Paeds · nephrology-urology-fluids-and-electrolytes
Hypospadias, cryptorchidism and common male genital disorders
Also known as Hypospadias · Cryptorchidism · Undescended testis · Orchidopexy · Retractile testis · Phimosis · Paraphimosis · Hydrocele · Inguinal hernia in infants · Testicular dysgenesis syndrome · Megameatus intact prepuce
Fellowship guide to hypospadias, cryptorchidism and the common male genital disorders of childhood. Covers the ectopic ventral urethral meatus and the hooded prepuce of hypospadias with its distal to proximal classification, the failure of testicular descent in cryptorchidism with the orchidopexy window of 6 to 18 months, the testicular dysgenesis syndrome that links the two, the absolute rule against circumcision in hypospadias, the distinction of the retractile from the truly undescended testis, the physiological from the pathological phimosis, and the communicating hydrocele and inguinal hernia that share a patent processus vaginalis, together with the urgent disorder-of-sex-development workup for the boy with bilateral non-palpable testes.
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Target exams
Red flags
- A newborn with bilateral impalpable testes, or hypospadias with an impalpable testis, that demands an urgent disorder-of-sex-development workup including karyotype and 17-hydroxyprogesterone to exclude congenital adrenal hyperplasia and salt-wasting crisis
- A hooded prepuce with a ventrally placed urethral meatus in any newborn that must never be circumcised because the dorsal foreskin is needed for the surgical reconstruction
- An undescended testis still present after six months of corrected age that will not descend spontaneously and requires surgical orchidopexy within the 6 to 18 month window to preserve germ-cell development and fertility
- Sudden severe scrotal pain in any boy that is testicular torsion until proven otherwise with a maximum six-hour window to salvage the testis
- A paraphimosis with a painfully swollen retracted foreskin and a constricting band behind the glans that is a urological emergency requiring prompt manual reduction
- An acute hydrocele in an older boy or a tense scrotal mass that cannot be reduced, raising the concern for an incarcerated inguinal hernia
Life stages
Care settings
Clinical exam formats
Board mappings
- Hypospadias as a ventral urethral meatus with a hooded prepuce and the absolute rule against circumcision
- Cryptorchidism and the orchidopexy window of 6 to 18 months after spontaneous descent becomes unlikely at 6 months
- The physiological phimosis and the non-communicating hydrocele that need reassurance rather than surgery
- Hypospadias classification from distal to proximal and the chordee that accompanies the proximal forms
- The palpable versus non-palpable undescended testis and the laparoscopic management of the non-palpable testis
- The disorder-of-sex-development workup for bilateral non-palpable testes or hypospadias with an impalpable testis
- Orchidopexy timing 6 to 18 months and the germ-cell maldevelopment that follows delay
- The retractile testis and acquired cryptorchidism and how each is followed
- Paraphimosis as the urological emergency and the reduction technique
- Short case: a newborn with a hooded prepuce and a ventral meatus
- Long case: a boy with an undescended testis and the fertility and cancer counselling
- Communication station on the no-circumcision rule and the plan for hypospadias repair
- Level 1: Recognition of hypospadias and the undescended testis on the newborn examination
- Level 2: Referral and correctly timed orchidopexy within the 6 to 18 month window
- Level 3: Coordination of urology and endocrinology for complex proximal hypospadias and bilateral non-palpable testes
- Hypospadias anatomy: meatal position, chordee and the hooded prepuce
- Cryptorchidism epidemiology and the two phases of testicular descent
- The testicular dysgenesis syndrome linking hypospadias, cryptorchidism, subfertility and testicular cancer
- Examination of the newborn genitalia and the assessment of testicular position
- Communication: explaining the no-circumcision rule and the timing of surgery to parents
- Recognition of the acutely painful scrotum and the paraphimosis
- Hypospadias and cryptorchidism: embryology, diagnosis and timing of surgery
- The undescended testis and the risk of infertility and malignancy
- Common scrotal swellings: hydrocele, inguinal hernia and varicocele
- Patient Care: newborn genital examination and the recognition of hypospadias and cryptorchidism
- Medical Knowledge: testicular descent and the rationale for early orchidopexy
- Systems-Based Practice: timely referral to paediatric urology within the evidence-based window
- Canadian approach to hypospadias and cryptorchidism with the 6 to 18 month surgical window
- Acquired undescended testis and the surveillance of the retractile testis
- Transition to adult care and lifelong testicular self-examination for the previously cryptorchid male
Overview & Definition
Three problems dominate the paediatric male genital examination at the newborn check and the infant clinic. The first is hypospadias, in which the urethral meatus opens on the undersurface of the penis rather than at the tip of the glans, almost always with a hooded prepuce that is deficient on its ventral aspect and often with a downward curvature of the shaft called chordee. [9] The second is cryptorchidism, the undescended testis, in which one or both testes fail to reach the bottom of the scrotum and come to rest somewhere along the line of normal descent or, less often, in an ectopic position. [1] The third is a group of common acquired disorders of the foreskin and the scrotal contents: the physiological and pathological phimoses, the paraphimosis, the communicating hydrocele, and the indirect inguinal hernia.
The reason these conditions are taught together is that hypospadias and cryptorchidism share an embryological and endocrine origin. Skakkebaek and colleagues proposed the testicular dysgenesis syndrome to explain why hypospadias, cryptorchidism, poor semen quality, and testicular germ-cell cancer have risen together over recent decades, attributing the cluster to disturbed gonadal development in fetal life under the influence of genetic susceptibility and environmental endocrine-disrupting chemicals. [7] A boy found to have both hypospadias and an undescended testis is therefore not a chance occurrence of two separate conditions but a signal that the whole genital tract developed abnormally, and that signal triggers a disorder-of-sex-development evaluation. [8]
The clinical task at the bedside is to detect these conditions on the newborn and infant examination, to distinguish the anomalies that need surgery from the variants that resolve on their own, and to time the surgical referral correctly. Two timing rules carry almost all of the examination marks. The foreskin of a boy with hypospadias must be preserved because it is the tissue used to reconstruct the urethra, so circumcision is absolutely contraindicated. [12] The undescended testis that has not reached the scrotum by six months of corrected age will not descend spontaneously, and orchidopexy between 6 and 18 months preserves the germ cells and the future fertility of that testis. [1] [3]
References12ShowHide
- [1]Kolon TF, Herndon CD, Baker LA, et al Evaluation and treatment of cryptorchidism: AUA guideline. J Urol, 2014.PMID 24857650
- [2]Skott M, Kennedy U, Gnech M, et al. European Association of Urology-European Society of Paediatric Urology Guidelines on Paediatric Urology: Summary of 2024 Updates. Eur Urol, 2025.PMID 40118740
- [3]Batra NV, DeMarco RT, Bayne CE A narrative review of the history and evidence-base for the timing of orchidopexy for cryptorchidism. J Pediatr Urol, 2021.PMID 33551366
- [4]Huff DS, Hadziselimovic F, Snyder HM 3rd, et al. Histologic maldevelopment of unilaterally cryptorchid testes and their descended partners. Eur J Pediatr, 1993.PMID 8101802
- [5]Lee PA, Houk CP Cryptorchidism. Curr Opin Endocrinol Diabetes Obes, 2013.PMID 23493040
- [6]Hutson JM, Balic A, Nation T, Southwell B Cryptorchidism. Semin Pediatr Surg, 2010.PMID 20610195
- [7]Skakkebaek NE, Rajpert-De Meyts E, Buck Louis GM, et al. Male Reproductive Disorders and Fertility Trends: Influences of Environment and Genetic Susceptibility. Physiol Rev, 2016.PMID 26582516
- [8]Toppari J, Kaleva M, Virtanen HE, et al Trends in the incidence of cryptorchidism and hypospadias, and methodological limitations of registry-based data. Hum Reprod Update, 2001.PMID 11392374
- [9]Kraft KH, Shukla AR, Canning DA Hypospadias. Urol Clin North Am, 2010.PMID 20569796
- [10]Kraft KH, Shukla AR, Canning DA Proximal hypospadias. ScientificWorldJournal, 2011.PMID 21516286
- [11]Nguyen V, Ngo L, Jaqua EE Cryptorchidism (Undescended Testicle). Am Fam Physician, 2023.PMID 37843945
- [12]Rampersad R, Nyo YL, Hutson J, et al. Foreskin reconstruction vs circumcision in distal hypospadias. Pediatr Surg Int, 2017.PMID 28856414