An 8-week-old baby boy presents to the GP with his father for his baby check. He is currently feeding well, opening his bowels and passing urine. There are no concerns regarding his growth and development as he is following the centiles adequately. On examination, he is fixing and following objects and smiling at his dad. The GP notices that he has a right unilateral undescended testicle.

Which of the following is the next best step in the management of this patient?

Options:
explanation: Urological surgery may be warranted if the testis remains undescended by 6 months. Unilateral undescended testis is common and usually resolves spontaneously within the first 3-6 months of life. Therefore, urological review is not required at this stage or urgently. This baby needs follow up at 3 months to see if the testicles have descended or not; by then, the child will be 4-5 months of age, and if the testicle hasn't persisted, will warrant referral to a urologist for review, as per NICE guidelines.
name: Refer to urology routinely
label: e
answer: no
explanation: Urological surgery may be warranted if the testis remains undescended by 6 months. Unilateral undescended testis is common and usually resolves spontaneously within the first 3-6 months of life. Therefore, urological review is not required at this stage or urgently.
name: Refer urgently to a senior urologist within 2 weeks
label: c
answer: no
explanation: Annual l follow-up is required if the testes descend after 3 months but remain retractile since there is a risk of the testes ascending over time. This baby needs follow up at 3 months to see if the testicles have descended or not; by then, the child will be 4-5 months of age, and if the testicle hasn't persisted, will warrant referral to a urologist for review, as per NICE guidelines.
name: Annual follow-up
label: d
answer: no
explanation: Bilateral undescended testes may represent a serious underlying endocrinological or developmental abnormality, such as congenital adrenal hyperplasia, and as such the NICE guidelines suggest urgent review within 2 weeks by a paediatrician.
name: Refer urgently to a senior paediatrician within 2 weeks
label: b
answer: no
explanation: This newborn has a unilateral undescended testicle which has been noted on the 8-week baby check up. This is a common presentation at the baby check with around 1/25 boys being born with undescended testicles. In most instances, these will descend naturally during the first 3-6 months of life, and no treatment will be required. Therefore, at this stage, follow up in 3 months is all that is required. If undescended by 6 months, then it is unlikely they will descend spontaneously, and as such surgery is warranted, ideally before the child reaches 12 months of age. Referral is usually done around 4-5 months of age if the testicles are undescended, in order to minimise delays. Note that by the first year of life, 2/3 of undescended testes resolve spontaneously.  Note that undescended testes are a big risk factor for testicular tumours which are identified as an inguinal lump later on in life.
name: Review at 3 months
label: a
answer: yes

Correct answer: a


Learning point: Unilateral undescended testicles often resolve spontaneously within the first six months, infants should be reviewed at 3 months.