POSTGRADUATE MED. J. (1966), 42, 270

THE RETRACTILE TESTIS

W. VAN ESSEN, F.'R.C.S.'(Ed.),

Consultant Surgeon, Woolwich Group, South-East Metropolitan Regional Hospital Board.

A YouNG 'boy is referred to the surgeon becauseon a single examina'tion his -testicles were ajbsentfrom the scrotum. There can be four distinctreasons for this finding, and a very serious effortmust be made to distinguish between them, be-cause they may affect the child's future and hisparents' peace of mind. The four possibilities tobe considered are:

1. There is nothing wrong2. Descent is merely delayed3. There is a barrier to the normall line of

descent4. The testis or testes are ectopic in position.

It is of the utmost importance to distinguishbetween -the first two and the second two of these.1 and 2 will need no treatment, whereas 3 and 4will almost certainly need operative procedures.

It might seem easy enough to eliminate the firstof these conditions, 'but in fact well over halfof all 'boys referred for undescended testicles arenormal, (Bunce, 1961), their organs being re-tracted out of the scrotum as a result of thecomlbined stimuli of cold, em'barrassment andfright. Wit-h the child lying flat on the examina-tion couch it may be quite impossible to manipu-late the testis into the scrotum, indeed persistentefforts have the reverse effect. These 'retractile'testes are often said ito ibe drawn into the inguinalcanal by the cremaster muscle; they are not inthe inguinal canal at all, 'but in a space belowand lateral to it described by Denis Browne as thesuperficial inguinal pouch (Browne, 1938), andunless the boy is obese 'they can easily bepalpated here. A testis in the inguinal canal isnot palpable, ,being soft and small and coveredby the firm aponeurotic sheet of the externaloblique muscle. Since a testis in the superficialinguinal pouch has already emerged from theinguinal canal it 'follows that the higher it is thelonger its cord must be, and the mnore easily itwill reach the scrotum.

In the examination of these children the vitalpoint is this: if the testis can be manipulatedinto the scrotum by any means it will eventuallycome down and stay t;here. These are the simpleretractile testicles, and they need no interference.That they 'often get it, in the form of surgery orhormones or both, cannot be denied, completelyinvalidating many statistics, and this is becausewith the boy lying flat or standing up the testisjust will not go into the scrotum and a specialmanoeuvre is necessary to get it there. The pur-pose of this paper is to draw attention to a

simple manoeuvre 'by wlhich the retractile testiscan be distinguished 'from the rest, thus eliminat-ing over half the referred cases with completeassurance.There is nothing new about the basic method

(Bunce, 1961); it was descrilbed in 1931 by LouiisOrr, 'but few people seem to know or apply it.As originally described, the boy sits on a chairwith his feet on the seat; he hugs his knees tohis chest, so that the thighs are flexed againstthe abdomen. In this position a simple retractiletestis descends into t'he scrotum and is easily seenand palpated there (Fig. 1). This boy is ten yearsold and has a normal testis on the 'left side, easilypalpable in the position shown. The right testisis also just palpable in the upper scrotum in thisposition, 'but is smaller than the left one. (Fig. 2).Neither testis is normally palpable in t'he scrotumlying flat.

I (have found a variation of this method evenmore useful. The 'boy squats on the couch, adopt-ing the very natural position shown in Fig. 3,with the legs separated as much as possi;ble.Once again all normal retractile testes will descendinto the scrotum, and having done so can begrasped and held '(Fig. 4) while the boy unwindsuntil 'he is lying flat on his back (Fig. 5). Therecan now 'be no shadow of doubt albout u-ltimatenormal descent even though, as in t;his particularcase, no toleralble manipulation would coax eithertestis into the scrotum with the iboy initially lyingflat, the scrotum remaining quite em'pty as seen inFig. 6. In this picture the position of t-he lefttestis is indicated 'by the arrow, and that of theexternal ring by a circle. The testis is easilypalpable and is beyond question lying outsidethe inguinal canal.

If the testis cannot be manitpulated into thescrotum, how long can one wait? It seemsreasonalbly certain that testes descending spon-taneously by the 6th year will 'be normal. Thosedown 'between 7 and 10 may show some de-generative changes on 'biopsy but will probablyfunction normally. After 11 years degenerationaccelerates, and is rapid after puberty '(Johnston,1965; Charney and Wolgin, 1957). Evidentlylbservation can 'be continued until 10 so long

as the organ is not ectopic or associated wvitha hernia. The boy D.B. '(Figs. 3-7) was first seenat five years as a complete cryptorchid. At sevenhe presented his left testis in the scrotum onsquatting. Now at 10 the left testis 'is normaland the right one advancing (Fig. 7), so it is clear

April, 1966 VAN ESSEN: The Retractile Testis 271

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272 POSTGRADUATE MEDICAL JOURNAL April, 1966

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that any previous interference by means of hor-mones or surgery wo,uld have been quite un-justified and probably disastrous. These ages areapproximate, 'for the 'boy's general sexual develop-ment must be considered. D.B. is small and isa long way 'behind puberty, and he can be safelydbserved for another year at least. T.R. (Fig. 1)at the same age shows every sign of rapid sexualadvance; first seen six months !ago, a decisionabout his almost stationary right testis must bemade very soon.The place of hormones may 'be mentioned.

They have two possilble indications: first, as adiagnostic measure when neither testis can be,palpated iby the age of six or sol the value ofthis is questionable. Seciond, as a pre-operativeaid; since regression occurs on withdrawal thebenefit 6f easier surgery could 'be negated. Apartfrom this they have no place in the handlingof these cases.

Early orchidectomy can seldom be justified;malignant disease of the testis before pulbertyis an extreme rarity.

REFERENCESBUNCE, P. L. (1961): Diagnosis of Undescended

Testes (Correspondence), Pediatrics, 27, 165.BROWNE, D. ;(1938): The Diagnosis of Undescended

Testicle, Brit. med. J., ii, 168, 171.CHARNY, C. W., and WOLGIN, W. (1957): Cryptorch-

ism. New York: Hoeber-Harper.JOHNSTON, J. H. (1965): Review Article. The Un-

descended Testis, Arch. Dis. Childh., 40, 113.MINOR, C. L. 1(1959): The Empty Scrotum, Pediat.

Clin. N. Amer., 6, 1137.