Palpable and Non-Palpable Testicle: The Most Important Distinction at Examination

In roughly four out of five cases of undescended testicle, the testicle can be felt on examination; in one out of five, it cannot. These two groups differ not only in location but also in the path that follows. For a palpable testicle, what needs to be done is largely clear from the examination room; for a non-palpable testicle, the first question that must be answered is whether the testicle exists at all.

The examination is performed in a warm room, with the child calm and, if possible, with warmed hands; cold and anxiety trigger the cremasteric reflex, pulling the testicle upward and giving a misleading result. Infants are examined lying on their back; older children are examined lying on their back and, if needed, sitting cross-legged, since the cross-legged position reduces the reflex.

• Can the testicle be felt, and if so, where (inguinal canal, canal exit, above the scrotum, ectopic location)?
• Can it be brought down into the scrotum, and does it stay there once released?
• How do its size and consistency compare with the other testicle?
• Is the other testicle noticeably enlarged?
• Is there an accompanying inguinal hernia, hydrocele, or penile finding?

A palpable testicle is most often located in the inguinal canal; some are found in a "low" position at the canal's outer exit or just above the scrotum, and a small number are in an ectopic location. The location determines which incision is used: inguinal orchiopexy (through a groin incision, fixing the testicle in the scrotum) is standard for a testicle in the inguinal canal; for selected testicles that are close to the scrotum and can be brought down easily, scrotal orchiopexy through a single scrotal incision is possible.

If the testicle is not palpable, there are three possibilities: the testicle is inside the abdomen; the testicle is in the groin but is not felt on examination because it is small, due to the child's weight, or due to muscle contraction; or the testicle does not exist, having been lost before birth due to a circulation problem (vanishing testis), leaving behind only a small remnant (nubbin). The literature reports that roughly half of non-palpable testicles are located within the abdomen, with the rest either found in the groin or absent altogether.

Combining diagnosis and treatment in the same session for a non-palpable testicle is important so that the child does not need a second anesthesia. The path forward is determined in the same session, based on what is seen during laparoscopy; in our practice, this decision is made through the joint assessment of two specialists. All scenarios are discussed in advance during the consent conversation.

• Testicle became palpable under anesthesia: standard inguinal or scrotal orchiopexy
• Testicle in the abdomen, vessels adequate: descent with laparoscopic orchiopexy in the same session
• Testicle just beside the internal ring (peeping testis): usually brought down in a single stage
• Vessels entering the inguinal canal: the groin is opened; a viable testicle is brought down, or a remnant (nubbin) is removed
• Vessels ending blindly within the abdomen: vanishing testis; there is no testicle to bring down
• Testicle very high up, vessels short: a staged approach (Fowler–Stephens or Shehata) is planned

• At the end of surgery, families are clearly told whether the testicle was found, where it was, and what was done; the findings are documented and form the basis for long-term follow-up.

Bringing your child to the examination well-fed, rested, and calm improves the accuracy of the exam. Notes from previous examinations, especially information such as "testicle was in the scrotum" or "could be felt," help distinguish whether the condition is congenital or an ascending testicle. Bring any previous ultrasound if one was done; if not, there is no need to have one done specifically for this visit.

• It is also helpful to observe at home, during bath time, whether the testicle appears in the scrotum. After the examination, you will be clearly told which group applies to your child and what that means.