in situ (CIS) of the testes. In 5-10% of testicular cancers, there is a history of cryptorchidism [1638]. The risk
of a germ cell tumour is 3.6-7.4 times higher than in the general population and 2-6% of men with a history
of cryptorchidism will develop a testicular tumour [1620]. Orchidopexy performed before the onset of puberty
has been reported to decrease the risk of testicular cancer [1639]. However, there is evidence to suggest that
even men who undergo early orchidopexy still harbour a higher risk of testicular cancer than men without
cryptorchidism [1640]. Therefore all men with a history of cryptorchidism should be warned that they are at

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