A 20-day-old term male infant is brought to the pediatric outpatient clinic by his first-time mother. She is very anxious and reports: "Doctor, yesterday while bathing my baby, I noticed that there is no testis on the right side of his scrotum. The left side feels normal. I checked again this morning and still cannot feel it. Is my baby missing a testis? Will he be able to have children later? Does he need surgery? I am very worried."
The infant was born at 39 weeks via normal vaginal delivery. Birth weight 3.2 kg. He is exclusively breastfed, active, and feeding well. There is no history of any illness. On examination, the infant is well-looking, thriving. The left testis is palpable in the scrotum. The right scrotal hemiscrotum appears underdeveloped (hypoplastic). No testis is palpable in the right scrotum. However, a small, mobile, ovoid mass is palpable in the right inguinal canal (just above the external inguinal ring). The mass can be gently manipulated but does not descend into the scrotum. The contralateral testis is normal. There is no hernia or hydrocele.
Task for the candidate: You are the pediatrician. Counsel the mother about the condition, its natural history, need for further evaluation, treatment options, timing of surgery (orchidopexy), and long-term implications (fertility, cancer risk). The examiner will observe your interaction and communication skills.
💡 Examiner instruction (interactive – observed counseling):
• The candidate must demonstrate empathy, active listening, and clear communication.
• Use simple, non-technical language (avoid jargon like "cryptorchidism" initially; explain step by step).
• Address the mother's anxiety first ("This is a common condition", "It is not your fault").
• Explain: what an undescended testis is (testis that stopped on its way down), natural history (may descend spontaneously in first 3-6 months, but unlikely after 6 months), examination findings (palpable in inguinal canal vs non-palpable).
• Discuss treatment: surgical orchidopexy if still undescended by 6-12 months (ideally before 18 months).
• Discuss risks of delayed surgery: infertility (heat damage to germ cells), increased risk of testicular cancer (but surgery reduces risk but does not eliminate it), risk of torsion, associated inguinal hernia.
• Mention follow-up after surgery (testicular growth, position).
• The examiner will then ask the candidate specific questions from the Q&A tab.
💬 Model Counseling Script – Candidate's Interaction with Mother
🗣️ Candidate's structured counseling (to be delivered to the mother):
1. Acknowledge and empathize:
“Thank you for bringing this to my attention. I understand you are very worried. This is a very common condition, and you have done the right thing by bringing your baby early.”
2. Explain what is happening (simple terms):
“During a baby’s development in the womb, the testicles form inside the abdomen and then slowly move down into the scrotum. In your baby’s case, the right testis has stopped along the way – it is in the groin (inguinal canal), not in the scrotum. This is called an undescended testis. The left testis is normal.”
3. Address natural history:
“In many babies, the testis can still descend on its own during the first 3 to 6 months of life. So we will wait and watch until he is about 6 months old. But if it has not come down by then, it is unlikely to come down on its own.”
4. Explain the need for surgery (orchidopexy):
“If the testis remains in the groin, we will need a simple surgery called orchidopexy. The surgeon will bring the testis down into the scrotum and fix it in place. This surgery is usually done between 6 and 12 months of age – ideally before 18 months. It is a day-care procedure in most cases.”
5. Discuss risks if not treated:
“If we leave the testis in the groin, the higher temperature there can damage the cells that produce sperm. That could affect his fertility later in life. Also, there is a slightly higher risk of testicular cancer, torsion (twisting), and sometimes an associated hernia. The surgery greatly reduces these risks, but does not completely eliminate the cancer risk – so he will need to learn self-examination when he is older.”
6. Discuss fertility and future children:
“Because the left testis is normal and healthy, his overall fertility is likely to be normal even if the right testis does not function perfectly. Most boys with one normal testis have normal fertility.”
7. What to do now (reassure, follow-up):
“For now, no treatment is needed. I will examine him again at his 2-month and 4-month checkups. If the testis is still not down by 6 months, I will refer him to a pediatric surgeon. You do not need to do anything special at home – just continue normal care. Do not try to pull the testis down yourself.”
8. Answer the mother's specific questions:
• “Is my baby missing a testis?” – No, it is present, just in the groin. We can feel it there.
• “Will he be able to have children?” – Yes, almost certainly, because the other testis is normal.
• “Does he need surgery?” – Possibly yes, if it does not come down by 6 months. The surgery is safe and effective.
• “Is this my fault?” – Absolutely not. This is a common birth difference; nothing you did caused it.
9. Summarize and close:
“To summarize: Your baby has an undescended testis on the right side. We will watch it for the next few months. If it does not come down by 6 months, we will do a small surgery to bring it down. His fertility should be normal. I will see him again in 4-6 weeks. Please do not worry – we will take care of it together.”
📌 Examiner observation points (communication skills):
• Did the candidate introduce themselves and listen actively?
• Did they use simple, empathetic language?
• Did they address the mother’s anxiety first?
• Did they explain the condition, natural history, and treatment clearly?
• Did they discuss risks (infertility, malignancy) appropriately without causing panic?
• Did they provide a clear follow-up plan?
• Did they answer the mother’s specific questions?
🔍 Examiner Questions (after counseling) – Click to reveal model answers
❓ Q1 (Examiner): “Define undescended testis (cryptorchidism). What is the difference between a truly undescended testis, a retractile testis, and an ectopic testis?”
✅ Candidate's answer:
• Undescended testis (cryptorchidism): Failure of one or both testes to descend into the scrotal position by birth. The testis lies along the normal path of descent (abdomen, inguinal canal, or just above scrotum).
• Retractile testis: Testis descends into scrotum but can be pulled up into groin by an overactive cremasteric reflex. It is normal and does not require surgery. Differentiated by ability to manually bring testis into scrotum without tension, where it remains for a while.
• Ectopic testis: Testis has deviated from the normal path of descent and lies in an abnormal location (perineum, femoral triangle, suprapubic region, opposite hemiscrotum). Requires surgery.
❓ Q2 (Examiner): “What is the prevalence of undescended testis at birth? How does it change by 6 months of age?”
✅ Candidate's answer:
• At birth (term infants): 2-4% (1-3% in full-term, up to 30% in preterm).
• At 6 months of age: Spontaneous descent occurs in many, especially in preterm and in the first 3 months. Prevalence drops to <1% by 6 months.
• Therefore, if a testis is still undescended at 6 months, it is unlikely to descend spontaneously, and surgery is indicated.
• Risk factors: Prematurity, low birth weight, small for gestational age, family history, maternal smoking, maternal diabetes, twin pregnancy.
❓ Q3 (Examiner): “How should you examine a neonate for undescended testis? What are the key steps and important maneuvers?”
✅ Candidate's answer:
• Environment: Warm room, infant calm (examine after feeding).
• Position: Supine with frog-leg position.
• Technique:
1️⃣ Inspect scrotum: asymmetry, hypoplastic hemiscrotum suggests absent or undescended testis.
2️⃣ Palpate scrotum first – if testis not felt, slide fingers from the internal inguinal ring (midway between ASIS and pubic tubercle) along the inguinal canal toward scrotum.
3️⃣ Use a “milking” or “bimanual” technique – one hand stabilizes the inguinal region while the other palpates.
4️⃣ If a mass is felt, attempt to manipulate it into the scrotum. If it goes into scrotum and stays, it is retractile; if it comes back immediately, it is undescended.
5️⃣ If no testis is palpable, it may be intra-abdominal (non-palpable) or absent (vanishing testis).
• Document: Position (intra-abdominal, inguinal, pre-scrotal), size, consistency.
❓ Q4 (Examiner): “Do you need imaging (ultrasound, MRI) for a palpable undescended testis? What about non-palpable testis?”
✅ Candidate's answer:
• Palpable undescended testis:Imaging is NOT needed. Ultrasound has low sensitivity for testis in the inguinal canal and does not change management (surgery is indicated regardless).
• Non-palpable testis (cannot be felt in inguinal canal or scrotum): May be intra-abdominal, absent (vanishing testis), or atrophic. Imaging may be considered: Ultrasound, MRI, or laparoscopy (gold standard). Laparoscopy is both diagnostic and therapeutic.
• In a non-palpable testis, laparoscopy can identify a vas deferens and vessels entering the internal ring (intra-abdominal) or a blind-ending vas (vanishing testis).
• Do NOT waste resources on ultrasound for palpable undescended testis.
❓ Q5 (Examiner): “What conditions are associated with undescended testis? What congenital anomalies should you look for?”
✅ Candidate's answer:
• Associated anomalies:
- Inguinal hernia (patent processus vaginalis) – occurs in ~10-15%.
- Hydrocele.
- Prune-belly syndrome (bilateral undescended testes + abdominal wall deficiency + urinary tract anomalies).
- Disorders of sexual development (DSD) – especially if bilateral, hypospadias, or ambiguous genitalia. Karyotype and endocrine evaluation needed.
- Genetic syndromes: Prader-Willi, Noonan, Kallmann, Down syndrome.
• Always examine: Contralateral testis, penis (for hypospadias), and look for signs of DSD if bilateral.
❓ Q6 (Examiner): “What is the recommended timing for orchidopexy in a child with a palpable undescended testis? Why is this timing important?”
✅ Candidate's answer:
• Recommended timing:6 to 12 months of age (ideally before 18 months).
• Reasons for early surgery:
1️⃣ Preserve fertility: Germ cell counts begin to decline after 12-18 months due to higher temperature in the inguinal canal/abdomen. Early orchidopexy maximizes germ cell survival.
2️⃣ Reduce risk of testicular malignancy: While orchidopexy does not eliminate cancer risk, it allows for easier examination and may reduce risk if done early.
3️⃣ Prevent torsion (twisting) of the undescended testis.
4️⃣ Repair associated hernia.
5️⃣ Psychological benefit (normal scrotal appearance).
• Delayed surgery (>2 years) is associated with higher rates of infertility and malignancy.
❓ Q7 (Examiner): “What is the long-term fertility prognosis for a boy with a unilateral undescended testis (like this infant) compared to bilateral undescended testes?”
✅ Candidate's answer:
• Unilateral undescended testis (like this case):Fertility is usually normal (85-90% achieve paternity). The contralateral normal testis compensates.
• Bilateral undescended testis: Significantly reduced fertility (30-50% may have low sperm counts); risk of azoospermia is higher. Early orchidopexy improves outcomes but may not normalize fertility completely.
• If surgery is delayed beyond 2 years, fertility outcomes worsen in both unilateral and bilateral cases.
• Role of testicular biopsy: Not routinely done; reserved for research or if concerns about germ cell malignancy (carcinoma in situ).
❓ Q8 (Examiner): “What is the risk of testicular cancer in a boy with a history of undescended testis? Does orchidopexy eliminate this risk?”
✅ Candidate's answer:
• Relative risk: 2- to 8-fold increased risk compared to the general population (lifetime risk ~0.4% vs 0.2% in general population).
• The risk is higher for intra-abdominal testes and bilateral undescended testes.
• Orchidopexy reduces but does NOT eliminate the risk. Cancer can still develop in the surgically descended testis, but earlier surgery (before puberty) may lower the risk compared to late surgery or no surgery. The mechanism is thought to be related to congenital germ cell abnormalities, not just temperature.
• Recommendation: Teach testicular self-examination (TSE) starting at puberty (age 13-15 years). Annual clinical examination by a physician.
• The contralateral normally descended testis also has a slightly increased risk (about 2-fold).
❓ Q9 (Examiner): “Is hormonal therapy (hCG or GnRH) effective for undescended testis? What is the current recommendation?”
✅ Candidate's answer:
• Hormonal therapy (hCG or GnRH) has been used in the past to stimulate testicular descent. Success rates are low (10-20%) and side effects include penile growth, pubic hair, and aggressive behavior.
• Current recommendation (AAP, CPSP, European guidelines): Hormonal therapy is NOT recommended for treatment of undescended testis. Surgery (orchidopexy) is the gold standard.
• Hormonal therapy may be considered in select cases of retractile testis (which is normal) or in research settings, but not for true undescended testis.
• Reason: Low efficacy, potential side effects, and no proven long-term benefit on fertility.
❓ Q10 (Examiner): “After successful orchidopexy, what follow-up is required? What complications can occur?”
✅ Candidate's answer:
• Follow-up:
- Clinical examination at 6-12 months post-surgery to ensure testis remains in scrotum, normal size, and no atrophy.
- Annual examination until puberty to monitor testicular growth and position.
- At puberty, teach testicular self-examination.
- Ultrasound may be used if testis is not palpable or if atrophy suspected.
• Complications of orchidopexy:
- Testicular atrophy (5-10% – higher for intra-abdominal testes).
- Recurrent ascent (testis retracts back up – may need reoperation).
- Damage to vas deferens or testicular vessels.
- Wound infection, hematoma, hernia recurrence.
• Success rate: >90% for palpable inguinal testes.
🗣️ Examiner's probing / high-yield points (Undescended Testis):
• "What is the most important step to differentiate retractile vs undescended testis?" → Ability to manually bring the testis into the scrotum without tension (retractile) vs cannot (undescended).
• "When is surgery indicated?" → If still undescended at 6 months of age.
• "What is the gold standard treatment?" → Orchidopexy (surgical fixation in scrotum).
• "What is the risk of testicular cancer after surgery?" → Reduced but not eliminated; teach self-examination.
• "Is hormonal therapy recommended?" → No – surgery is the standard.
• "What is the complication of delayed surgery?" → Infertility, higher cancer risk, torsion, associated hernia.
📘 Undescended Testis (Cryptorchidism) – Core Revision for TOACS
🔍 Definition Failure of one or both testes to descend into the scrotum by birth. Prevalence 2-4% in term newborns, drops to <1% by 6 months.
🧬 Types Palpable (inguinal, pre-scrotal) vs non-palpable (intra-abdominal, absent/vanishing). Retractile (normal) vs ectopic (abnormal location).
🩺 Examination Warm room, frog-leg position, milk from internal ring toward scrotum. Distinguish retractile vs undescended.
📋 Diagnosis Clinical diagnosis. Imaging (ultrasound) NOT needed for palpable testis. Laparoscopy for non-palpable testis.
💊 Management Observe until 6 months (spontaneous descent possible). If still undescended at 6-12 months → orchidopexy. No role for hormonal therapy.
⭐ High-yield pearls for TOACS (Undescended Testis – Counseling Station):
• Empathy first: “This is common, not your fault, we will fix it.”
• Natural history: May descend by 6 months; after that, unlikely.
• Surgery (orchidopexy): 6-12 months of age (ideal before 18 months).
• Risks of no surgery: Infertility (especially bilateral), cancer (2-8x risk – teach self-examination after puberty).
• Do NOT order ultrasound for palpable undescended testis.
• No hormonal therapy – surgery is gold standard.