Factors influencing delay in undescended testis referral
Da David Jiang, MD, Ann Martinez, BS MPH, Aaron Bayne, MD, Christopher Austin, MD, Casey Seideman, MD.
Oregon Health & Science University, Portland, OR, USA.
Background: Undescended testicle (UDT) is one of the most common disorders in boys, affecting 1.0-4.6% of full-term newborns. Although UDT can undergo spontaneous descent in the first months of life, it is rare after 6months. Older boys with untreated UDT are at an increased risk for developing testicular malignancy. Furthermore, biopsy studies have shown that UDT is associated with compromised fertility from germ cell loss, impaired germ cell maturation, and testicular fibrosis. Age at orchiopexy has been shown to be an important predictive factor for fertility later in life. Both AUA and EAU have released guidelines recommending orchiopexy by 18 months age at the latest. Our goal is to determine factors that are associated with delay in UDT referral. Methods: We created an IRB approved, prospective database that captured data for all boys seen with UDT on exam at Doernbecher. All patients who underwent orchiopexy from March 2017 to May 2018 were reviewed for demographic and clinical data. Patients referred after 18 months were considered delayed. Factors associated with delay in UDT referral were explored using univariate and multivariate analysis (MVA). All statistical analysis were performed on Stata/MP v14.1. Results: During the 15 month-study-period, 122 patients underwent routine orchiopexy for UDT. The median age of referral visit was 45 months (IQR 12-96), of those, 79 (65%) were referred after 18-months of age. On univariate analysis, abnormal birth testicular exam (p<0.001), diagnosis of retractile testicle (p<0.001), long gap without seeing pediatrician (p=0.050), new primary care physician (PCP) or other physician (p<0.001), and primary language not English at home (p=0.031) were associated with delay in referral. Insurance status, BMI, circumcision status, family history of UDT, distance to our center, unilateral or bilateral UDT were not found to be significant on univariate analysis. On MVA, delayed UDT referral was associated with diagnosis of ‘retractile testis’ (OR 3.2, 95% 1.4-7.5, p=0.007) as well as non-English speakers (OR 7.2, 95% CI 1.2-43.8, p=0.033). Compared to regular PCP, ‘new PCP’ and ‘other’ were more likely to diagnose delayed UDT (‘new PCP’ OR 17.8, 95%CI 1.4-154.7, p=0.024; ‘other’ OR 4.7, 95% CI 1.8-26.5, p=0.006). Conclusion: Despite clear consensus guidelines, the median age of referral for UDT at our tertiary center is 3.8-years-old and 65% of patients were referred after 18-months of age. Delayed UDT referral is associated with previous diagnosis of ‘retractile testis’ and non-primary-English speaking families. This highlights the importance of education for families regarding diagnosis to prevent delay in orchiopexy. Emphasis should be made with families with retractile testes to continue annual exams with PCP until puberty per guideline statements. Lastly, our study highlights the importance of full history and physical including annual testicular exams with PCP as delayed UDT were more likely to be discovered by providers other than the regular primary physician, suggesting a missed a diagnosis by their regular PCP.
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