Surgery MCQ 226

A 3-year-old boy presents for a routine check-up, and during the examination, it is noted that one of his testicles is not palpable in the scrotum. The pediatrician suspects undescended testis. What is the most important associated risk for a child with an undescended testis?

A. Indirect inguinal hernia
B. Epididymo-orchitis
C. Sterility
D. Testicular torsion
E. Increased risk of malignancy


Correct Answer:

E. Increased risk of malignancy


Explanation:

Undescended testis, or cryptorchidism, refers to a condition in which one or both testicles fail to descend into the scrotum before birth. This condition is commonly diagnosed in infants and young children and can be associated with various complications if left untreated.

Why “E. Increased risk of malignancy” is the Correct Answer:

  1. Increased Risk of Malignancy:
    • One of the most serious long-term complications associated with an undescended testis is an increased risk of testicular cancer. The undescended testis remains in a higher temperature environment, which may impair its normal development and function, thereby increasing the likelihood of malignant transformation. Men with a history of cryptorchidism have an increased risk of developing testicular germ cell tumors later in life.
    • The risk of malignancy is higher if the testis is not corrected early. Early orchiopexy (surgical repositioning of the testis) is recommended before the child reaches 2 years of age to reduce the risk of cancer and preserve fertility.
  2. Other Complications:
    • Undescended testis can be associated with other complications, but the increased risk of malignancy is the most critical one, especially in adulthood.

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Analysis of Other Options:

A. Indirect inguinal hernia:

  • An indirect inguinal hernia is a common association with undescended testis. The testicle fails to descend through the inguinal canal, which is also a pathway for the hernia. However, while inguinal hernia can be found in cases of cryptorchidism, it is not the most significant long-term risk when compared to malignancy. It is, however, important to address it surgically during the same time as orchiopexy to prevent complications like incarceration.

B. Epididymo-orchitis:

  • Epididymo-orchitis (inflammation of the epididymis and testicle) is typically a complication of infection, often due to sexually transmitted infections (STIs) or urinary tract infections (UTIs), and is not a common association with undescended testis. Cryptorchidism does not directly predispose the testis to infection-related complications like epididymo-orchitis.

C. Sterility:

  • Sterility or infertility can be a consequence of cryptorchidism, particularly in cases where both testicles are undescended or if the condition is not corrected by the time the child reaches puberty. However, the risk of infertility is lower compared to the increased risk of malignancy. Orchiopexy performed early significantly reduces the risk of infertility, allowing the testicle to function normally and produce sperm.

D. Testicular torsion:

  • Testicular torsion (twisting of the spermatic cord) can occur in individuals with an undescended testis, particularly if the testis remains in an abnormal position. While torsion is a serious and painful emergency, it is not the most common or important complication in the long-term management of cryptorchidism. The increased risk of malignancy and potential for infertility are of greater concern.

Key Points to Remember:

  1. Increased risk of malignancy is the most important long-term complication of undescended testis (cryptorchidism), particularly if left untreated.
  2. Orchiopexy, the surgical procedure to reposition the testis into the scrotum, is recommended ideally before the child reaches 2 years of age to reduce the risks of malignancy and infertility.
  3. Indirect inguinal hernia is commonly associated with undescended testis, but it is less critical than malignancy and can be managed surgically.
  4. Testicular torsion is a risk in undescended testes, but it is not the most important complication in the long term.
  5. Infertility is a concern for undescended testis, particularly in untreated cases, but the risk of testicular cancer remains the most serious concern.

Clinical Management:

  • Diagnosis of undescended testis is made clinically, often noted during routine physical examinations in newborns or infants.
  • Orchiopexy should be performed at 6 months to 1 year of age to decrease the risk of complications such as malignancy and infertility. This procedure involves the surgical repositioning of the testis into the scrotum, where it can function normally.
  • Follow-up care after surgery is essential to monitor for any complications such as recurrent undescended testis, atrophy, or malignancy.

Summary:

Undescended testis (cryptorchidism) is associated with several risks, the most important of which is the increased risk of malignancy in the affected testicle. Surgical intervention, such as orchiopexy, is crucial to reduce the risk of testicular cancer and to ensure normal function of the testis. Other complications, including indirect inguinal hernia, testicular torsion, and infertility, can also arise but are secondary to the risk of cancer. Early diagnosis and treatment are key to preventing long-term complications.

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