International Journal of Clinical Case Reports 2017, Vol.7, No.4, 15-18
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undescended testicle, sometimes called a cryptorchid testicle, can be found in 3% of the term newborns and
0.5-1.0% of adults. (Longui, 2005) Cryptorchidism is more commonly seen in premature babies and associated
with genetic disorders in 10% of the cases. The common causes of cryptorchidism include premature birth, spina
bifida, hormonal disorders, testicular absence and/or, retractile testes. Jensen MS et al concluded that smoking
more than 10 cigarettes a day during pregnancy increased the risk of cryptorchidism. (Jensen et al., 2007)
Kaftanovskaya EM et al concluded that the second inguino-scrotal stage of testicular descent is clearly
androgen-dependent. (Kaftanovskaya et al., 2012) The diagnosis of cryptorchidism is made by physical
examination. The diagnosis of cryptorchidism should be considered when non-palpable testis and inguinal hernia
are present, although, each patient might experience the symptoms differently. Nonetheless, for inguinal hernia,
the clinical presentation varies, depending on the contents of the hernial sac and the degree of herniation. Because
of its varied presentation, clinical examination is often inconclusive. (Kassir et al., 2013) In our case, the diagnosis
of cryptorchidism was not arrived-at before carrying-out the surgical procedure as ultrasound abdomen was
normal in the pre-operative period. The correct diagnosis of inguinal hernia is usually made during an inguinal
hernia repair, although ultrasonography (USG) and computerized tomography (CT) have been used to identify an
inguinal hernia. (Tasian et al., 2011) Laparoscopy is useful for both diagnosis and treatment of atypical inguinal
hernias. (Mehendale et al., 2013; Kassir et al., 2013) The major complications of unrepaired cryptorchidism
mainly include testicular cancers, inguinal hernia, testicular torsion and infertility. The testicles begin to lose the
process of spermatogenesis if they are not in the scrotum possibly because of variations in temperature and other
conducive environmental factors. This process explains the link between cryptorchidism and infertility. Very little
is known, however, about the link between cryptorchidism and testicular germ cell tumor (TGCT) genesis. In our
case, despite the age, histopathological examination confirmed the absence of tumor. Because the incidence of
testicular cancer generally increases in cryptorchid testes, long-term follow-ups become mandatory. Usually,
cryptorchidism resolves without any intervention before the age of 6 months. Surgical repair for cryptorchidism is
carried-out if the testicles have not descended till this age and surgical intervention becomes mandatory. The
prognosis of cryptorchid testes is related to the precocity of the management. Most studies have concluded that
there is a direct correlation between how long the testis was subjected to a cryptorchid position and the testicular
germ cell tumor (TGCT) incidence. Pettersson A et al. demonstrated that individuals who had corrective surgery
after the age of 13 had an incidence rate of 5.4% whereas those who were treated before had an incidence rate of
2.23%. (Pettersson et al., 2007) In our case, we did not find a correlation between the time of surgery and risk of
TGCT incidence. As far as our case was concerned, histopathological examination confirmed a normal testis and
the presence of the Leydig cells and the seminiferous tubule without testicular germ cell tumor (TGCT). The
treatment of cryptorchidism improves the risks of infertility and gonadal neoplasia. Surgical repair for
cryptorchidism results in an early detection of an eventual tumor. It is difficult to understand the surgical anatomy
of inguinal hernias but once the surgical exploration is performed, surgical repair is uneventful. It is controversial
whether a contralateral orchidopexy is needed. Furthermore, the incidence of testicular cancer generally increases
in fixed testes. (Walsh et al., 2007) In our case, the contralateral orchidopexy was not performed. An alternative
therapeutic option is hormonal treatment with a series of injections of HCG (Human Chorionic Gonadotropin)
which stimulate the testis. Kjaer S. and Mikines K.J. concluded that there was no age dependency observed of the
HCG treatment effects though the position of the testis before treatment influenced the success rate. (Kjaer and
Mikines, 2006) This treatment is recommended if the testis is very close to the scrotum. Our case was notable
because of the unusual presentation of cryptorchid testis as an incarcerated inguinal hernia at the age of 60 years
and the patient remained asymptomatic for 60 years. To our knowledge, the present case represents the first case
of cryptorchid testis revealed at the age of 60 years with an inguinal hernia.
3 Conclusions
The surgeon must always be alert to the possibility of cryptorchid testis during a surgical exploration of an
inguinal hernia. In suspected cases, ultrasonography (USG) and computerized tomography (CT) as well as
laparoscopic evaluation may be helpful in diagnosing this atypical inguinal hernia before carrying-out the
requisite surgical procedure.
