1. EVIDENCE BASED MEDICINE Intern 胡鈺薇 Clerks 劉郁軒 指導老師 : 駱至誠 醫師

2. CLINICAL SCENARIO A mother brings a 3 year-old boy with retractile testes came to OPD for help Question: Do the benefits of surgery outweigh than observation?

3. BACKGROUND KNOWLEDGE  Definition a testicle that may move back and forth between the scrotum and the groin. When the retractile testicle is residing in the groin, it may be easily guided by hand into its proper position in the scrotum — the bag of skin hanging behind the penis — during a physical examination.

4. BACKGROUND KNOWLEDGE  Signs and symptoms The testicle may be moved by hand from the groin into the scrotum and won't immediately retreat to the groin. It may spontaneously appear in the scrotum and remain there for a time. It may spontaneously disappear again for a time.

5. BACKGROUND KNOWLEDGE  Complications Testicular cancer. Testicular cancer usually begins in the cells in the testicle that produce immature sperm. What causes these cells to develop into cancer is unknown. Men who have had an undescended testicle have a greater risk of testicular cancer. Fertility problems. Low sperm counts, poor sperm quality and low fertility rates are more likely among men who have had an undescended testicle. Testicular torsion. Testicular torsion is the twisting of the spermatic cord. This painful condition cuts off blood to the testicle. If not treated promptly, it may result in the loss of the testicle. An undescended testicle increases the risk of testicular torsion.

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8. ASK A child with retractile testis P Surgical intervention I Conservative treatment C Prognosis and complications O

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10. ACQUIRE Database: medline Keywords: retractile testis

14. THE EVIDENCE PYRAMID

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16. OXFORD CENTRE FOR EBM LEVELS OF EVIDENCE

17. Level: IV CASE SERIES

19. RESULT The 150 boys, total number of retractile testes : 205 average age : 5.2 +- 3.0 years (median, 4.7 ). Follow-up duration : 3.8+- 3.0 years (median, 3.0 ), with 6 patients followed up with past age 14 years. right-sided for 58 patients, left-sided for 37, and bilateral for 55 (36.7%); 6 patients (4%)had an associated contralateral undescended testis (3 on the right and 3 on the left).

20. THE RETRACTILE TESTES POSITIONS AND CORD TENSIONS ARE REPORTED IN TABLE 1.

21. THE INDICATION FOR SURGERY IN THIS SERIES 1. the retractile testis ascended and became cryptorchid in 34 cases 2. testicular size decreased during follow-up(3 cases) compared with the contralateral testis or with a previous examination. Ps. Among the patients still in follow up, 3 patients (2%) may require surgery in the future because of persisting moderate spermatic cord tension. In this study, 37 testes (18.0% of all retractile testes) required surgery in 34 patients (22.7% of all patients) at an average age of 8.7 3.0 years

22. THERE IS A POSITIVE RELATIONSHIP BETWEEN ORCHIDOPEXY REQUIREMENT AND INCREASED CORD TENSION (X; P <.001).

23. orchidopexy was required more frequently( P <.001) in patients with an associated hernia (68.8% of cases) than in patients without hernias (9.2%).

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27. DISCUSSION Why retractile testes occurred? – Genitofemoral nerve(L1-L2) stimulated. – Absent at birth, becomes active at about 3 months of age, present in neurologically normal children after the age of 2 years. Does hCG treatment improve the situation? – hCG treatment is inefficient in this series(hCG treatment was attempted in 2 patients, 1 case succeed, 1 case have only 1 testis descended.

28. DISCUSSION In this paper, the author mentioned about patients with retractile testes should closely follow up to check the testes’ condition, so we want to know how many percentage did these patients have undescended testes?

29. DISCUSSION Stec AA, et al. Incidence of testicular ascent in boys with retractile testes. Journal of Urology. 2007;178:1722. Result: This set of boys initially had a total of 392 involved testes, of which 2 underwent orchiopexy elsewhere before resolution. The incidence of secondary ascent was 3.2% in the combined set of patients.

30. CONCLUSION The results of this case series suggest that the majority of patients (77.3%) with retractile testes have a spontaneously favorable evolution by 14 years of age and do not require surgical treatment. Patients with retractile testes should be followed up to detect increased either spermatic cord tension or decreased testicular volume.

31. Thank you for your attention!