A 3-day-old boy is being evaluated in the newborn nursery. The patient was born at 35 weeks gestation due to preterm prelabor rupture of membranes. The pregnancy and delivery were otherwise unremarkable. The workup for infection is negative. The patient is breastfeeding every 1-3 hours with adequate elimination. His parents have begun to give him a supplemental multivitamin. Length and weight are in the 25th percentile, adjusted for gestational age. Physical examination shows a sleeping newborn. The anterior fontanel is open, soft, and flat. Red reflexes are present bilaterally. The palate is intact. Cardiopulmonary examination is normal. The abdomen is soft with no organomegaly. Genitourinary examination shows an uncircumcised penis of normal length. The left testis is located within the inguinal canal, and the right testis is palpable in the scrotum. Which of the following is the best next step in management of this patient?

Question

A 3-day-old boy is being evaluated in the newborn nursery.  The patient was born at 35 weeks gestation due to preterm prelabor rupture of membranes.  The pregnancy and delivery were otherwise unremarkable.  The workup for infection is negative.  The patient is breastfeeding every 1-3 hours with adequate elimination.  His parents have begun to give him a supplemental multivitamin.  Length and weight are in the 25th percentile, adjusted for gestational age.  Physical examination shows a sleeping newborn.  The anterior fontanel is open, soft, and flat.  Red reflexes are present bilaterally.  The palate is intact.  Cardiopulmonary examination is normal.  The abdomen is soft with no organomegaly.  Genitourinary examination shows an uncircumcised penis of normal length.  The left testis is located within the inguinal canal, and the right testis is palpable in the scrotum.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d6dc_e365_bc81_ebbcb123f29e_MD0003_00 Cryptorchidism, or an undescended testis, is due to failure of in utero testicular descent from the abdomen into the scrotum. Risk factors include prematurity, small for gestational age, and low birth weight (<2.5 kg). At birth, boys with cryptorchidism typically have an empty, poorly rugated scrotum. The testis may be palpable in the inguinal canal, as seen in this patient, or undetectable. empty, poorly rugated scrotum Because the cryptorchid testis often descends spontaneously in the first few months of life, monitoring for testicular descent is appropriate for this patient with unilateral cryptorchidism. However, testes that have not descended by age 6 months are unlikely to descend and require surgical intervention. Orchiopexy (surgical pinning of the testis) is performed, ideally before age 1, to reduce complications associated with cryptorchidism such as testicular torsion, infertility, and testicular malignancy. (Choices A and C) Bilateral nonpalpable testes are concerning for a disorder of sex development, such as congenital adrenal hyperplasia (CAH). Workup includes karyotyping to distinguish a virilized genotypic female from an undervirilized genotypic male. In addition, electrolyte monitoring is required to evaluate for salt-wasting CAH, which can result in a potentially fatal adrenal crisis. In contrast, this patient has unilateral cryptorchidism with a palpable testis in the inguinal canal. (Choice B) Immediate surgical correction is required for testicular torsion, which occurs with increased frequency in cryptorchid testes. Torsion of an undescended testis presents with inguinal pain and swelling (intracanalicular testis) or an acute abdomen (intraabdominal testis). In contrast, asymptomatic unilateral cryptorchidism, as seen in this patient, is not an emergency, and routine monitoring is appropriate. (Choice E) Increased local testosterone is required for testicular descent. Systemic testosterone therapy is not recommended because it does not sufficiently increase the local testosterone level. Educational objective: Unilateral cryptorchidism can be monitored until age 6 months, after which spontaneous descent is unlikely. In such a case, orchiopexy is indicated before age 1 to reduce the risk of testicular torsion, infertility, and testicular malignancy. References: Evaluation and treatment of cryptorchidism: AUA guideline. (http://www.ncbi.nlm.nih.gov/pubmed/24857650) Risk factors for cryptorchidism. (http://www.ncbi.nlm.nih.gov/pubmed/28654092) Cryptorchidism. (http://www.ncbi.nlm.nih.gov/pubmed/23493040)

A 3-Day-Old Boy Is Being Evaluated in the Newborn Nursery