Chapter 127: Surgical Diseases of the Newborn: Urologic Disorders

INTRODUCTION

Renal masses are discussed in Chapter 126.

UNDESCENDED TESTIS (CRYPTORCHIDISM)

I. DEFINITION

Undescended testis (UDT), or cryptorchidism, refers to the absence of the testis within the scrotum and is the most common congenital anomaly of the male genitalia. The incidence is 1% to 4% in full-term neonates and up to 45% in preterm neonates; 10% to 25% of patients with UDT at birth have bilateral cryptorchidism.

II. CLINICAL PRESENTATION

UDT is diagnosed by physical exam. A UDT may be nonpalpable or palpable. Other exam findings may include ipsilateral hypoplastic scrotum, inguinal hernia, and hydrocele. UDT can be an isolated finding or occur as part of a syndrome (eg, disorder of sexual differentiation, Eagle-Barrett syndrome, bladder exstrophy).

III. DIAGNOSIS

Begin the exam with the patient in a supine position and legs abducted. Sweep a hand lateral to medial from the anterior superior iliac spine toward the ipsilateral scrotum. If the UDT is palpable, note the location, size, mobility, and consistency of the testis. The contralateral testis and penis should be examined as well.

1. Palpable testis. A palpable testis is a testis that can be felt on exam within the inguinal canal, upper scrotum, perineum, or an ectopic location. Neonates with palpable UDT should be reexamined as they grow to ensure proper descent by age 6 months.

2. Nonpalpable testis. If the testis cannot be palpated on exam, it may be intra-abdominal, absent, or atrophic (vanishing testis or testicular regression). If both testes are nonpalpable, urgent evaluation for congenital adrenal hyperplasia (CAH) in a genetic female or other disorder of sexual differentiation (DSD) is warranted.

IV. MANAGEMENT

Spontaneous descent of the testis can occur within the first 3 to 6 months of life. After age 6 months corrected for gestational age, surgery is recommended for a UDT. Inguinal or scrotal orchiopexy is done for palpable testes. Diagnostic laparoscopy and potential laparoscopic orchiopexy are standard of care for nonpalpable testes. Imaging studies are not recommended to help locate nonpalpable undescended testes, as they usually do not alter management recommendations. Neonates with hypospadias and UDT should undergo urgent evaluation for underlying genetic or endocrine anomaly such as CAH or other DSD. CAH with salt wasting can be life threatening.

SCROTAL AND TESTICULAR MASSES

I. DEFINITION AND CLINICAL PRESENTATION

The differential diagnosis of neonatal scrotal masses includes the following:

1. Hydrocele. Characterized by transilluminating fluid within the scrotum, which often has a bluish tint. Communicating hydroceles are contiguous with the peritoneal cavity via a patent processus vaginalis and present with size fluctuation in the scrotum. Simple hydroceles are confined to the tunica vaginalis and present as painless scrotal enlargement that does not ...