SA Journal of Radiology

ISSN: (Online) 2078-6778, (Print) 1027-202X

Page 1 of 6 Pictorial Essay

Abnormal descent of the testis and its complications:

A multimodality imaging review

Authors: Cryptorchidism refers to an absence of the testis in the scrotal sac. Testicular descent occurs in two
Pankaj Nepal1
stages: transabdominal and gubernacular. The descent of the testis can be arrested in its usual path
Devendra Kumar2
Vijayanadh Ojili3 of descent (true undescended testis) or can migrate from the usual path of descent (ectopic testis).
Localising the missing testis is important for surgical planning, as well as for identification of
Affiliations: complications that are more common with cryptorchidism. Ultrasound is the initial imaging
1
St. Vincent’s Medical Center,
modality to visualise, as well as localise the testis in cryptorchidism. However, ultrasound imaging
Connecticut, United States
is limited in visualising testes that are not superficial in location. This article highlights various
Hamad Medical Corporation,
2 examples of abnormal descent of the testis in usual as well as unusual locations and complications
Doha, Qatar of undescended testes. Further evaluation with computed tomography scan or magnetic resonance
imaging is needed in indeterminate cases and for identification of complications. We have
3
Department of Radiology, highlighted the role of specific modalities with imaging findings in this pictorial review for the
University of Texas Health,
San Antonio, United States
appropriate selection of each modality in clinical practice.

Corresponding author:
Pankaj Nepal,
pankaj-123@live.com
Introduction
An absence of the testis in the scrotal sac is defined as cryptorchidism. The true undescended
Dates: testis has arrested migration along its usual path of descent, or it is termed ectopic testis when it
Received: 10 June 2018 migrates from its usual path of descent to lie in an unusual location. An atrophic or congenital
Accepted: 31 July 2018
Published: 27 Sept. 2018 absence of the testis may simulate a similar situation. In infants, correct localisation of the testis is
essential for surgical management, because the approach may vary with the location. In adults,
How to cite this article: however, it is still important to localise the testes and identify the complications.
Nepal P, Kumar D, Ojili V.
Abnormal descent of the
Undescended testes are seen in approximately 1% – 6% of newborn males. The incidence is even
testis and its complications:
A multimodality imaging higher in preterm infants, reported at 30%.1 Most undescended testes migrate into the lower
review. S Afr J Rad. 2018; scrotum within the first 3 months of life, probably as a consequence of a postnatal surge of
22(1), a1374. https://doi. testosterone. Only in less than 1% of the cases does the testis remain persistently undescended by
org/10.4102/sajr.v22i1.1374 the age of 1 year.1 Cryptorchidism occurs four times more commonly unilaterally than bilaterally.
Copyright:
© 2018. The Authors. Around 70% of undescended testes are palpable on clinical examination. Clinically, it can
Licensee: AOSIS. This work sometimes be difficult to distinguish an undescended testis from a retractile testis, which is
is licensed under the excessively mobile.2
Creative Commons
Attribution License.
Discussion
In 80% of patients with cryptorchidism, the testis is manually palpable in the inguinal canal.3 The
normal course of testicular descent is retroperitoneally from the inferior pole of the kidney to the
scrotum.4 The testis shares its embryological development with the kidney, and thus, it initially
develops in the upper abdomen and migrates towards the inguinal canal through the deep
inguinal ring after 21 weeks of gestation. The migration is almost complete at 30 weeks of
gestation. Various factors influence the descent: hormones, including gonadotropins and
testosterone, as well as active migration of the gubernaculum, determine its final position. The
gubernaculum is the ligament that connects the developing testis to the scrotum and is responsible
for inguinoscrotal descent. Under the influence of hormones (e.g. testosterone), the gubernaculum
contracts and the testis descends into the scrotum. The gubernacular phase is more prone to error,
whereas the transabdominal phase of arrest accounts for 5% – 10% of cases. On imaging,
cryptorchidism can be broadly divided into two groups: arrested descent or ectopic testes.

Read online:
Scan this QR Arrested descent
code with your
smart phone or Descent of the testes is along the normal path, but incomplete. The testis may be located in the
mobile device inguinal canal (80%), near the pubic tubercle or, uncommonly, in the abdomen. The testis is often
to read online.
small and abnormal with a short spermatic cord.

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 Page 2 of 6 Pictorial Essay

True Ectopic

Prepenile
Abdominal
Superficial
ectopic
Inguinal
Transverse
scrotal
Suprascrotal Femoral

Perineal

Cryptorchidism
Note: The size and echotexture of the testes are normal. Tracking of the undescended testis
Source: Cryptorchidism. The Origin, the Cure [image on the Internet]. [cited 2017 Feb 2017]. is performed along the common femoral vessels (white arrow), described as the ‘tracking
Available from: http://tophealthnews.net/cryptorchidism the cord technique’. Note the presence of a hydrocele in the persistent processus vaginalis
(black arrow).
FIGURE 1: The most frequent locations of true and ectopic undescended testis.
FIGURE 2: Greyscale ultrasound in a 6-month-old infant showing an undescended
testis in the right inguinal canal (star).
Ectopic descent
Descent of the testes is away from the normal path. The testis
is most often found in the superficial inguinal pouch. Other
uncommon locations are perineal, abdominal wall, pelvic,
crural, penile and femoral. The testis and spermatic cord are
usually normal. Most frequent locations to aid a directed
search for the testicles are shown in Figure 1.6

Imaging modalities
The purposes of imaging are to correctly localise the testis
and assess viability and size (assess for atrophy). The aim is
also to detect cases of vanished testis or agenesis. Ultrasound
is an initial imaging modality to localise the testes, as well as
to assess vascularity on colour Doppler imaging. If the testis
Note: A superficial ultrasound image demonstrates a small ectopic testis along the rectus
is not identified in the scrotum on ultrasound, then the sheath (*). The ectopic testis shows peripheral vascularity on colour Doppler imaging (bold
‘tracking the cord’ technique is useful.5 Starting below the white arrow), indicating viability.

inguinal crease, the common femoral artery and vein can be FIGURE 3: Sagittal ultrasound image of the left upper abdomen with a linear
probe in a 2-year-old male child with left cryptorchidism.
traced with the ultrasound probe in the transverse axis
(Figure 2). The spermatic cord is identified in the inguinal
Cross-sectional imaging modalities like computed tomography
canal, seen as an oval echogenic structure, anteromedial to
(CT) scans and magnetic resonance imaging (MRI) are used
the common femoral vessels. The common iliac and internal
in indeterminate cases on ultrasonography, as well as in the
iliac vessels can then be traced cranially up to the bifurcation
assessment of complications. The testes appear hypodense
of the aorta to look for an abdominal testis. A superficial scan
on CT, and it may be difficult to differentiate them from
of the iliac fossa and pelvis is also performed to search for the
lymph nodes or small cystic structures. CT scan involves
testes.
significant radiation and raises concerns regarding the
Ultrasound is particularly useful in visualising superficially radiation dose as the majority of imaging for cryptorchidism
localised testes in the inguinal canal, inguinal pouch and occurs in the paediatric age group. CT scan is, however,
subcutaneous location. Ultrasound has approximately superior in evaluating and staging known cases of testicular
40%–50% sensitivity, 70%–80% specificity and around 88% malignancy.
accuracy for localisation of an undescended testis.7 It has
superior resolution in demonstrating the superficial location Magnetic resonance imaging has a higher sensitivity of
of testes, such as along the rectus sheath, inguinal canal or approximately 90% and specificity of almost 100% in
perineum. Colour Doppler imaging is excellent in localising the testes compared to ultrasound.9 Plain and
demonstrating vascularity within the testes (Figure 3). The contrast-enhanced Coronal T1-weighted (T1W) MRI can
limited accuracy of ultrasound is because of difficulty in differentiate the gubernaculum, testes and spermatic cord.
visualising intra-abdominal, pelvic, retroperitoneal or ectopic The spermatic cord can be followed to locate the undescended
testes (20%).8 Another limitation of ultrasound is failure to testes. The ectopic, pelvic or retroperitoneal location of the
differentiate an atrophic testis from a lymph node or the testes can be easily identified (Figure 4). The testis normally
gubernaculum. appears hyperintense on T2-weighted (T2W) MRI. Recently,

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a b

Note: The testes are normal size and show normal hyperintense signal on T2W imaging (a) and hypointense signal in T1W axial imaging (b).
FIGURE 4: (a) Coronal T2-weighted (T2W), (b) T2W axial and (c) T1-weighted (T1W) axial magnetic resonance images in a 12-month-old male with bilateral undescended
testes, demonstrating ectopic testes at the superficial inguinal ring (white arrows).

a b

FIGURE 5: (a) Coronal and (b) axial T2-weighted (T2W) magnetic resonance images in 9-month-old male child showing true undescended right testis (star) at the level of
the root of penis, near the pubic tubercle (black arrow). The crura of the penis are seen at this level (circles). The inguinal canal (white arrow) is well visualised on coronal
section.

diffusion-weighted MRI has been used to show a markedly testes suffer a progressive loss of germ cells as well as
hyperintense signal within testes, which helps to differentiate Leydig cells.11 Prepubertal orchidopexy addresses the issue
it from lymph nodes and surrounding structures.10 Contrast- of infertility, and there has been worldwide evidence that it
enhanced MRI is also better for visualisation, demonstrating may decrease the risk of testicular cancer in children with
testicular enhancement, which is also indicative of viability cryptorchidism.12
(Figures 4, 5, and 6).
Imaging algorithm
If until the age of 6 months (corrected for gestational age) a Seventy per cent of undescended testes are palpable
testis has not descended, surgery should be performed manually, and in the remaining 30% of non-palpable
within the subsequent year, preferably by the age of 18 undescended testis, the current algorithm is to perform
months. Histological examination proves that undescended abdominal-scrotal ultrasound first. Ultrasound is sensitive

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a b

Note: The homogenous enhancement signifies viability, and surgery was performed in this patient with a successful outcome.
FIGURE 6: Use of contrast-enhanced imaging in a 7-month-old male with an undescended left testis: (a) Coronal T2W image shows a true undescended testis in the left
iliac fossa (bold white arrow). (b) Axial post-contrast subtraction image confirms a homogenously enhancing undescended left testis (bold arrow).

in visualising testes in the inguinoscrotal region or localised

to the superficial abdomen wall and perineum. If the Is the tess palpable
ultrasound findings are non-diagnostic, the next imaging manually ?

modality is MRI. CT is non-invasive but is unreliable in YES NO

identifying the testes and carries the risk of radiation. As
per international guidelines from the American Association USG scrotum +/-
Ambiguous genitalia
of Urology (2014), imaging in cryptorchidism is currently Hypospadias abdomen
Previous surgery
advocated as an adjunct. According to their guidelines, Small size testes Tess viable: YES
diagnostic laparoscopy or open exploration must be Orchidopexy
Tess visualized
performed on all non-palpable cryptorchid patients.13 This Tess atrophic:
Orchidectomy NO
should, however, take into account the local expertise and USG/MRI
practice available. Viable and normal size undescended MRI abdomen +
contrast
testes are treated with orchidopexy, depending upon DWI MRI
expertise, with laparoscopy or an open surgical approach. A
small and atrophic intra-abdominal testis can be treated MRI, magnetic resonance imaging; DWI MRI, Diffusion-weighted magnetic resonance
imaging; USG, Ultrasound.
with orchiectomy.
FIGURE 7: Imaging algorithm in undescended testis.

Preoperative localisation of the testis definitely aids in

surgical planning and approach.14 It may reduce the extent of
Complications
exploration and time for anaesthesia. Accurate pre-surgical Complications of undescended testes include an increased
localisation of the testis can provide the surgeon with the incidence of infertility, trauma, malignancy, torsion, other
anatomic knowledge to tailor the operative approach. MRI associated anomalies, as well as inguinal hernia. Although
has almost 100% specificity in identifying and localising the there has been dispute regarding orchiopexy reducing the
testes. Laparoscopy and surgery are difficult in children who risk of testicular cancer, it certainly increases the detection of
have had previous inguinal or scrotal surgery because of malignancy through testicular self-examination.15 The
scarring, increased risk of injury and reduced mobility of the incidence of testicular malignancy among men with an
spermatic cord. Cryptorchidism associated with ambiguous undescended testicle is approximately 1 in 1000–2500, which
genitalia or hypospadias also need mandatory imaging to is certainly higher than the normal population. Testicular
evaluate for the presence of Mullerian structures. The authors malignancy has been reported in 10% – 15% of patients with
feel that this topic has not received much attention in the undescended testes16 (Figures 8 and 9).
literature recently. This then begs the question that in the
absence of visualisation of testes with MRI, is it logical to If a testicle is located in the inguinal location, it might be
undergo surgery? Further research into the role of imaging in prone to trauma or pressure against the pubic bone because
undescended testis is necessary before concluding imaging of its superficial location (Figure 10). The incidence of
just as an adjunct. A simple imaging algorithm for testicular torsion is thought to be higher in undescended
cryptorchidism has been designed by the authors and testes than in normal scrotal testes.11 Torsion of an
illustrated in Figure 7. undescended testis can be attributed to the development of

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Note: A CT scan performed to exclude nephrolithiasis revealed a well-defined, densely

calcified mass in the mesentery (bold white arrow). Retrospective clinical examination
revealed an empty right hemiscrotum. The mass was surgically removed and proved to be a
germ cell tumour within an ectopic testis at postoperative histopathology.
FIGURE 8: Coronal non-contrast computed tomography abdomen of a 35-year- FIGURE 9: A 30-year-old male patient with a left-sided undescended testis:
old male who presented to the emergency department with right flank pain. (a)  Ultrasound imaging in the left inguinal location showed an atrophic and
echogenic testis (bold white arrowhead). Postoperative findings were consistent
with testicular non-seminomatous germ cell tumour and epididymis disjunction.
(b) Contrast computed tomography for systemic work-up revealed necrotic
a testicular tumour, increasing the weight and distorting the heterogeneous lymph nodal metastasis (bold white arrow) in the left para-aortic
normal anatomy of the organ. Torsion of an intra-abdominal location, which regressed after chemotherapy.
testicle may present as an acute abdomen. Inguinal hernias
may be associated with the cryptorchidism17 (Figure 11).

Conclusion
Clinicians and radiologists should be aware of the
chronology of normal testicular descent, the common and
uncommon locations of cryptorchidism, the specific
imaging approach, as well as the complications associated
with undescended testes.

Acknowledgements Note: Ultrasound imaging revealed a left undescended testis in the inguinal region which
demonstrated an ill-defined hypoechoic area (bold white arrow) in the upper pole and
The authors would like to thank Dr Devendra Kumar, absent testicular vascularity on colour Doppler imaging. The findings were consistent with
testicular fracture.
Consultant, Hamad Medical Corporation, for his contribution FIGURE 10: A 15-year-old boy with trauma to the inguinal region presented to
the emergency department.
of images.

Authors’ contributions
Competing interests
P.N. was responsible for cases collection and writing of
The authors declare that they have no financial or personal the manuscript. V.O. was responsible for editing of the
relationships which may have inappropriately influenced manuscript and study design and D.K. contributed towards
them in writing this article. the images and case collection.

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a b c

FIGURE 11: A 30-year-old male presented to the emergency department with pain in the right inguinal region with a large inguinoscrotal hernia on clinical examination:
(a) Coronal and (b) sagittal images of a computed tomography abdomen demonstrated an undescended testis (arrow on image a) along its path in the right lower
abdomen, located lateral to the surface of urinary bladder (U). There was an associated large right omental hernia (arrow on image b). (c) The undescended testis is
hyperintense (arrow on image c) on axial T2-weighted magnetic resonance images.

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