Retractile Testis

Retractile testis is a normally descended testis that moves up out of the scrotum into the groin because of an overactive cremasteric reflex, and that can be manipulated back into the scrotum without tension and stays there at least temporarily. It is a normal variant, not a form of cryptorchidism.

• Typical age 4 to 10 years (cremasteric reflex strongest then); most resolve at puberty as testicular volume increases and the reflex weakens.
• A proportion (variable in reports, up to about a third) become "ascending testes": the testis stops staying in the scrotum and becomes an acquired undescended testis; this typically occurs between 4 and 11 years of age, so follow up is necessary.
• Retractile testes retain normal fertility and have no increased cancer risk if they remain in the scrotum; ascending testes carry the same risks as undescended testes (reduced fertility, torsion, malignancy).
• Triggers for retraction: cold, touch, anxiety, examination, exercise.

• Parents report that one or both testes are sometimes in the scrotum (for example in a warm bath) and sometimes not.
• On examination in a warm room, with the child relaxed and warm hands, in supine and squatting or sitting cross legged position: the testis can be milked from the groin to the scrotum, remains there without tension at least briefly, is of normal size and consistency. Scrotum is well developed.
• Features that suggest undescended or ascending testis: testis cannot be manipulated to the scrotum, returns immediately like a "yo yo" with tension, smaller testis than the opposite side, underdeveloped hemiscrotum.
• Red flags: absent testis, testis stuck above the scrotum, a hernia or hydrocele, hypospadias, abnormal genitalia, a testis that becomes progressively higher, small or soft testis, sudden scrotal pain (torsion).

• Clinical examination by an experienced clinician. Record testicular position and size at each visit.
• Imaging is generally not helpful. Ultrasound can locate a testis in the groin but does not change management.
• Hormonal evaluation (LH, FSH, testosterone, anti-Mullerian hormone) and genetic tests only for bilateral impalpable testes or associated disorders of sex development.

• Reassure parents that this is normal. Explain the signs of torsion (sudden severe testicular pain, vomiting, swelling), which need emergency care.
• Annual examination by a clinician until puberty (every 6 to 12 months) to detect ascent. Teach the family and, when appropriate, the older child.
• Refer to a paediatric surgeon or urologist if: testis cannot be manipulated into the scrotum or does not stay there; a previously retractile testis no longer stays in the scrotum; the testis becomes smaller; a hernia is present; or parents or clinicians are uncertain.
• Surgery (orchidopexy) for an ascending testis, ideally before puberty and preferably between 6 and 18 months for congenital undescended testes. Hormonal therapy with human chorionic gonadotropin or GnRH analogues is not recommended for retractile testis.
• Adolescents and adults: teach testicular self-examination from puberty.