Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Follow-up for cryptorchidism
New diagnosis of cryptorchidism
II. History of Present Illness:
Age at diagnosis (if newly diagnosed)
Unilateral or bilateral undescended testis (location – inguinal or abdominal)
Any associated symptoms (pain, swelling)
Previous surgeries for cryptorchidism (orchiectomy – testis removal, orchidopexy – fixation of undescended testis)
III. Past Medical History:
Prematurity (risk factor for cryptorchidism)
History of inguinal hernia
IV. Family History:
Family history of cryptorchidism
V. Physical Exam:
Genital exam:
Inspection for presence of palpable testes in scrotum (bilateral or unilateral)
Palpation of inguinal or abdominal regions for possible undescended testes
Assessment of scrotal development
VI. Imaging Studies (consider as appropriate):
Ultrasound (first-line imaging) to locate undescended testis and assess viability
MRI (may be used in complex cases to differentiate between undescended testis and vanishing testis syndrome)
VII. Assessment:
Confirmed or suspected cryptorchidism (unilateral or bilateral) based on physical exam findings.
Location of undescended testis (inguinal or abdominal)
Testis viability (important for treatment decisions)
VIII. Plan:
Treatment depends on age, location of undescended testis, and testis viability:
Orchidopexy: Surgical procedure to bring the undescended testis down into the scrotum ideally before 1 year of age to optimize fertility potential.
Hormonal therapy: May be considered in some cases before orchidopexy, but efficacy is debated.
Orchiectomy: Removal of undescended testis may be considered if the testis is non-viable or malignancy is suspected.
Regular follow-up to monitor testicular descent and development.
IX. Prognosis:
Early orchidopexy (before 1 year) offers the best chance of preserving fertility and reducing the risk of testicular cancer.
Discuss the potential complications of undescended testis (infertility, testicular cancer) and the benefits of treatment.
X. Notes:
Include any additional observations or concerns, such as parental understanding and concerns, potential need for referral to a pediatric urologist, and timing of surgery.
XI. Resources:
Consider providing patient education materials on cryptorchidism from reputable sources (e.g., American Urological Association, National Institute of Child Health and Human Development).