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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 18-20

The role of physical assessment in primary health care in the early detection of pediatric undescended testis in Saudi Arabia


1 Department of Urology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
2 Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
3 Department of Urology, Dammam Medical Complex, Dammam, Saudi Arabia
4 Department of Family Medicine, Family Medicine Academy, MOH 1st Health Cluster in Eastern Province, Dammam, Saudi Arabia

Date of Submission02-Oct-2021
Date of Acceptance16-Jan-2022
Date of Web Publication27-Jul-2022

Correspondence Address:
Abdullah Mousa Alzahrani
STB 11, Ad Dammam, P.O. 32444
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/KKUJHS.KKUJHS_43_21

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  Abstract 

Background: The early detection of undescended testis is the key to minimizing infertility and malignancy risks associated with this condition. Thorough routine physical examination during scheduled visits for vaccines during the first year of a child's life can lead to early detection and referral to a surgeon for evaluation and surgical intervention in a timely manner. We aimed to investigate the role of physical examinations in primary health care for the discovery of undescended testis. Methods: Anonymous structured interviews were conducted in the waiting areas of a hospital and primary health-care center. Parents were asked about their perceptions of undescended testis and their experience during primary health-care visits for routine vaccinations. A descriptive analysis was carried out, and the percentage of boys who underwent genital examinations in a primary health-care setting was determined. Results: We interviewed a total of 352 parents, most of whom did not have a child with undescended testis (n = 322, 91%). Only 25 (7%) reported that a formal clinical genital examination was done at every primary health-care visit, whereas 50 (14%) indicated that their boy had been examined only once among their many vaccination visits. However, 160 (46%) parents stated that their primary health-care provider did not examine their boys' genitalia during any of these visits. Conclusion: Late detection of undescended testis could result from failure to adhere to the recommended genital clinical examinations of boys during immunization visits for infants among primary health-care providers.

Keywords: Genital examination, orchiopexy, primary health care, undescended testis, well-child clinic


How to cite this article:
Alzahrani AM, Basalelah JH, Khamis A, Almahaish AA, Aljehani SH, Alhejji FM, Almadi MK. The role of physical assessment in primary health care in the early detection of pediatric undescended testis in Saudi Arabia. King Khalid Univ J Health Sci 2022;7:18-20

How to cite this URL:
Alzahrani AM, Basalelah JH, Khamis A, Almahaish AA, Aljehani SH, Alhejji FM, Almadi MK. The role of physical assessment in primary health care in the early detection of pediatric undescended testis in Saudi Arabia. King Khalid Univ J Health Sci [serial online] 2022 [cited 2022 Nov 28];7:18-20. Available from: https://www.kkujhs.org/text.asp?2022/7/1/18/352523


  Introduction Top


Undescended testis (UDT) is when one or both testicles are not present in the scrotum at the time of birth. The ascent of a previously normally descended testicle can also occur and is known as acquired UDT.[1] The prevalence of UDT is about 4% among full-term infants and is ten times higher among those born prematurely.[2] The recommended age for orchiopexy is 6–18 months according to numerous international guidelines.[3],[4],[5] Early detection is recommended in all guidelines due to its value in avoiding later complications. However, numerous factors contribute to delayed surgical treatment of UDT.

In Saudi Arabia, the median age when orchiopexy is performed was found to be twice that of the international recommendations. This difference is likely due to delays in diagnosis by nonsurgical specialist physicians (e.g., primary health-care providers, general practitioners, and pediatricians), in addition to the long wait time from referral to a surgeon followed by long waiting lists for elective surgery.[6],[7] Therefore, the aim of this study is to describe the role of primary health-care providers and general pediatricians in the early detection of UDT through proper and complete physical examination during routine vaccine visits in the first year of life.

Methods

During the period of March 2021 to May 2021, structured interviews were performed with parents visiting the waiting area of a large governmental hospital's clinics in the city of Al Khobar, Eastern Province of Saudi Arabia, as well as a primary health-care center in Dammam city. Informed consent was obtained from all parents before they participated in this study. The interview questions were provided in Arabic and English languages and required approximately 5 min to complete. The interview items included the age of participants, their child's history of UDT diagnosis if any, and perceptions of genital examination during primary health-care visits for their boys. In addition, descriptive data were collected to reflect how the participants responded to the questions. Statistical analyses were then performed using IBM SPSS Statistics software, v. 27 (Armonk, N.Y., USA).


  Results Top


A total of 352 participants were interviewed. Their age ranges were 19–40 years (54%), 41–60 years (39%), and older than 60 years (7%). The majority had heard about UDT (55%) from either family or friends (43%), followed by doctors (24%), medical websites (13%), and social media (8%). About 33 (9%) participants had a child diagnosed with UDT. Most parents (46%) claimed that their primary health-care provider did not examine their boys' genitalia during vaccine visits. Moreover, 33% did not know whether their boys had ever been examined, whereas 14% claimed that their boys had been examined once among many visits, and only 7% were examined at every routine vaccine visit.


  Discussion Top


A delay in surgical intervention for UDT beyond 18 months of age increases future risks of infertility and testicular tumors compared with the unaffected population.[8],[9] Several studies have been conducted in Saudi Arabia in regard to the timing of UDT repair, which diverges greatly from the international recommended guidelines with a median age of orchiopexy of 24–47 months.[6],[7],[10] A waiting period of 3 months is recommended for spontaneous descent of a palpable UDT diagnosed at birth. If it does not occur, then surgical intervention is indicated in the period of 6–18 months of age. This provides the highest probability of fertility preservation and minimizes testicular malignancy risk when performed within a year after the conservative follow-up period.[1]

The community, family, primary health-care providers, pediatricians, and surgeons each contribute to the inferred factors of surgery delay. Insufficient awareness among families about the consequences of delayed diagnosis or lack of regular follow-up and delay of operation are principal concerns. Primary health-care providers and general pediatricians play a key role in the spread of general awareness about many conditions, including the importance of assessment for UDT in boys at an early age. In this regard, further delay could arise when obtaining approval from the parents or the caregiver for genital examination as well as eventual consent for surgical intervention for UDT if indicated.[11]

Families' compliance with vaccine visits provides an opportunity to detect UDT at an appropriate age, which is supported by the recommendations of the American Academy of Family Physicians with a primary mission of preventive health services. Overlooking genital examination during these routine vaccine visits is undoubtedly a cause for the late discovery of this condition. Subsequently, more time is needed until the patient is seen by a surgical specialist, followed by even more time until an elective orchidopexy can be scheduled if indicated.[12],[13]

The use of ultrasound for UDT diagnosis and hormone therapy is against current recommendations and leads to unnecessary postponement.[14],[15] We found that about half of our participants reported a lack of physical examination during their routine scheduled immunization visit. Despite any potential recall bias, this percentage is high and excludes the 33% who were not sure if their child had been examined or not. The knowledge background of the referring physician is another culprit for delayed orchiopexy. Examples include underestimating the time required for referral, not performing the genital examination properly, providing the parents with the option of hormone therapy before considering surgical intervention, and mandating that a scrotal ultrasound be done before a referral, which all lead to unwarranted time delays.[11],[16]

Jiang et al. noticed that pediatricians were more likely than primary health-care providers to adhere to guidelines concerning genital examination in children, perhaps due to their awareness about this condition. Furthermore, new family physicians are more likely to detect UDT than a familiar family physician.[17] Two extensive retrospective studies from the USA and UK were conducted on 35,000 and 28,000 patients with UDT, respectively. Notably, these studies revealed differences in referrals according to the surgeons' specialties (general surgeons, pediatric surgeons, and urologists). In addition, insurance status, race, and treating hospital were identified as factors contributing to referral delays.[18],[19]

Patients with retractile testes are at high risk for acquired UDT and have a three times greater delay in referral.[20] Guven and Kogan studied 177 patients who underwent late orchiopexies beyond the age of 2 years. They emphasized the link between referral delay and acquired UDT in about 45% of all late cases compared with other causes of delay, including parent-related delays (22%), iatrogenic UDT (9%), and other idiopathic reasons (8%).[21] Therefore, health-care providers must routinely provide genital examinations for all patients regardless of their medical history, as per the recommendations.[17]

The most effective solutions include physician education, proper counseling, and public awareness programs targeting the community, general practitioners, and families. Such programs should emphasize the importance of early detection and proper management of common conditions in childhood. A study from the UK examined primary health-care providers using written information and several educational exhibits, including brochures distributed to families. Eventually, they noticed a decline in the median age of referral in their community.[3] Similar studies from China provided handouts and informational lectures to primary health-care providers, after which they observed a significant downward slope in the median age of referral.[22],[23]

The present study has several limitations. We focused exclusively on assessing parents' experience with genital clinical examination during scheduled routine vaccine visits in primary health care. However, we did not examine other contributing factors for possible delays of diagnosis, which could be explored in future studies.


  Conclusion Top


Delayed detection of UDT could arise from failure to adhere to the recommendations for genital clinical examination in boys during vaccination visits for infants among primary health-care providers or general pediatricians. The successful implementation of educational programs geared toward families, primary health-care providers, and general pediatricians could decrease the age at diagnosis and the median referral time. Establishing clear guidelines for local primary health-care vaccination visits could increase adherence to performing genital examinations on boys in this age group, thus improving the overall outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hutson JM, Balic A, Nation T, Southwell B. Cryptorchidism. Semin Pediatr Surg 2010;19:215-24.  Back to cited text no. 1
    
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Brown JJ, Wacogne I, Fleckney S, Jones L, Ni Bhrolchain C. Achieving early surgery for undescended testes: Quality improvement through a multifaceted approach to guideline implementation. Child Care Health Dev 2004;30:97-102.  Back to cited text no. 3
    
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Yiee JH, Saigal CS, Lai J, Copp HL, Churchill BM, Litwin MS, et al. Timing of orchiopexy in the United States: A quality-of-care indicator. Urology 2012;80:1121-6.  Back to cited text no. 5
    
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Alsowayan OS, Basalelah JH, Alzahrani AM, Alshaibani AM, Alalyani NS, Alsubiani TA, et al. Age at presentation of undescended testicles: A single-center study in Saudi Arabia. Ann Saudi Med 2018;38:137-9.  Back to cited text no. 6
    
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Cortes D, Thorup JM, Visfeldt J. Cryptorchidism: Aspects of fertility and neoplasms. A study including data of 1,335 consecutive boys who underwent testicular biopsy simultaneously with surgery for cryptorchidism. Horm Res 2001;55:21-7.  Back to cited text no. 8
    
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Mohammad Alnoaiji MS, Alrashidi TN, Ghmaird AS, Alsalem SS, Alanazi MS, Albazei AI, et al. Age at surgery and outcomes of undescended testes at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia. Cureus 2019;11:e6413.  Back to cited text no. 10
    
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Shields LB, White JT, Peppas DS, Rosenberg E. Scrotal ultrasound is not routinely indicated in the management of cryptorchidism, retractile testes, and hydrocele in children. Glob Pediatr Health 2019;6:2333794X19890772. doi: 10.1177/2333794X19890772.  Back to cited text no. 14
    
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Jiang DD, Acevedo AM, Bayne A, Austin JC, Seideman CA. Factors associated with delay in undescended testis referral. J Pediatr Urol 2019;15:380.e1-6.  Back to cited text no. 17
    
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Thorup J, Cortes D. Surgical management of undescended testis – Timetable and outcome: A debate. Sex Dev 2019;13:11-9.  Back to cited text no. 20
    
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