Knowledge and Awareness of Screening for Children With Cryptorchidism in the Al-Qunfudhah Governorate, Saudi Arabia

Background Undescended testis is a common pediatric surgical presentation condition with potential long-term consequences if left untreated. It is characterized by the failure of one or both testes to descend into the scrotum. This study aims to measure and enhance awareness and knowledge about undescended testis through comprehensive medical research and provide evidence-based recommendations. Objective The objective of this study was to evaluate participants' knowledge regarding undescended testes and assess the level of interest and awareness among individuals and parents about the importance of early examination and treatment. Methods It is a cross-sectional, nationwide study targeting the population of Al-Qunfudhah. The study was conducted in December 2023 using a validated questionnaire distributed through social media platforms. Results The study analyzed data from 459 participants to assess their knowledge and attitudes regarding undescended testis. Participants' knowledge was evaluated. In general, the mean ± SD score of knowledge was 3.61 ± 2.33. Higher education level, occupation, and having children were associated with greater knowledge. Attitudes were measured. The mean attitudes score was 2.37 ± 1.58. Higher education level, occupation, and marital status influenced attitudes. Conclusion This study provides valuable insights into the knowledge and attitudes of individuals regarding undescended testis. Participants displayed moderate levels of knowledge and positive attitudes, with educational attainment and occupation playing significant roles. These findings highlight the importance of targeted educational interventions to improve awareness and promote positive attitudes toward undescended testis.


Introduction
The awareness of the undescended testis (UDT) screening is crucial for early detection, treatment, and prevention of complications.The primary causes of UDT treatment are elevated risks of infertility, testicular cancer, torsion, and/or associated inguinal hernia, and can significantly affect a person's quality of life [1][2][3][4][5].Previous research indicates that there are large observed numbers of delayed presentations of children diagnosed with UDT in our community [6].
It is crucial to have a comprehensive understanding of UDT screening by parents who want to have children to develop effective interventions to prevent late presentation and to minimize the risk of infertility and malignancy which are complications associated with UDT.
The most prevalent congenital urogenital abnormality in boys is undescended testicles (UDT), medically termed cryptorchidism [7,8].It is referred to as the failure of the testis to descend into the usual scrotal position on one or both sides by the time of birth [9].Until now the cause of UDT is unknown [10].It is estimated that the incidence of UDT in full-term infants or those weighing more than 2.5 kg is 4.6%, whereas the incidence in preterm infants or those weighing less than 2.5 kg varies from 1.1% to 45.3%; in a previous Saudi study, 22.4% of cases were diagnosed immediately after birth, 21.4% within the first three months of life, 12.4% between three and six months, 12.1% between seven months and a year, and 31.7% over a year [6,7].The normal spontaneous testicular descent occurs in the first six months of life due to an elevated level of gonadotropins and androgenic hormones; after that, the possibility of a spontaneous descent will decrease [11,12,3].Testicular descent is necessary for spermatogenesis [10].The importance of early treatment and diagnosis lies in the prevention of later complications.According to numerous international guidelines, surgical correction (orchidopexy) is recommended between the ages of 6 and 18 months and ideally completed before one year of age.Meeting these timing recommendations is crucial for preserving male fertility in adulthood, primarily due to potential issues with semen quality [13,14].
In Saudi Arabia, the median age at the time of surgical correction of UDT was found to be twice that of the international recommendations, exceeding the recommended surgery time [13].A study done in Saudi Arabia in 2023 found that a total of 2360 people were enrolled.Over half didn't know about UDT.The age of the presentation was not known by 48.5% of the participants [7].This is primarily due to the late referral age, the lengthy waiting period for elective surgery [9], and the lack of awareness of the existence of this defect and delayed diagnosis.
There is a need for further study on the awareness of UDT screening in the general population in the Al-Qunfudhah governorate due to limited research in this area.The objective of this study was to examine the level of awareness for undescended testis screening in the Al-Qunfudhah governorate by gathering the number of the general population who are aware of the importance of early screening of UDT for their children.Additionally, the research aimed to investigate the knowledge about UDT and its treatment and complications in the Al-Qunfudhah governorate.

Study population (participants)
The inclusion criteria constituted the general population living in the Al-Qunfudhah region of Saudi Arabia who agreed to participate in the study.They had to be adults, meaning they had to be greater than or equal to 18 years of age.They had to have access to social media platforms.Exclusion criteria include any participant who did not live in the Al-Qunfudhah region of Saudi Arabia.

Study tool and data collection
A cross-sectional observational electronic questionnaire (see Appendices) was used to assess the knowledge and awareness of people about screening in children with UDT in the Al-Qunfudhah governorate, Kingdom of Saudi Arabia.The survey was created in Google Forms (Google LLC, Mountain View, California, United States) and distributed through social media platforms (e.g., Twitter (X Corp., San Francisco, California, United States), Instagram (Meta Platforms, Inc., Menlo Park, California, United States), and WhatsApp (Meta Platforms, Inc., Menlo Park, California, United States)).The result was 533 participants.The questionnaire consisted of 21 questions and was divided into three sections.The first part was about the respondents' demographic information (e.g., gender, age, material status, educational level, occupation, and whether they had children).In the second part, the participants were asked 10 questions about UDT, and the purpose of these questions was to find out if they had sufficient experience and information and also to evaluate the extent of their awareness and knowledge about UDT.(At which age does UDT arise?Does a UDT affect testicular function?Does UDT have any complications?What is the treatment for UDT?What is the optimum time for surgery?Is there any benefit from early treatment?Do you think testicular atrophy is a potential harm of delaying the intervention?Do you think infertility is a potential harm of delaying the intervention?Do you think testicular torsion is a potential harm of delaying the intervention?Do you think malignancy risk is a potential harm of delaying the intervention?)Finally, in the third part of the questionnaire, questions were asked to know the extent of interest and awareness of individuals and parents about the issue of undescended testicles.The aim of these questions was to evaluate community awareness and provide recommendations and advice on the importance of early treatment for children with undescended testicles.Among these questions are: Do you advise other parents to have their children examined to ensure that the testicle is not descended?What factors might influence your recommendation to other parents to have their child screened for undescended testicles?How important is early detection and treatment of undescended testicles to the child's overall health and wellbeing?If you have a friend or family member whose child suffers from undescended testicles, would you encourage him to seek medical evaluation and treatment?How confident are you in your knowledge about undescended testicles and their possible consequences?

Calculation of the knowledge and attitudes scores
Participants' knowledge in the current study was assessed based on eight items.An overall knowledge score was calculated for each participant by assigning a score of 1 to correct answers and a score of 0 to incorrect answers or responses such as "do not know" for each of the eight knowledge items related to UDT.These scores were then summed up to derive the participant's total knowledge score, which ranged from 0 to 8. A higher score indicated a greater level of knowledge regarding UDT, with a maximum achievable score of 8 representing perfect knowledge.Regarding participants' attitudes, we used four items to evaluate participants' perceptions regarding UDT.One of the four items was a multiple-choice item, with four available choices indicating positive attitudes.Therefore, we had a total of seven choices reflecting positive attitudes.A confirmed response to a positive attitude item was assigned 1 and other responses were assigned zero.Therefore, an overall positive attitudes score ranged between 0 and 7, with higher scores indicating more positive attitudes.

Statistical analysis
The statistical analysis was conducted using RStudio software (R version 4.3.1,R Foundation, Vienna, Austria).Descriptive statistics were used to summarize the sociodemographic characteristics of the participants, attitudes, and knowledge regarding UDT.Frequencies and percentages were calculated for categorical variables, while means and standard deviations were calculated for continuous variables.Inferential analysis was performed to identify associations, knowledge, and attitudes regarding UDT.Inferential tests included the Wilcoxon rank-sum test or the Kruskal-Wallis test.Multivariable regression analysis was conducted to identify predictors of knowledge and attitudes by including the significantly associated variables from the inferential analysis as independent variables.We used the knowledge and attitudes scores as dependent variables (each score in a separate model).Beta coefficients along with 95% confidence intervals were reported for the regression analysis.Variables with a p-value < 0.05 were considered statistically significant.

Sociodemographic characteristics
Initially, we collected data from 533 respondents.However, we excluded 10 records of those who refused to participate and 64 records of respondents aged < 18 years.Therefore, we analyzed the responses of 459 participants in the current study.Among them, the majority were female (n=243, 52.9%).Regarding age distribution, the largest proportion fell within the 18 to 25 years bracket (n=142, 30.9%).In terms of marital status, married individuals constituted the highest proportion (n=150, 32.7%).Bachelor's degree holders comprised the largest educational group (n=161, 35.1%), and among occupations, the employed category had the highest representation (n=158, 34.4%).Moreover, a considerable majority resided in urban areas (n=272, 59.3%).Less than half of the sample had children (n=207, 45.8%) (Table 1).

Knowledge regarding UDT and the associated factors
In assessing awareness and knowledge regarding UDT, it was found that 42.5% of participants correctly identified that it arises since birth (n=195  In general, the mean ± SD score of knowledge was 3.61 ± 2.33.The distribution of the knowledge score is depicted in Figure 1.On the multivariable regression analysis, participants with a higher educational level, specifically those with a bachelor's degree (beta = 1.17, 95% CI: 0.27 to 2.06, p = 0.011) or post-graduate education (beta = 1.17, 95% CI: 0.12 to 2.22, p = 0.030), demonstrated significantly greater knowledge compared to those with less education.

Attitudes regarding UDT
Regarding attitudes regarding undescended testis, 44.0% of participants expressed a positive attitude by indicating that they would definitely recommend other parents to have their child screened for undescended testis (n=202).Factors influencing this recommendation included the availability of effective treatment options (n=224, 48.8%), awareness of potential long-term consequences of untreated undescended testis (n=163, 35.5%), personal experience or knowledge of someone with UDT (n=166, 36.2%), and advice from healthcare professionals (n=119, 25.9%).Furthermore, 24.8% of participants considered early detection and treatment of UDT as extremely important for a child's overall health and well-being (n=114).Additionally, 22.0% stated that they would encourage a friend or family member to seek medical evaluation and treatment for their child with UDT without hesitation (n=101) (Table 4).

Characteristic
Together, these findings contribute to a comprehensive understanding of UDT, advocating for enhanced public education efforts and streamlined clinical protocols to optimize patient outcomes.
This is an important study [16], which aimed to assess whether the management of UDT could be improved with educational updates and a new transferring model among referring providers (RPs) in a hospital setting in China.The study analyzed the age of orchidopexies performed before and after the implementation of educational updates and new transferring models.It found that despite educational efforts, the median age of orchidopexy did not match the target age of 6-12 months.However, there was a statistically significant downward trend in the age of orchidopexy after the intervention, suggesting some improvement in the management of UDT.
This study has several limitations.Firstly, reaching a representative sample of the population in the Al-Qunfudhah governorate through social media platforms may have introduced sampling bias, as individuals without internet access or social media accounts were excluded.Additionally, the reliance on self-reported data may have introduced response bias, as participants may have provided socially desirable answers.Furthermore, cultural and societal norms regarding discussing sensitive topics such as reproductive health could have affected participants' willingness to engage with the questionnaire.Lastly, interpreting the results may have been challenging due to variations in educational backgrounds and levels of health literacy among participants, impacting the accuracy of knowledge and attitudes assessments.

Conclusions
The management of UDT remains a critical issue in pediatric healthcare, with significant implications for long-term fertility and health outcomes.The goal of recent studies, including ours, has been to improve the timely diagnosis and treatment of UDT to mitigate associated risks.While interventions such as educational updates and new transferring models among healthcare providers have shown promising results in reducing the age at orchidopexy, challenges persist in achieving optimal outcomes.
Our study, along with others, has highlighted the need for continued efforts to streamline referral pathways, increase awareness among healthcare providers, and enhance collaboration between primary care and specialty centers.Despite improvements in certain aspects of UDT management, further research is warranted to address remaining barriers and optimize treatment protocols.
To future researchers, doctors, and parents, we advise prioritizing early detection and timely intervention for UDT cases.It is essential to advocate for comprehensive educational initiatives, standardized referral pathways, and multidisciplinary care approaches to ensure that children with UDT receive timely and appropriate treatment, ultimately safeguarding their future reproductive health and overall well-being.

FIGURE 2 :
FIGURE 2: Participants' responses regarding their self-confidence in knowledge about undescended testis and its potential consequences

FIGURE 3 :
FIGURE 3: The distribution of the scores of attitudes (B) regarding undescended testis

TABLE 1 : Sociodemographic characteristics
*The variable had seven missing records

TABLE 3 : Factors and predictors of knowledge regarding undescended testis
How important do you think early detection and treatment of undescended testis is for a child's overall health and well-being?

TABLE 5 : Factors and predictors of attitudes regarding undescended testis
CI = Confidence Interval; SD: standard deviation; NA: non-applicable Data are represented as mean ± SD for the inferential analysis and beta coefficients (95% confidence intervals) for the multivariable regression *The variable had seven missing records 2024 Taha et al.Cureus 16(5): e59770.DOI 10.7759/cureus.59770