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Prof. Dr. Ali Avanoğlu
Undescended Testicle • Diagnosis and evaluation

Bilateral Non-Palpable Testicle: Hormonal and Genetic Evaluation

Both testicles being non-palpable is a different topic from unilateral undescended testicle. Here the first question isn't 'where are the testicles' but 'is there testicular tissue, and is it functioning' — so hormonal, and if needed genetic, evaluation is carried out before surgery. This page explains why and how, in plain language.

Who this is forFamilies of infants and children in whom neither testicle is palpable
Reading≈6 min
ByProf. Dr. Ali AvanoğluUpdated
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inside the abdomen · bilateral
01 · Why is a bilateral case approached differently?02 · What does the hormonal evaluation look at?03 · Genetic evaluation and the possibility of DSD04 · The role of imaging and laparoscopy05 · Treatment and the long term: why closer follow-up?
In brief5 madde
  • Why is a bilateral case approached differently?: Roughly one-third of undescended testicle cases are bilateral; however, cases where neither testicle is palpable are a smaller subgroup within that and require…
  • What does the hormonal evaluation look at?: The goal is to demonstrate the presence of functioning testicular tissue through blood tests.
  • Genetic evaluation and the possibility of DSD: If neither testicle is palpable — especially with a difference in penile structure or hypospadias present — chromosome analysis (karyotype) is performed.
  • The role of imaging and laparoscopy: Imaging, not recommended in unilateral cases, can gain a limited role in bilateral non-palpable testicle: abdominal and pelvic ultrasound may be requested to assess…
  • Treatment and the long term: why closer follow-up?: In bilateral cases, early surgery matters even more, because reproductive potential is directly related to how long both testicles spend in a warm environment.
01

Why is a bilateral case approached differently?

Roughly one-third of undescended testicle cases are bilateral; however, cases where neither testicle is palpable are a smaller subgroup within that and require special attention. In a unilateral non-palpable testicle, if the other testicle is healthy, hormonal balance is preserved; when neither testicle is palpable, that safety net doesn't exist.

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  • Two key reasons make this evaluation necessary. First, the possibility that testicular tissue is entirely absent, or that both testicles have been lost (anorchia), needs to be ruled out — this is information that should be known before proceeding to laparoscopy. Second, bilateral non-palpable testicle can, rarely, be part of a broader picture called a difference of sex development (DSD).
  • For this reason, the guidelines recommend that pediatric endocrinology, and genetics when needed, join the evaluation early alongside pediatric urology in bilateral non-palpable testicle. When identified in the newborn period, this evaluation should take place within the first days and weeks.
02

What does the hormonal evaluation look at?

The goal is to demonstrate the presence of functioning testicular tissue through blood tests. The testicle produces hormones through two groups of cells: Leydig cells produce testosterone, while Sertoli cells secrete inhibin B and AMH (anti-Müllerian hormone). Measurable levels of these hormones strongly indicate that testicular tissue exists somewhere.

  • Testosterone, LH, FSH (baseline during mini-puberty; with hCG stimulation afterward)
  • Inhibin B and AMH: direct markers of Sertoli cell presence
  • Electrolytes and adrenal hormones if needed (in certain DSD presentations)
  • Karyotype and, if needed, additional genetic testing
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  • In the first months of life, infants undergo a natural hormone surge (a 'mini-puberty'); during this window, measuring testosterone, LH, FSH, inhibin B, and AMH is informative. Once this window closes, the testicles may need to be stimulated: in the hCG stimulation test, one or a few doses of hCG are given and the testosterone response is measured. A rise in testosterone suggests functioning testicular tissue exists, while no rise at all, together with clearly elevated FSH/LH, suggests the absence of testicular tissue.
  • Because inhibin B and AMH show the presence of Sertoli cells without needing stimulation, they've been used increasingly in recent years; undetectably low AMH and inhibin B combined with elevated gonadotropins are interpreted in favor of anorchia. Results are interpreted together, not from a single test, and in the context of the child's age; the decision is made jointly with pediatric endocrinology.
03

Genetic evaluation and the possibility of DSD

If neither testicle is palpable — especially with a difference in penile structure or hypospadias present — chromosome analysis (karyotype) is performed. The purpose of this step isn't to alarm the family, but to catch rare but important conditions early. In the great majority of cases the karyotype comes back as expected (46,XY), and the picture remains 'undescended testicle only.'

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  • However, the combination of bilateral non-palpable testicle with hypospadias is one the guidelines say 'should be considered a DSD until proven otherwise.' This means carefully examining the testicular tissue and internal reproductive structures, completing the hormone profile, and requesting additional genetic testing if needed. This workup most often ends reassuringly; rarely, it reveals information that changes the treatment plan, and it's important for the child that this is known before surgery.
  • Throughout this process, an open, calm, and respectful conversation is maintained with the family. What's being done is gathering the information needed to understand the testicles' status and to protect future reproductive and hormonal function.
04

The role of imaging and laparoscopy

Imaging, not recommended in unilateral cases, can gain a limited role in bilateral non-palpable testicle: abdominal and pelvic ultrasound may be requested to assess the internal reproductive structures. However, ultrasound or MRI is still not reliable for 'searching' for the testicles; the definitive answer comes from laparoscopy.

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  • Once hormone tests show functioning testicular tissue is present, examination under anesthesia and diagnostic laparoscopy are planned; both sides are assessed in the same session. If both testicles are found inside the abdomen, they're usually brought down either in the same session or in two planned stages; rather than starting a staged approach on both sides at once, completing one side first may be preferred. These decisions are made through the joint evaluation of two pediatric urologists.
  • Even when hormone tests suggest an absence of testicular tissue, many centers still prefer to confirm this with laparoscopy; even a small remaining piece of tissue can later require a decision about monitoring or removal.
05

Treatment and the long term: why closer follow-up?

In bilateral cases, early surgery matters even more, because reproductive potential is directly related to how long both testicles spend in a warm environment. While paternity rates are close to the general population after a unilateral history, they drop noticeably after a bilateral one; the 6–12-month window the guidelines recommend should be carefully protected in this group.

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  • Hormone therapy (hCG or GnRH) is not routinely recommended to bring a testicle down in unilateral undescended testicle; in bilateral cases, however, postoperative endocrine therapy to support reproductive potential may be considered in selected situations. This isn't a rule but an individual decision made jointly by pediatric urology and endocrinology.
  • Follow-up is more frequent than in unilateral cases: testicular growth, pubertal development, the hormone profile at puberty, and, if needed, semen analysis are all addressed. In this team, follow-up continues with the same physicians from pediatric urology into adult urology; it's especially important for young men with a bilateral history to undergo one more detailed evaluation after puberty and to learn self-examination.
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Frequently asked questions
If neither testicle is palpable, is surgery done right away?
No. Hormonal, and if needed genetic, evaluation comes first; once functioning testicular tissue is demonstrated, examination under anesthesia and laparoscopy are planned. The order matters — surgery is planned according to the age window the guidelines recommend, without rushing but also without delay.
Does the hCG stimulation test bother the baby?
It involves one or a few intramuscular injections followed by a blood draw; aside from brief discomfort, there's no other effect. During the natural hormone window in the first months, baseline measurements are sometimes enough without needing the stimulation test.
Does requesting a karyotype mean our baby's sex is uncertain?
No. Karyotype is a standard test performed in bilateral non-palpable testicle to rule out rare but important conditions, and in the great majority of cases it comes back as expected. Results are discussed with you calmly and openly.
Does bilateral undescended testicle prevent having children?
Reproductive potential is noticeably reduced after a bilateral history compared with a unilateral one; however, with early surgery, endocrine support when needed, and good follow-up, many men are able to become fathers. A definitive assessment is made in adulthood with semen analysis and hormone profiling.
If hypospadias is also present, how does the process change?
When bilateral non-palpable testicle occurs together with hypospadias, pediatric urology, endocrinology, and genetics evaluate the child jointly. The order and timing of testicular surgery and hypospadias repair are planned based on the outcome of this evaluation.
Prof. Dr. Ali Avanoğlu's publications on this topic · 2
  1. Şentürk Pilan B, Özbaran B, Çelik D, et al. (2020). Psychiatric view for disorders of sex development: a 12-year experience of a multidisciplinary team in a university hospital. Journal of pediatric endocrinology & metabolism. PubMed ↗
  2. Korkmaz Ö, Özen S, Özcan N, et al. (2017). Persistent Müllerian Duct Syndrome with Transverse Testicular Ectopia: A Novel Anti-Müllerian Hormone Receptor Mutation. Journal of clinical research in pediatric endocrinology. PubMed ↗
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Related pagesFull index →
BasicsUnilateral and Bilateral Undescended TesticleAbout one-third of undescended testicle cases are bilateral, and this distinction changes the treatment plan. In a unilateral case, the other testicle is healthy and the paternity rate is close to that of the general population; in a bilateral case, both testicles are affected, so reproductive potential is more significantly affected, and hormonal evaluation and early surgery become even more important.Surgery in childrenHormone Therapy‘Can’t it be brought down with an injection or a spray?’ is one of the questions families ask most often. Hormone therapy (hCG or GnRH) is not routinely recommended for bringing down a unilateral undescended testicle; success rates are low, and the testicle often retracts again. In bilateral and selected cases, it is a separate matter, evaluated together with endocrinology to support reproductive potential.Special situationsUndescended Testicle and Hypospadias TogetherUndescended testicle and hypospadias (in which the urinary opening is located on the underside of the penis rather than at its tip) can occur together in the same child. In most cases, the two conditions are independent of one another; however, when proximal (more posteriorly located) hypospadias occurs together with a non-palpable testicle in particular, an additional evaluation is carried out before surgery, and treatment is managed by a team that plans both conditions together.Diagnosis and evaluationDiagnostic LaparoscopyDiagnostic laparoscopy (a minimally invasive procedure) is direct visualization of the inside of the abdomen through a thin camera introduced at the navel, and it's the only method that definitively answers both 'is there a testicle' and 'where' in a non-palpable testicle. This page explains how the procedure is performed and how the plan proceeds for every possible finding.
Undescended Testicle topic clustersMain treatment page →
Basics 7Diagnosis and evaluation 6Surgery in children 10Special situations 4After surgery 6Adolescents and adults 6Follow-up 3
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