Cryptorchidism in children: clinical guidelines

Applies tochildren2026 editionQ53.0, Q53.1, Q53.2, Q53.9

Clinical Guidelines of the Russian Ministry of Health, children. 2026 edition, ICD-10 codes: Q53.0, Q53.1, Q53.2, Q53.9.

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Brief for Practice

WhiteCoat Pro editorial summary of the guideline text, 2026 edition. Each point links to the original section — verify with it before prescribing.

Cryptorchidism is the absence of one or both testes from the scrotum due to a delay or deviation in their descent pathway. These guidelines are intended for the management of children: the key objectives are to confirm the form of cryptorchidism, rule out disorders of sex development and testicular torsion, and perform early surgical treatment.

Key points

Diagnostics

  1. An anamnesis is collected: when the absence of the testis was detected, whether it was previously in the scrotum, and whether there is dragging pain. Marked distress in a boy with redness and swelling of the scrotum suggests torsion of an undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed und diagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed und diagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed und diagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed und diagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed undiagnosed und diagnosed undiagnosed undiagnosed und diagnosed undiagnosed undiagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und 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diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed and diagnosed (due to torsion of an undiagnosed undiagnosed undiagnosed undiagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und 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diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed und diagnosed and diagnosed testis, or due to untreated cryptorchidism). → in text
  2. The examination is performed in a warm room with warm hands, first in a supine position with abducted and flexed legs, then in a vertical position. The size of the scrotum and its halves are evaluated, as the side where the testis was never located is usually smaller. → in text
  3. Palpate along the inguinal canal in the caudal direction and across it. If the testis is absent along its normal pathway of descent, check for femoral, perineal, and contralateral scrotal ectopia. → in text
  4. Differentiate true cryptorchidism from a retractile testis: a retractile testis can be easily brought down into the scrotum, where it remains without fixation until the cremasteric reflex is triggered. → in text
  5. In unilateral cryptorchidism, assess the volume of the presumably healthy contralateral testis to prognosticate the condition of the non-palpable gonad (Level of Reliability of Evidence (LRE) B, Level of Determinacy of Data (LDD) 3). → in text
  6. Routine imaging to locate a non-palpable gonad is not performed: ultrasound has a specificity of 45% and a sensitivity of 78% and does not improve diagnostic accuracy (LRE C, LDD 5). Ultrasound or a measuring tape is acceptable for measuring testicular dimensions (LRE B, LDD 1). → in text
  7. If torsion is suspected, perform ultrasound with Doppler imaging of the scrotal contents or inguinal region (LRE C, LDD 4). → in text

Treatment

When to refer and how to monitor

Frequently asked questions

When should cryptorchidism be operated on?

Surgical treatment is initiated at 6–12 months and aimed to be completed by 18 months. After 6 months, spontaneous descent of the testis is unlikely. → in text

Is an ultrasound necessary if the testis is not palpable?

Routine ultrasound is not recommended for diagnosing a non-palpable gonad, as it does not improve diagnostic accuracy. Ultrasound is used to assess testicular size, and with Doppler imaging if torsion is suspected. → in text

Can cryptorchidism be treated with hormones?

No, hormone therapy is not used for testicular descent, including cases of a retractile testis (LRE C, LDD 5). → in text

What should be done in case of bilateral cryptorchidism?

In addition to a urological evaluation, perform karyotyping and determine LH, FSH, total testosterone, androstenedione, and AMH levels; then involve a geneticist and pediatric endocrinologist (LRE B, LDD 3). → in text

How to recognize torsion of an undescended testis?

It may manifest as a swelling or lump in the groin, local hyperemia, sometimes without severe pain, as well as inconsolable crying, refusal of food or fluids, and vomiting. → in text

Status
Applied · approved by the Scientific and Practical Council of the Russian Ministry of Health
Database ID
1038, edition 1 (ID 1038_1)
Publication date
May 18, 2026
Age category
children
ICD-10 codes
Q53.0Q53.1Q53.2Q53.9
Specialties
UrologyPediatric SurgeryPediatrics
Developers
All-Russian Public Organization "Russian Association of Pediatric Surgeons"
All-Russian Public Organization "Russian Society of Pediatric Urologists-Andrologists"
Official text
Minzdrav Russia Rubricator — 1038_1

List of Abbreviations

ICD-10 – International Classification of Diseases 10th Revision

MRI – magnetic resonance imaging

MSCT – multislice computed tomography

FP – Fowler-Stephens procedure

VRT – Vanishing testis syndrome

US – ultrasound examination

AUA – American Urological Association

BAPS / BAUS – British Association Paediatric Surgeons/British Association of Urological Surgeons Limited

CUA – Canadian Urological Association

EAU – European Association of Urology

ESPU – European Society for Paediatric Urology

Terms and Definitions

Cryptorchidism is a synonym for the term "undescended testis", in which one or both testes are absent from the scrotum.

Retention is a delay in the descent of the testis along its pathway from the abdominal cavity into the scrotum (inguinal retention and abdominal retention).

Palpable testes include true cryptorchidism, false cryptorchidism, and testicular ectopia.

Testicular ectopia is a deviation from the normal path of testicular descent into the scrotum (inguinal, perineal, femoral, pubic, penile).

Transverse ectopia is the location of the testis in the opposite hemiscrotum.

False cryptorchidism (retractile testes) is a condition where the testis is pulled up into the inguinal canal, but it can be brought down into the scrotum freely and without tension, though it does not remain there.

Acquired cryptorchidism is a condition where the gonad was palpable in the scrotum after birth, and subsequently changed its location (inguinal position).

Non-palpable testes include the abdominal form of cryptorchidism, the inguinal form, and testicular aplasia.

Monorchism is a condition characterized by the presence of only one testis.

Anorchism is a condition characterized by the absence of testes.

Polyorchism is an anomaly characterized by the presence of an accessory testis.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Cryptorchidism is an anomaly of testicular position in which one or both testes are absent from the scrotum, being "delayed" along the path of descent from the abdominal cavity to the scrotum, and can be detected in the inguinal canal (inguinal cryptorchidism) or in the abdominal cavity (abdominal cryptorchidism), or outside the path of testicular descent (ectopia) [59].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

There are several theories describing the process of testicular descent in embryogenesis. According to the two-phase theory, testicular descent is divided into the transabdominal phase and the inguinoscrotal phase. The five-phase theory of human fetal testicular descent corresponds to the stages of embryogenesis, but is divided into a larger number of fragments compared to the two-phase theory [1].

Disorders at any stage of the complex anatomical processes occurring under the control of an equally complex endocrine regulation and ensuring embryonic development and migration of the testis can lead to the development of unilateral or bilateral cryptorchidism [2].

Cryptorchidism is the most frequent cause of non-obstructive azoospermia in adulthood [47]. The incidence of azoospermia in unilateral cryptorchidism is 13%, and in bilateral cryptorchidism, 32%.

About 10% of infertile men from the general population have a history of cryptorchidism and orchiopexy [48].

Infertility in patients with unilateral cryptorchidism occurs twice as often as in the general population.

The earlier treatment is initiated, the lower the probability of reproductive function impairment.

With a unilateral non-palpable testis, fertility is reduced, but paternity rates are not impaired.

Fertility rates and paternity frequency are significantly lower in patients with bilateral cryptorchidism [49].

In unilateral cryptorchidism, the level of retention does not significantly affect fertility and paternity rates.

The higher the testis is located in the abdominal cavity and the later orchiopexy is performed, the more pronounced reproductive function disorders and spermatogenic dysfunction are caused by the effect of high temperatures [50].

A history of cryptorchidism determines a significant risk of developing malignant testicular neoplasms. Early performance of orchiopexy (especially important before the onset of puberty) more than doubles the risk of malignant testicular involvement. The higher the level of retention, the higher the probability of developing a malignant testicular neoplasm and detecting a seminoma [86, 87].

1.3 Epidemiology of the Disease or Condition

Cryptorchidism is the most common anomaly of the male genital organs. The incidence of cryptorchidism at birth ranges from 1.8% to 8.4%, and by the end of the first year of life, this figure ranges from 1.3% to 6.7%. In approximately 80% of cases, the testes descend into the scrotum within the first 6 months of life, leading to a decrease in the incidence of cryptorchidism to 1% by 1 year of age [3, 4]. Bilateral forms are recorded in 11.5–45% of cases. Palpable forms occur in 73–80% of cases, while in 10–27% the testis cannot be palpated [5, 6, 7, 8]. Among non-palpable forms, in 45.6–72.6% of cases the testes are located in the abdominal cavity [9, 10, 11, 12, 13]. In 30% of cases, a significantly hypoplastic gonad is discovered [6, 7], complete absence of one testis (monorchism) occurs in 4%, and the absence of both testes (anorchism) occurs in less than 1% of cases [14].

Testicular torsion of an undescended testis. The incidence of torsion of an undescended testis is about 23% among all cases of testicular torsion [37].

1.4 Features of Coding the Disease or Condition

Q53.0 Ectopic testis (unilateral or bilateral testicular ectopia)

Q53.1 Undescended testicle, unilateral

Q53.2 Bilateral cryptorchidism

Q53.9 Undescended testicle, unspecified

1.5 Classification of the disease or condition

Depending on localization, cryptorchidism can be unilateral or bilateral.

Undescended testes should be divided into two groups: congenital cryptorchidism and acquired cryptorchidism. Congenital cryptorchidism is subdivided into palpable and non-palpable forms. Acquired cryptorchidism is subdivided into primary and secondary.

The classification of undescended testes according to the European Association of Urology guidelines [79] is presented below.

1.5 Classification of the disease or condition — Cryptorchidism in children
Palpableforms of cryptorchidism are divided into inguinal, ectopic, and retractile. Retractile testis is the most commonly used term, serving as an equivalent to previously used expressions: false cryptorchidism, pseudocryptorchidism, or hypermobile testis.

Testes classified as retractile are those that are located extrascrotally, but can be easily brought down into the scrotum and remain there without manual fixation until the cremasteric reflex is elicited.

Testicular ectopia is a disorder of migration direction in which the testis is located outside the scrotum after passing through the inguinal canal and exiting through the superficial inguinal ring. Testicular ectopia occurs in 5% of boys with cryptorchidism.

Variants of testicular ectopia:

1) pubopenile – the gonad is located at the base of the penis and lies on the pubic bone;

2) femoral – the gonad is located in the femoral triangle closer to the medial surface of the thigh;

3) perineal – the gonad is located under the skin of the perineum;

4) inguinal – the testis is located in the cavity formed between Scarpa's fascia and the fascia of the external oblique abdominal muscle adjacent to the superficial ring of the inguinal canal. In foreign literature, this anatomical structure is referred to as the "Denis Browne pouch" or superficial inguinal pouch.

Non-palpable testes are classified as abdominal and absent.

In the abdominal form, the testes can be located in the region of the internal inguinal ring at a distance of more than 2 cm from it – high abdominal retention, or less than 2 cm from it – low abdominal retention. In the abdominal cavity, gonads can be located in the renal region, on the anterior abdominal wall, and in the urinary bladder region. The category of intra-abdominal testes located near the internal inguinal ring is referred to as "peeping" testes.

Absent testes (testicular regression syndrome) are most often atrophic gonads resulting from impaired blood supply during their migration into the scrotum. Cases of testicular agenesis are also classified as "absent testes".

Acquired cryptorchidism. There are primary and secondary forms. Primary acquired cryptorchidism refers to cases where at birth the testes were located intrascrotally, which is documented during medical examinations, but subsequently assumed an extrascrotal position. The etiology of primary acquired cryptorchidism remains unclear. Secondary acquired cryptorchidism is diagnosed when the testis is in an extrascrotal position following its orchidopexy or herniorrhaphy.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnostic criterion for cryptorchidism is the absence of one or both testes in the scrotum during physical examination of the patient.

The physician's task in making a diagnosis is to determine the following characteristics:

- localization: unilateral/bilateral cryptorchidism;

- origin: congenital/acquired;

- form: palpable/non-palpable gonads.

During the diagnosis of cryptorchidism, an important step is to differentiate between true cryptorchidism and pseudocryptorchidism (hyper-mobile/retractile testes).

It is worth noting that bilateral undescended testes may indicate a number of diseases and syndromes (congenital adrenal hyperplasia, various disorders of sex development, Noonan syndrome, prune-belly syndrome, etc.) requiring both in-depth uro-andrological evaluation and consultations with specialists in other fields.

2.1 Complaints and Anamnesis

The main complaint of patients with cryptorchidism is the absence of one or both testes in the scrotum. As a rule, the absence of a testicle in the scrotum is discovered at the child's birth. In some cases, the detection of cryptorchidism is an incidental finding during a routine preventive examination by a pediatric surgeon. In rare cases, a dull, aching pain is noted. Complaints of severe distress in a boy with redness and swelling of the scrotum are typical for torsion of an undiagnosed undescended testicle or when orchidopexy has not been performed. Cryptorchidism in adults is a casuistic phenomenon.

2.2 Physical Examination

The patient is examined in a warm room with warm hands, in the frog-leg position, where with the patient lying supine with abducted thighs and knees flexed, the heels of both feet touch each other.

During the examination, it is necessary to pay attention to the condition and size of the scrotum, especially on the side ipsilateral to the cryptorchidism, since the scrotum or its half, where the testis has never been located, is predictably reduced in size.

In addition to the standard horizontal examination, an examination in the upright position is advisable, in which increased intra-abdominal pressure creates prerequisites for the descent of the retained gonad down towards its normal migration into the scrotum. The optimal examination of a boy is in the vertical position when he is held in arms, with the patient's legs pulled up to the anterior abdominal wall. Palpation of the gonad must be performed in two directions: along the inguinal canal in the caudal direction and across the line of the inguinal canal.

If it is not possible to palpate the gonad along the normal path of its migration into the scrotum, femoral and perineal ectopia, as well as ectopia into the contralateral half of the scrotum, must be ruled out.

Based on the examination results, it is necessary to classify the position of the testis. The normal position of the testis is intrascrotal; this is a position where the center of the testis is at the border between the upper and lower halves of the scrotum or below it [15].

It is recommended to evaluate the testicular volume of the supposedly healthy contralateral gonad to predict the condition of the non-palpable gonad in unilateral cryptorchidism [60, 61, 62].

GCR BLOCE 3Grade of Recommendation B (Level of Evidence 3)

It is recommended in bilateral undescended testes or signs of differences of sex development (DSD), including mixed-type genitalia or scrotal hyperpigmentation, to perform endocrinological and genetic studies, including karyotyping (cytological study (karyotype)) and hormone profile analysis (blood levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone, androstenedione, and anti-Müllerian hormone (AMH)), followed by consultation with relevant specialists (medical geneticist, pediatric endocrinologist) to confirm or rule out DSD [59, 63].

GCR BLOCE 3Grade of Recommendation B (Level of Evidence 3)

The clinical presentation of testicular torsion in an undescended testis is very blurred and often presents with non-specific symptoms. Torsion of a non-palpable testis is most frequently misdiagnosed as inguinal lymphadenitis, incarcerated hernia, acute intestinal obstruction, or acute appendicitis [38].

The most common symptoms are: a swelling/lump in the inguinal region, not always accompanied by pain, local hyperemia of the inguinal region, as well as non-specific symptoms such as inconsolable crying, refusal of food/fluid, and vomiting [39]. Combined with the low awareness of primary care specialists regarding this issue, this leads to late diagnosis and subsequent loss of the testis [40].

2.3 Laboratory Diagnostics

Laboratory diagnostic tests are not informative for establishing the diagnosis.

2.4 Instrumental Diagnostics

Ultrasound examination of the scrotal organs (A04.28.003) and ultrasound examination of the abdominal organs (A04.16.001) demonstrate unsatisfactory specificity and sensitivity (45% and 78%, respectively) in the diagnosis of non-palpable forms of cryptorchidism [16-18].

It is not recommended for patients with cryptorchidism to undergo ultrasound examination or other imaging methods for diagnostic purposes according to the guidelines of the AUA [19], BAPS / BAUS [20], CUA [21], and EAU [22], as their performance does not improve diagnostic accuracy.

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comment: MRI may be used in children with suspected DSD to identify Müllerian structures [79].

It is recommended to use ultrasound examination of the scrotal organs (A04.28.003) or measurement of the gonad with a centimeter ruler to determine the size of the testis in patients with cryptorchidism [24, 91].

GCR BLOCE 1Grade of Recommendation B (Level of Evidence 1)

Comment: currently, there are two formulas for determining testicular volume using the ellipsoid method: V = (length × width × thickness) × 0.523 and Lambert [24]: V = (length × width × thickness) × 0.71. The ellipsoid formula is advisable to use when measuring with a centimeter ruler. The Lambert formula has proven to be more accurate for ultrasound data. However, some ultrasound machines have the ellipsoid formula pre-installed. For Tanner stages 1–3 of development, the thickness of the scrotal skin is assumed to be 1.5 mm; for Tanner stages 4–5 of sexual development, the thickness of the scrotal skin is 2 mm. When measuring the dimensions of the testis using a ruler, the value of the scrotal skin thickness based on the Tanner stage of sexual development must be subtracted from the obtained dimensions.

The use of a ruler, taking into account the correction for scrotal skin thickness for measuring testicular size and the Lambert formula for calculating volume, allows obtaining gonad volume values completely comparable to the data obtained by ultrasound measurements.

It is recommended for patients with cryptorchidism suspected of having torsion of an undescended testis to undergo ultrasound examination with dopplerography of the scrotal organs/inguinal region for diagnosis and final diagnosis establishment [41].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Treatment of cryptorchidism consists of ensuring a fully scrotal position of the testis (this is a position where the center of the testis is at the border between the upper and lower halves of the scrotum or below it).

3.1 Hormonal therapy

It is not recommended to use hormone therapy to achieve testicular descent into the scrotum, including in patients with retractile testes [25].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: the anatomical features of the undescended testis (short testicular vessels, patent processus vaginalis of the peritoneum, abnormal attachment of the gubernaculum, abdominal position of the gonad, and obliteration of the processus vaginalis in abdominal retention) are an important factor limiting the potential efficacy of hormone therapy. When considering hormone therapy administration, side effects of its use should be kept in mind.

The expediency of adjuvant hormone therapy after performing orchidopexy to improve future reproductive function is a subject of study; indications for its selective use will be determined over time.

3.2 Surgical Treatment

3.2.1 Timing of surgical treatment

It is recommended to start surgical treatment of cryptorchidism in the interval from 6 to 12 months and aim to complete it by the age of 18 months [26, 64, 65, 66].

GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2)

Comment: if the testis has not completed its descent by 6 months (adjusted for gestational age), spontaneous descent after this age is unlikely.

Management algorithm for a patient with a unilateral non-palpable testis proposed by the European Association of Urology [90]:

3. Treatment — Cryptorchidism in children

3.2.2 Orchiopexy for palpable gonads

It is recommended to perform surgical testicular descent in palpable forms of cryptorchidism in order to preserve the fertility index and reduce the risk of infertility in patients [88, 89, 92].

GCR ALOCE 2Grade of Recommendation A (Level of Evidence 2)

Comment: testicular descent in palpable forms of cryptorchidism is performed using inguinal (transinguinal) or scrotal approaches. During testicular revision using either inguinal or scrotal approaches, if an appendix of the epididymis or testis is found, its removal is indicated [66, 79].

3.2.2.1 Transinguinal approach for orchiopexy (Shoemaker procedure)

The classical two-incision transinguinal orchidopexy technique is universal and can be used for any level of retention of a palpable testis [43].

The classical two-incision transinguinal orchidopexy technique includes transinguinal orchidofuniculolysis followed by descent and fixation of the testis according to Schmaker via a transscrotal approach. This approach provides excellent visualization of the spermatic cord elements, makes it possible to perform high mobilization and ligation of the processus vaginalis of the peritoneum with an efficacy of up to 92%. The rate of malposition and testicular atrophy with the inguinal approach reaches 1%.

3.2.2.2 Transscrotal approach for orchiopexy

Transscrotal approach – Bianchi operation, indicated for patients with a unilateral process in whom the testis can be brought down below the superficial inguinal ring upon examination (testicular descent A16.21.018) [27].

In bilateral inguinal cryptorchidism, it is advisable to use the Welsling approach performed along the median raphe of the scrotum. Subsequent manipulations are performed similarly to the Bianchi operation.

In 80% of cases, undescended testes are low-lying, located distal to the superficial inguinal ring [28]. In such anatomical positions, a scrotal incision can be used for orchidopexy. The efficacy of transscrotal orchidopexy ranges from 88 to 100%. The recurrence rate reaches 3.5%, and testicular atrophy is less than 0.5% [29]. Tissue dissection during access creation and isolation of the distal part of the processus vaginalis is accompanied by the destruction of structures used for testicular fixation in the "dartos pouch" technique.

It has been proposed to use a fixation technique that involves creating a "cuff" from subcutaneous adipose tissue in a caudal direction, starting from the level of the superficial inguinal ring, by suturing the tissue above and below the spermatic cord elements with interrupted sutures.

3.2.2.3 Laparoscopic approach for palpable forms of cryptorchidism

It is recommended in cases of high inguinal retention and when the testis is either palpable upon examination or absent from the inguinal region due to migration from the abdominal cavity into the inguinal canal, to consider using a laparoscopic approach for high mobilization of the testicular vessels and vas deferens [30, 31, 79, 93].

GCR ALOCE 2Grade of Recommendation A (Level of Evidence 2)

Comment: a limitation to using the laparoscopic approach in lowering palpable gonads is the need for the anatomical possibility to return the gonad into the abdominal cavity with subsequent division of the gubernaculum to complete gonad mobilization. This limitation can be overcome by transscrotal mobilization of the processus vaginalis down to the reflection fold, followed by invagination of the latter into the abdominal cavity. Currently, a consensus has not yet been established regarding the indications for laparoscopic access in the treatment of palpable forms of cryptorchidism.

3.2.3 Orchiopexy for non-palpable gonads

3.2.3.1 Choice of primary surgical approach

It is recommended that patients with non-palpable gonads undergo diagnostic laparoscopy as the primary surgical stage to verify the anatomical location of the testis within the abdominal cavity [19, 30, 31, 94].

GCR ALOCE 2Grade of Recommendation A (Level of Evidence 2)

  • If the testicular vessels and vas deferens end blindly at a distance from each other and from the deep inguinal ring, and the entrance to the deep inguinal ring is closed, further surgical manipulations are not recommended — the situation is classified as testicular agenesis [85].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

  • In cases of testicular regression syndrome (laparoscopic findings characterized by vessels and vas deferens entering the inguinal canal and a closed deep inguinal ring), it is recommended to perform a revision scrototomy to search for testicular remnants [84].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

Comment: compensatory (vicarious) hypertrophy of the contralateral testis (greater than 2 cm3) in unilateral non-palpable cryptorchidism may be an indicator of testicular regression syndrome. The initial surgical access should utilize transinguinal or transscrotal incisions, which allow the identification of so-called testicular remnant "nodules". The presence of germ cells or seminiferous tubules within these "nodules" entails the risk of malignant transformation of these formations. If "nodules" are found intraoperatively, the question of their removal must be addressed.

  • If the vessels and vas deferens enter the inguinal canal and the deep inguinal ring is open, it is recommended to perform an exploration of the inguinal canal followed by orchidopexy (testicular lowering) if the testis is found [30].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

  • Upon discovering a peeping testis directly at the entrance to the inguinal canal and a patent processus vaginalis, it is recommended to lower the testis via an inguinal approach [31].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: if a peeping testis is discovered and it is impossible to lower it using standard transinguinal access, it is advisable to supplement orchidofuniculolysis with laparoscopic mobilization of the testicular vessels and vas deferens.

  • In cases of a high-lying testis (located more than 2 cm from the deep inguinal ring), a two-stage treatment is recommended: ligation/transection of the testicular vessels followed by laparoscopic testicular lowering (Fowler-Stephens operation [FSO]) [82, 83].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

Comments: the second stage of the FSO is performed no earlier than 6 months after the first stage. The efficacy of the 2-stage FSO is 93%. The presence of a long loop of the vas deferens is an important cause of testicular atrophy following the FSO. If a long vas deferens loop and its deep penetration into the inguinal canal are identified, transinguinal mobilization of the processus vaginalis along with the vas deferens during the 2nd stage of the FSO is advisable to reduce the risks of iatrogenic injury to the vas deferens.

  • In cases where the testis is located in the abdominal cavity at a distance of less than 2 cm from the deep inguinal ring, it is recommended to perform laparoscopic testicular lowering without dividing the testicular vessels [82, 83].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

Comments: the risk of testicular atrophy with preservation of the testicular vessels is 3% [33, 82].

3.2.4 Orchiopexy in adolescents

Testicular lowering during or after puberty significantly increases the risk of malignancies. In patients with postpubertal congenital cryptorchidism, the possibility of performing an orchiectomy should be discussed with the patient's parents. If the parents refuse and orchidopexy is performed, the patient requires lifelong rigorous follow-up [34].

Orchiectomy is not indicated for boys after the completion of puberty in primary acquired cryptorchidism [35].

It is recommended to perform laparoscopic orchiectomy in postpubertal patients with the abdominal form of testicular retention [36].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

3.2.5 Torsion of an undescended testis

It is recommended in cases of torsion of an undescended testis to perform detorsion and fixation of the testis — testicular detorsion [42].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

The degree and duration of torsion correlate with the risk of testicular necrosis. The salvage rate for undescended gonads in torsion ranges from 0% to 37.5% [43, 44].

It is recommended to perform an orchiectomy in abdominal forms of retention regardless of the viability of the torsed testis [45, 46].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

3.2.6 Surgery for cryptorchidism recurrence

The recurrence rate of cryptorchidism using the inguinal approach reaches 1%, and the scrotal approach 3% [51]. The incidence of secondary acquired cryptorchidism following surgeries for pathology of the processus vaginalis reaches 2% [52].

It is recommended to use both inguinal and scrotal approaches to resolve secondary acquired cryptorchidism [53-55].

GCR BLOCE 3Grade of Recommendation B (Level of Evidence 3)

Comments: when using the inguinal approach, the technique of en-bloc spermatic cord isolation has become widespread; its essence lies in harvesting a strip of the external oblique abdominal aponeurosis fused with the elements of the spermatic cord from previous surgery, thereby reducing the risk of trauma during orchidofuniculolysis. Success rates using this method range from 80% to 100% [56]. The advantage of the scrotal approach is provided by operating on tissues that are less subject to scarring and are not constrained by aponeurotic and muscular structures as in the inguinal approach. The use of either scrotal or inguinal access for the treatment of secondary acquired cryptorchidism provides comparable efficacy and safety.

3.2.7 Testicular prosthesis

It is recommended to perform testicular prosthetics to eliminate psychological and cosmetic discomfort in patients with anorchia [80, 81].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

Comment: the surgery involves creating a new channel in the corresponding half of the scrotum via an inguinal incision, creating a pocket for the prosthesis, and fixing it to the dartos fascia of the scrotum. Special silicone prostheses (testicular prosthesis 183390) are used, which are as close as possible in their physical properties to testicular tissue.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not provided.

5. Prevention and Dispensary Observation

In the postoperative period, the child is monitored by a pediatric urologist-andrologist and an endocrinologist. An ultrasound examination of the testes is performed annually with mandatory assessment of blood flow in the organ.

  • To detect secondary acquired cryptorchidism and gonad atrophy after orchidopexy, it is recommended to examine patients at 1, 6, and 12 months post-surgery. Following the examination, the need for a gonad ultrasound is determined. Subsequent follow-up is carried out at scheduled intervals; during the prepubertal and pubertal periods, an examination by an endocrinologist with an assessment of the patient's hormonal profile is mandatory [60, 64, 67-78].

GCP ALE 3Grade of Recommendation A (Level of Evidence 3)

6. Organization of Medical Care

Testicular torsion requires emergency hospitalization in a hospital for evaluation and surgical treatment (see the corresponding section).

7. Additional Information

Not applicable.

Criteria for Evaluating the Quality of Medical Care

№

Quality criteria

Evaluation of compliance

1

Assessment of the testicular volume of the presumably healthy contralateral gonad was performed in unilateral cryptorchidism.

Yes/No

2

Endocrinological and genetic studies were performed in bilateral cryptorchidism or signs of disorders of sex development.

Yes/No

3

Ultrasound examination with Doppler flow imaging of the scrotum / inguinal region was performed in suspected torsion of an undescended testis.

Yes/No

4

Surgical treatment of cryptorchidism was performed between 6 and 18 months of age.

Yes/No

5

A two-stage Fowler-Stephens operation was performed for a high-lying intra-abdominal testis.

Yes/No

6

Laparoscopic testicular mobilization without division of the testicular vessels was performed for abdominal cryptorchidism when the testis was located less than 2 cm from the deep inguinal ring.

Yes/No

7

Laparoscopic orchiectomy was performed in a postpubertal patient with an abdominal form of testicular retention.

Yes/No

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Appendix A1. Working Group Composition

Sergey N. Zorkin – MD, Professor, Head of the Research Institute of Pediatric Nephrourology, Head of the Urological Department with Groups of Reproductology and Transplantation, National Medical Research Center for Children's Health of the Russian Ministry of Health.

Mikhail I. Kogan – MD, Professor, Head of the Department of Urology and Human Reproductive Health with a Course of Pediatric Urology-Andrology and Faculty of Advanced Training and Professional Retraining of Specialists of Rostov State Medical University, Director of the Research Institute of Urology and Nephrology, Rostov State Medical University.

Vladimir V. Sizonov – MD, Professor, Professor at the Department of Urology and Human Reproductive Health with a Course of Pediatric Urology-Andrology, Rostov State Medical University of the Russian Ministry of Health.

Aleksey G. Makarov – PhD in Medicine, Assistant at the Department of Pediatric Surgery and Orthopedics, Rostov State Medical University; pediatric urologist-andrologist at the Pediatric Uroandrological Department, Regional Children's Clinical Hospital, Rostov-on-Don, Russia.

Nail R. Akramov – MD, Professor, Head of the Department of Urology, Nephrology, and Transplantology, Kazan State Medical Academy – branch of the Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health.

Yury E. Rudin – MD, Professor, Head of the Pediatric Urology Group, Lopatkin Scientific Research Institute of Urology and Interventional Radiology – branch of the National Medical Research Radiological Center of the Russian Ministry of Health.

Dmitry V. Sizyakin – MD, Professor, Professor at the Department of Urology and Human Reproductive Health with a Course of Pediatric Urology-Andrology and Faculty of Advanced Training and Professional Retraining of Specialists, Rostov State Medical University; Chief Medical Officer of City Hospital No. 1 named after N.A. Semashko, Rostov-on-Don, Russia.

Svetlana Yu. Komarova – PhD in Medicine, Associate Professor at the Department of Pediatric Surgery, Ural State Medical University of the Russian Ministry of Health, Chief freelance pediatric urologist-andrologist of the Ural Federal District.

Alexandra T. Galuzinskaya – PhD in Medicine, Senior Researcher at the Research Institute of Pediatric Nephrourology, National Medical Research Center for Children's Health of the Russian Ministry of Health.

Conflict of interest: all members of the working group confirmed the absence of financial support / conflict of interest that needs to be reported.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of these clinical guidelines

1. Pediatric surgeon;

2. Pediatric urologist-andrologist;

3. Pediatrician;

4. District pediatrician;

5. City (district) pediatrician;

4. General practitioner (family physician);

5. Obstetrician-gynecologist;

6. Neonatologist;

7. Anesthesiologist-intensivist;

8. Surgeon;

9. Urologist;

10. Physician (internist);

11. Adolescent physician;

12. District internist;

11. Functional diagnostics physician.

Methods used for collecting/selecting evidence: searching electronic databases.

Description of methods used for assessing the quality and strength of evidence: the evidence base for the recommendations includes publications included in the Cochrane Library, EMBASE, MEDLINE, and PubMed databases. Search depth – 10 years.

Methods used to assess the quality and strength of evidence:

  • expert consensus;

  • assessment of significance in accordance with the rating scheme.

Methods used for evidence analysis:

  • reviews of published meta-analyses;

  • systematic reviews with evidence tables.

Description of methods used for evidence analysis

When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its validity. The result of this examination affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendations.

To minimize potential bias, each study was evaluated independently. Any discrepancies in evaluations were discussed by the full panel of authors. If a consensus could not be reached, an independent expert was involved.

Evidence tables: compiled by the authors of the clinical guidelines.

Methods used for formulating recommendations: expert consensus.

Good Practice Points (GPPs)

Recommended good clinical practice is based on the clinical experience of the authors of these guidelines.

Economic analysis

Cost analysis was not performed, and pharmacoeconomic publications were not analyzed.

Recommendation validation method

  • External expert review.

  • Internal expert review.

Description of the recommendation validation method

The draft of these recommendations was reviewed by independent experts who were primarily asked to comment on how comprehensible the interpretation of the evidence underlying the recommendations is.

All comments received from the experts were thoroughly systematized and discussed by the members of the working group (authors of the recommendations). Each item was discussed individually.

Consultation and peer review

The draft recommendations were reviewed by independent experts who were primarily asked to comment on the clarity and accuracy of the interpretation of the evidence base underlying the recommendations.

Working Group

For the final revision and quality control, the recommendations were re-evaluated by the members of the working group, who concluded that all comments and feedback from the experts had been taken into account and the risk of bias in the development of the recommendations was minimized.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

LoE

Definition

1

Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis

2

Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis

3

Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies

4

Non-comparative studies, case report

5

Only justification of mechanism of action or expert opinion is available

Table 2. Scale for grading levels of evidence (LoE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

LoE

Definition

1

Systematic review of RCTs with meta-analysis

2

Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis

3

Non-randomized comparative studies, including cohort studies

4

Non-comparative studies, case reports or case series, case-control studies

5

Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available

Table 3. Scale for grading grades of recommendation (GoR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, rehabilitation interventions)

GoR

Definition

A

Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent)

B

Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent)

C

Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent)

Appendix A3. Reference Materials

  1. European Association of Urology Clinical Guidelines 2024.

  2. American Urological Association Clinical Guidelines 2016.

  3. Order of the Ministry of Health of Russia dated October 31, 2012 No. 561n "On approval of the procedure for providing medical care in the field of 'pediatric urology-andrology'."

  4. Order of the Ministry of Health of the Russian Federation dated February 28, 2019 No. 103n "On approval of the procedure and timeframe for the development of clinical guidelines, their revision, standard form of clinical guidelines and requirements for their structure, composition and scientific validity of the information included in the clinical guidelines."

Appendix B. Physician Action Algorithms

Appendix B. Physician action algorithms — Cryptorchidism in children

Appendix C. Patient Information

By the time of birth, both testes in boys should be visualized and palpable in the scrotum.

If one or both testes are not visualized, consultation with a pediatric urologist-andrologist is indicated.

Further management tactics are determined by the pediatric urologist-andrologist.

Following surgical treatment, the child should be followed up by a pediatric urologist-andrologist at the following intervals: at 1, 6, and 12 months postoperatively, and thereafter at designated mandatory check-up intervals.

Children who have undergone surgical treatment for cryptorchidism are indicated for a consultation with a pediatric endocrinologist during the prepubertal and pubertal periods.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable within the scope of these clinical guidelines.

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Answers based on Russian clinical guidelines right in ChatGPT and Claude Connect the WhiteCoat Pro connector, and the assistant will answer using the guidelines «Cryptorchidism in children» and other active Clinical Guidelines of the Russian Ministry of Health with references to the specific section, rather than retelling foreign guidelines. Address: mcp.pervoklassno.ru/mcp. How to configure ChatGPT, Claude, Gemini, and Perplexity for Russian Clinical Guidelines

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