Bridging the Gap in Cryptorchidism Care: Knowledge and Practices of Primary Care Physicians in Tunisia

Bridging the Gap in Cryptorchidism Care: Knowledge and Practices of Primary Care Physicians in Tunisia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bridging the Gap in Cryptorchidism Care: Knowledge and Practices of Primary Care Physicians in Tunisia Cyrine Saadi, Chayma Bouali, Souha Laarif, Aida Daib, Malak Boughdir, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8862118/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Abnormal testicular migration (ATM), or cryptorchidism, is a common congenital condition in boys, with early detection and timely surgical referral crucial to prevent long-term complications such as infertility and testicular cancer. Primary care physicians (PCPs) play a key role in identifying and managing ATM, but their knowledge and practices in Tunisia remain poorly understood. Methods This national cross-sectional survey, conducted from December 2022 to June 2023, assessed the knowledge, attitudes, and practices of 504 PCPs involved in pediatric care across Tunisia using a structured electronic questionnaire. Sociodemographic data, knowledge of ATM, and clinical practices were collected, and associations between variables were analyzed using chi-square tests (p < 0.05). Results Although nearly all participants reported familiarity with ATM, only 30.2% correctly defined the condition. Knowledge of optimal timing for surgical correction was limited, with fewer than 10% recognizing that surgery before one year of age aligns with international guidelines. Misconceptions persisted regarding spontaneous testicular descent and long-term risks. Routine testicular examinations were inconsistently performed, and ultrasounds were frequently requested despite guideline recommendations. Most physicians referred patients to pediatric surgeons, yet referral timing varied. Higher knowledge scores were significantly associated with pediatric specialization, longer clinical experience, urban practice, and routine genital examination. Conclusion : In conclusion, while awareness of ATM is widespread among Tunisian PCPs, gaps remain in detailed knowledge and adherence to evidence-based practices. Strengthening continuing medical education and improving collaboration with pediatric surgical services could enhance early detection and standardize management, ultimately reducing the risk of adverse outcomes for affected children. Abnormal testicular migration (ATM)- Primary care physicians- Pediatric care-Knowledge attitudes practices (KAP)- Early detection- Surgical referral Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Testicular migration disorders, commonly referred to as cryptorchidism or abnormal testicular migration (ATM), represent one of the most common congenital anomalies of the male genital tract. Their prevalence ranges from 1–4% in full-term infants and may reach 30% among preterm newborns [ 1 ]. Although spontaneous testicular descent can occur during the first months of life, persistence beyond infancy is associated with significant long-term complications, including subfertility, increased risk of testicular malignancy, torsion, inguinal hernia, and potential psychological consequences if not appropriately managed [ 2 ]. International guidelines consistently emphasize the importance of early diagnosis and timely surgical intervention. Current recommendations advocate referral within the first six months of life, with orchidopexy ideally performed before 12–18 months to optimize fertility outcomes and reduce complications [ 1 , 3 ]. Delayed treatment has been shown to negatively affect germ cell maturation and long-term reproductive potential [ 4 ]. Primary care physicians play a central role in the early detection and management of ATM. Through routine neonatal and infant examinations, they are responsible for identifying abnormal testicular position, distinguishing between undescended, ectopic, and retractile testes, counseling parents, and ensuring timely referral to pediatric surgical services. However, previous studies have highlighted gaps in knowledge and variability in clinical practice, including confusion between clinical entities and unnecessary use of imaging modalities such as ultrasound [ 5 – 8 ]. In Tunisia, primary care physicians constitute the first point of contact within the healthcare system and are essential for the early recognition of congenital conditions. Despite this central role, no national data are currently available regarding their knowledge, attitudes, and practices concerning ATM. This study aimed to assess the knowledge, attitudes, and practices of primary care physicians in Tunisia regarding ATM and to identify factors associated with appropriate clinical management. Methods Study design and reporting We conducted a national, descriptive, multicenter cross-sectional survey among primary care physicians in Tunisia between December 2022 and June 2023. The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. A knowledge, attitudes, and practices (KAP) framework was adopted to evaluate current clinical behaviors and identify potential gaps in the management of abnormal testicular migration (ATM). This approach was chosen to inform future educational interventions and public health strategies at the national level. Study setting and participants The study targeted physicians involved in primary pediatric care throughout Tunisia, including general practitioners, pediatricians, family medicine residents, and pediatric residents. Participants were practicing in both public and private healthcare settings. To ensure national representation, recruitment encompassed physicians working in local dispensaries, school health services, regional hospitals, and university hospitals across different geographic regions. Eligibility criteria Inclusion criteria Eligible participants were general practitioners and pediatricians working in public or private practice, as well as family medicine and pediatric residents currently practicing in primary or tertiary healthcare facilities in Tunisia. Participation required voluntary consent to complete the questionnaire. Non-inclusion and exclusion criteria Physicians from specialties other than general medicine or pediatrics were not eligible. Retired physicians or those no longer practicing clinical medicine were excluded. Questionnaires that were incomplete or contained inconsistent responses were also excluded from the final analysis. Sample size calculation The sample size was calculated using the formula for estimating a prevalence in cross-sectional studies. In the absence of prior national data assessing physicians’ knowledge and practices regarding ATM, a conservative expected prevalence of 50% was assumed to maximize the required sample size. With a 95% confidence level (Z = 1.96), a margin of error of 5%, and an alpha risk of 5%, the minimum required sample size was estimated at 400 participants. Questionnaire development and data collection As no validated instrument currently exists to assess physicians’ knowledge, attitudes, and practices regarding ATM, a structured questionnaire was specifically developed for this study. The questionnaire was designed following: A review of the relevant literature International clinical guidelines on cryptorchidism Expert input from pediatric surgery and primary care specialists Content validity was reviewed and approved by the Tunisian National Medical Council prior to dissemination. The final instrument consisted of 26 closed-ended questions divided into three sections: Sociodemographic and professional characteristics Including age, specialty, type and location of practice, years of professional experience, and prior exposure to pediatric surgery during training. Knowledge assessment Addressing definition of ATM, recommended timing of referral and surgery, understanding of associated risks, and long-term consequences. Clinical practices and attitudes Evaluating routine genital examination, use of complementary investigations, referral patterns, and perceived need for additional training. The questionnaire was administered electronically using Google Forms. It was distributed via professional email addresses provided by the Tunisian National Medical Council, following official authorization. Data collection occurred between December 22, 2022, and June 22, 2023. Participation was voluntary and anonymous, and no financial incentives were provided. Outcome measures The primary outcome was the reported age at referral of children with ATM to pediatric surgical services. Secondary outcomes included: Frequency of systematic genital examination during pediatric consultations Level of knowledge regarding ATM Reported diagnostic and referral practices Statistical analysis Statistical analyses were performed using SPSS software (2019 version). Descriptive statistics were presented as absolute frequencies and percentages with 95% confidence intervals where appropriate. Associations between categorical variables were assessed using Pearson’s chi-square test. A p-value < 0.05 was considered statistically significant. Ethical approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Habib Thameur University Hospital, Tunis, Tunisia. Authorization to distribute the questionnaire was granted by the Tunisian National Order of Physicians. Participation was voluntary, and electronic informed consent was obtained from all participants prior to completing the questionnaire. All responses were anonymous and confidentiality of the data was strictly maintained . Consent for publication Not applicable. No individual data are presented in this manuscript. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Results A total of 504 physicians participated in the study (response rate based on 7800 invitations). Most participants were older than 35 years (62%) (figure 1). General practitioners represented the majority (64.5%), followed by pediatricians (19.8%) and family medicine residents (15.7%) as indicated in the figure 2. Physicians practiced across various healthcare settings, including private urban clinics (41%), university hospitals (24.6%), dispensaries (18.1%), and regional hospitals (16.1%). Nearly two-thirds were based in major urban areas (Grand Tunis or Sousse). Approximately one-third reported prior exposure to pediatric surgery during their training. Knowledge regarding ATM Although almost all respondents (99%) reported being familiar with ATM and 80.4% had previously diagnosed the condition, detailed knowledge appeared limited. Only 30.2% correctly identified the complete definition of ATM, while others provided partial or incorrect definitions (figure 3). Most physicians were able to differentiate between ectopic testes and cryptorchidism (74.4%) and between ectopic and retractile testes (80.4%). However, knowledge regarding optimal timing of surgery was inconsistent. While 40.9% indicated that surgery should be performed between 1 and 2 years of age, only 9.9% identified the recommended age of before one year (figure 3) . More than one-quarter (27%) reported immediate referral upon diagnosis. Encouragingly, the majority recognized the prognostic importance of early management (95.8%). However, misconceptions persisted: half of respondents believed spontaneous descent could occur beyond infancy, and only 38.3% identified malignancy as a long-term risk. Hormonal therapy was correctly considered ineffective by 82.9% of participants. Attitudes and clinical practices Routine clinical examination practices were suboptimal. Only 53% reported systematically palpating the testes during pediatric consultations. Most physicians did not request laboratory investigations (78.6%), which aligns with recommendations. However, 61.1% reported ordering ultrasound examinations, despite guidelines discouraging routine imaging. Referral practices were generally appropriate, with 88% referring patients to pediatric surgeons. Nevertheless, the timing of referral varied considerably. Only 31.7% referred children between 6 and 12 months of age, while others delayed referral until preschool age or beyond (figure 4). Factors associated with knowledge and practice Better knowledge was significantly associated with older age (>35 years), pediatric specialization, longer professional experience (>15 years), practice in tertiary centers or major urban regions, and routine performance of testicular examination (p < 0.05). Early referral to pediatric surgery was also positively correlated with correct knowledge. Exposure to pediatric surgery during training showed a positive trend toward better knowledge, although this did not reach statistical significance ( table 1). Discussion This national survey reveals substantial variability in knowledge and practice regarding ATM among primary care physicians in Tunisia. While self-reported familiarity with the condition was high, detailed understanding of definitions and guideline-recommended timing of surgery was frequently incomplete. Misclassification between retractile, ascending, and undescended testes emerged as a recurring issue, consistent with findings from international studies [5–7]. Importantly, delayed referral appears to stem more from diagnostic uncertainty and misconceptions about spontaneous descent than from structural barriers to surgical access. Although most physicians acknowledged the importance of early management, only a minority correctly identified the recommended age for orchidopexy. Similar discrepancies between theoretical awareness and practical implementation have been reported in other healthcare settings [1,3,9]. The persistent overuse of ultrasound reflects a gap between evidence-based guidelines and real-world practice [3,7,10]. This may indicate defensive medical behavior, parental reassurance demands, or insufficient dissemination of guideline recommendations. Physicians practicing in tertiary centers and those with pediatric specialization demonstrated better knowledge and more appropriate referral practices. These findings suggest that structured exposure to pediatric surgery and continuing professional development may improve adherence to recommendations. Targeted educational strategies should therefore focus particularly on physicians practicing in peripheral regions. From a public health perspective, strengthening collaboration between primary care and pediatric surgical services is essential. Simplified referral algorithms, continuing medical education programs, and incorporation of guideline-based content into undergraduate and postgraduate curricula may help reduce delays and improve long-term outcomes. Strengths of this study include its national scope and large, diverse sample of primary care providers. Limitations include potential response bias and the absence of a previously validated KAP questionnaire. Nevertheless, this study provides the first national overview of primary care practices regarding ATM in Tunisia. Conclusion Despite high levels of self-reported familiarity with abnormal testicular migration, significant gaps persist in detailed knowledge and clinical practice among primary care physicians in Tunisia. Delayed referral and unnecessary imaging remain common. Targeted educational interventions and strengthened collaboration between primary care and pediatric surgery services are crucial to ensure timely, evidence-based management and to optimize long-term reproductive outcomes in affected children. Declarations Funding The authors received no specific funding for this work. Author Contribution C.B and M.B did the data collection C.S and S.L wrote the main manuscript text A.D and Y. H reviewed the papierAll authors reviewed the manuscript Acknowledgments The authors would like to thank all primary care physicians who participated in this study. Data Availability The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. References American Urological Association. Evaluation and Treatment of Cryptorchidism: AUA Guideline. Published; 2025. Spencer BA, Liu DB, Nehra D et al. Cryptorchidism: review for the primary care provider. South Dakota State Medical Association . 2024. Available from: https://pubmed.ncbi.nlm.nih.gov/37603872/ Radmayr C, Bogaert G, Dogan HS, et al. EAU guidelines on paediatric urology. Eur Urol. 2023;84(1):1–26. Hutson JM, Li R, Southwell BR, Petersen BL, Thorup J, Cortes D. Germ cell development in the descended and cryptorchid testis and the effects of orchidopexy. Pediatr Surg Int. 2015;31(4):317–25. Presson AP, Rodgers BM, Canning DA. Undescended testis: level of knowledge among potential referring health-care providers. J Paediatr Child Health . 2015;51(3):315–321. Available from: https://pubmed.ncbi.nlm.nih.gov/25939451/ Cools M, van de Velde S, van Bogaert P et al. National survey of physicians in Swedish child health centres finds insecurity and unawareness regarding management of undescended testicles. Acta Paediatr . 2024;113(5):1034–1042. Available from: https://pubmed.ncbi.nlm.nih.gov/38415505/ Taha OA, Aldossary N, Alqarni A et al. Knowledge and awareness of screening for children with cryptorchidism in Al-Qunfudhah Governorate, Saudi Arabia: a nationwide cross-sectional study. J Pediatr Urol . 2024. Available from: https://pubmed.ncbi.nlm.nih.gov/38846244/ Trump T, Elbakry AA, Al-Omar O. Referral patterns for undescended testis: a comparative analysis before and after guideline publication. J Pediatr Urol. 2021;17(5):736. e1-736.e6 . Schneuer FJ, Holland AJ, Pereira G, et al. Timing of orchidopexy in children with cryptorchidism and risk of adverse outcomes. Pediatrics. 2018;142(2):e20180687. Kolon TF, Herndon CDA, Baker LA et al. Guidelines on management of cryptorchidism. J Urol . 2014. Available from: https://www.auanet.org/guidelines-and-quality/guidelines/cryptorchidism-guideline Tables Table 1. Factors associated with correct knowledge and practices regarding ATM Factor Category Correct knowledge (%) p-value 95% CI Age >35 years 38% 0.004 1.20–2.85 ≤35 years 24% Specialty Pediatricians 42% 0.002 1.30–3.40 General practitioners 29% Years of experience 15 years 39% Routine testicular examination Yes 44% <0.001 1.50–3.55 No 26% Referral to pediatric surgery Yes 39% <0.05 1.15–2.80 No / Observation 27% Pediatric surgery rotation Yes 34% 0.10 0.90–1.75 No 30% Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 22 Apr, 2026 Reviewers agreed at journal 17 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviewers invited by journal 07 Apr, 2026 Editor invited by journal 10 Mar, 2026 Editor assigned by journal 15 Feb, 2026 Submission checks completed at journal 15 Feb, 2026 First submitted to journal 12 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8862118","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":620563207,"identity":"fddb3cc4-b6fd-44e3-8b32-6352554cb7ee","order_by":0,"name":"Cyrine 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(n=504)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8862118/v1/48719d72d19539f9faf00ab9.png"},{"id":107042892,"identity":"342bafa9-04f0-4ec5-9cac-2604c2fe02f9","added_by":"auto","created_at":"2026-04-16 06:43:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":527314,"visible":true,"origin":"","legend":"\u003cp\u003eAge of distribution of participating physicians (n=504)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8862118/v1/db788862161db976db97499a.png"},{"id":107042893,"identity":"91a15f6b-f28e-452b-a072-b6d6e5a32428","added_by":"auto","created_at":"2026-04-16 06:43:57","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":255762,"visible":true,"origin":"","legend":"\u003cp\u003eKnowledge of ATM definition and age of surgery\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8862118/v1/05b420d4d4840b7b5198dbfe.jpeg"},{"id":107042894,"identity":"6fa5818d-8725-4bb8-9e2a-5d89a8321b4a","added_by":"auto","created_at":"2026-04-16 06:43:57","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":277149,"visible":true,"origin":"","legend":"\u003cp\u003eRefferal practices and age of first pediatric surgery consultation\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8862118/v1/7b0cb9f1d1c3ccfd7462d6be.jpeg"},{"id":107480768,"identity":"e19cdfa6-92a6-46cd-961d-bd70728a87cf","added_by":"auto","created_at":"2026-04-22 02:13:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1948297,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8862118/v1/e0f1845e-0fcd-484c-8b16-e1ffeb4e5a73.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eBridging the Gap in Cryptorchidism Care: Knowledge and Practices of Primary Care Physicians in Tunisia\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTesticular migration disorders, commonly referred to as cryptorchidism or abnormal testicular migration (ATM), represent one of the most common congenital anomalies of the male genital tract. Their prevalence ranges from 1\u0026ndash;4% in full-term infants and may reach 30% among preterm newborns [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although spontaneous testicular descent can occur during the first months of life, persistence beyond infancy is associated with significant long-term complications, including subfertility, increased risk of testicular malignancy, torsion, inguinal hernia, and potential psychological consequences if not appropriately managed [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e International guidelines consistently emphasize the importance of early diagnosis and timely surgical intervention. Current recommendations advocate referral within the first six months of life, with orchidopexy ideally performed before 12\u0026ndash;18 months to optimize fertility outcomes and reduce complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Delayed treatment has been shown to negatively affect germ cell maturation and long-term reproductive potential [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrimary care physicians play a central role in the early detection and management of ATM. Through routine neonatal and infant examinations, they are responsible for identifying abnormal testicular position, distinguishing between undescended, ectopic, and retractile testes, counseling parents, and ensuring timely referral to pediatric surgical services. However, previous studies have highlighted gaps in knowledge and variability in clinical practice, including confusion between clinical entities and unnecessary use of imaging modalities such as ultrasound [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Tunisia, primary care physicians constitute the first point of contact within the healthcare system and are essential for the early recognition of congenital conditions. Despite this central role, no national data are currently available regarding their knowledge, attitudes, and practices concerning ATM.\u003c/p\u003e \u003cp\u003eThis study aimed to assess the knowledge, attitudes, and practices of primary care physicians in Tunisia regarding ATM and to identify factors associated with appropriate clinical management.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and reporting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a national, descriptive, multicenter cross-sectional survey among primary care physicians in Tunisia between December 2022 and June 2023. The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.\u003c/p\u003e\n\u003cp\u003eA knowledge, attitudes, and practices (KAP) framework was adopted to evaluate current clinical behaviors and identify potential gaps in the management of abnormal testicular migration (ATM). This approach was chosen to inform future educational interventions and public health strategies at the national level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study targeted physicians involved in primary pediatric care throughout Tunisia, including general practitioners, pediatricians, family medicine residents, and pediatric residents. Participants were practicing in both public and private healthcare settings.\u003c/p\u003e\n\u003cp\u003eTo ensure national representation, recruitment encompassed physicians working in local dispensaries, school health services, regional hospitals, and university hospitals across different geographic regions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEligible participants were general practitioners and pediatricians working in public or private practice, as well as family medicine and pediatric residents currently practicing in primary or tertiary healthcare facilities in Tunisia. Participation required voluntary consent to complete the questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNon-inclusion and exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhysicians from specialties other than general medicine or pediatrics were not eligible. Retired physicians or those no longer practicing clinical medicine were excluded. Questionnaires that were incomplete or contained inconsistent responses were also excluded from the final analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated using the formula for estimating a prevalence in cross-sectional studies. In the absence of prior national data assessing physicians’ knowledge and practices regarding ATM, a conservative expected prevalence of 50% was assumed to maximize the required sample size.\u003c/p\u003e\n\u003cp\u003eWith a 95% confidence level (Z = 1.96), a margin of error of 5%, and an alpha risk of 5%, the minimum required sample size was estimated at 400 participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuestionnaire development and data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs no validated instrument currently exists to assess physicians’ knowledge, attitudes, and practices regarding ATM, a structured questionnaire was specifically developed for this study.\u003c/p\u003e\n\u003cp\u003eThe questionnaire was designed following:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eA review of the relevant literature\u003c/li\u003e\n \u003cli\u003eInternational clinical guidelines on cryptorchidism\u003c/li\u003e\n \u003cli\u003eExpert input from pediatric surgery and primary care specialists\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eContent validity was reviewed and approved by the Tunisian National Medical Council prior to dissemination.\u003c/p\u003e\n\u003cp\u003eThe final instrument consisted of 26 closed-ended questions divided into three sections:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eSociodemographic and professional characteristics\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Including age, specialty, type and location of practice, years of professional experience, and prior exposure to pediatric surgery during training.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eKnowledge assessment\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Addressing definition of ATM, recommended timing of referral and surgery, understanding of associated risks, and long-term consequences.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eClinical practices and attitudes\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Evaluating routine genital examination, use of complementary investigations, referral patterns, and perceived need for additional training.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe questionnaire was administered electronically using Google Forms. It was distributed via professional email addresses provided by the Tunisian National Medical Council, following official authorization. Data collection occurred between December 22, 2022, and June 22, 2023. Participation was voluntary and anonymous, and no financial incentives were provided.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was the reported age at referral of children with ATM to pediatric surgical services.\u003c/p\u003e\n\u003cp\u003eSecondary outcomes included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eFrequency of systematic genital examination during pediatric consultations\u003c/li\u003e\n \u003cli\u003eLevel of knowledge regarding ATM\u003c/li\u003e\n \u003cli\u003eReported diagnostic and referral practices\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using SPSS software (2019 version). Descriptive statistics were presented as absolute frequencies and percentages with 95% confidence intervals where appropriate.\u003c/p\u003e\n\u003cp\u003eAssociations between categorical variables were assessed using Pearson’s chi-square test. A p-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Habib Thameur University Hospital, Tunis, Tunisia. Authorization to distribute the questionnaire was granted by the Tunisian National Order of Physicians. Participation was voluntary, and electronic informed consent was obtained from all participants prior to completing the questionnaire. All responses were anonymous and confidentiality of the data was strictly maintained\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. No individual data are presented in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 504 physicians participated in the study (response rate based on 7800 invitations). Most participants were older than 35 years (62%) (figure 1). General practitioners represented the majority (64.5%), followed by pediatricians (19.8%) and family medicine residents (15.7%) as indicated in the figure 2. Physicians practiced across various healthcare settings, including private urban clinics (41%), university hospitals (24.6%), dispensaries (18.1%), and regional hospitals (16.1%). Nearly two-thirds were based in major urban areas (Grand Tunis or Sousse). Approximately one-third reported prior exposure to pediatric surgery during their training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge regarding ATM\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough almost all respondents (99%) reported being familiar with ATM and 80.4% had previously diagnosed the condition, detailed knowledge appeared limited. Only 30.2% correctly identified the complete definition of ATM, while others provided partial or incorrect definitions (figure 3).\u003c/p\u003e\n\u003cp\u003eMost physicians were able to differentiate between ectopic testes and cryptorchidism (74.4%) and between ectopic and retractile testes (80.4%). However, knowledge regarding optimal timing of surgery was inconsistent. While 40.9% indicated that surgery should be performed between 1 and 2 years of age, only 9.9% identified the recommended age of before one year (figure 3) . More than one-quarter (27%) reported immediate referral upon diagnosis.\u003c/p\u003e\n\u003cp\u003eEncouragingly, the majority recognized the prognostic importance of early management (95.8%). However, misconceptions persisted: half of respondents believed spontaneous descent could occur beyond infancy, and only 38.3% identified malignancy as a long-term risk. Hormonal therapy was correctly considered ineffective by 82.9% of participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttitudes and clinical practices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRoutine clinical examination practices were suboptimal. Only 53% reported systematically palpating the testes during pediatric consultations. Most physicians did not request laboratory investigations (78.6%), which aligns with recommendations. However, 61.1% reported ordering ultrasound examinations, despite guidelines discouraging routine imaging.\u003c/p\u003e\n\u003cp\u003eReferral practices were generally appropriate, with 88% referring patients to pediatric surgeons. Nevertheless, the timing of referral varied considerably. Only 31.7% referred children between 6 and 12 months of age, while others delayed referral until preschool age or beyond (figure 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors associated with knowledge and practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetter knowledge was significantly associated with older age (\u0026gt;35 years), pediatric specialization, longer professional experience (\u0026gt;15 years), practice in tertiary centers or major urban regions, and routine performance of testicular examination (p \u0026lt; 0.05). Early referral to pediatric surgery was also positively correlated with correct knowledge.\u003c/p\u003e\n\u003cp\u003eExposure to pediatric surgery during training showed a positive trend toward better knowledge, although this did not reach statistical significance ( table 1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis national survey reveals substantial variability in knowledge and practice regarding ATM among primary care physicians in Tunisia. While self-reported familiarity with the condition was high, detailed understanding of definitions and guideline-recommended timing of surgery was frequently incomplete.\u003c/p\u003e\n\u003cp\u003eMisclassification between retractile, ascending, and undescended testes emerged as a recurring issue, consistent with findings from international studies [5–7]. Importantly, delayed referral appears to stem more from diagnostic uncertainty and misconceptions about spontaneous descent than from structural barriers to surgical access.\u003c/p\u003e\n\u003cp\u003eAlthough most physicians acknowledged the importance of early management, only a minority correctly identified the recommended age for orchidopexy. Similar discrepancies between theoretical awareness and practical implementation have been reported in other healthcare settings [1,3,9].\u003c/p\u003e\n\u003cp\u003eThe persistent overuse of ultrasound reflects a gap between evidence-based guidelines and real-world practice [3,7,10]. This may indicate defensive medical behavior, parental reassurance demands, or insufficient dissemination of guideline recommendations.\u003c/p\u003e\n\u003cp\u003ePhysicians practicing in tertiary centers and those with pediatric specialization demonstrated better knowledge and more appropriate referral practices. These findings suggest that structured exposure to pediatric surgery and continuing professional development may improve adherence to recommendations.\u003c/p\u003e\n\u003cp\u003eTargeted educational strategies should therefore focus particularly on physicians practicing in peripheral regions.\u003c/p\u003e\n\u003cp\u003eFrom a public health perspective, strengthening collaboration between primary care and pediatric surgical services is essential. Simplified referral algorithms, continuing medical education programs, and incorporation of guideline-based content into undergraduate and postgraduate curricula may help reduce delays and improve long-term outcomes.\u003c/p\u003e\n\u003cp\u003eStrengths of this study include its national scope and large, diverse sample of primary care providers. Limitations include potential response bias and the absence of a previously validated KAP questionnaire. Nevertheless, this study provides the first national overview of primary care practices regarding ATM in Tunisia.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite high levels of self-reported familiarity with abnormal testicular migration, significant gaps persist in detailed knowledge and clinical practice among primary care physicians in Tunisia. Delayed referral and unnecessary imaging remain common.\u003c/p\u003e\n\u003cp\u003eTargeted educational interventions and strengthened collaboration between primary care and pediatric surgery services are crucial to ensure timely, evidence-based management and to optimize long-term reproductive outcomes in affected children.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eC.B and M.B did the data collection C.S and S.L wrote the main manuscript text A.D and Y. H reviewed the papierAll authors reviewed the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThe authors would like to thank all primary care physicians who participated in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Urological Association. Evaluation and Treatment of Cryptorchidism: AUA Guideline. Published; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpencer BA, Liu DB, Nehra D et al. Cryptorchidism: review for the primary care provider. \u003cem\u003eSouth Dakota State Medical Association\u003c/em\u003e. 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/37603872/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/37603872/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRadmayr C, Bogaert G, Dogan HS, et al. EAU guidelines on paediatric urology. Eur Urol. 2023;84(1):1\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHutson JM, Li R, Southwell BR, Petersen BL, Thorup J, Cortes D. Germ cell development in the descended and cryptorchid testis and the effects of orchidopexy. Pediatr Surg Int. 2015;31(4):317\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePresson AP, Rodgers BM, Canning DA. Undescended testis: level of knowledge among potential referring health-care providers. \u003cem\u003eJ Paediatr Child Health\u003c/em\u003e. 2015;51(3):315\u0026ndash;321. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/25939451/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/25939451/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCools M, van de Velde S, van Bogaert P et al. National survey of physicians in Swedish child health centres finds insecurity and unawareness regarding management of undescended testicles. \u003cem\u003eActa Paediatr\u003c/em\u003e. 2024;113(5):1034\u0026ndash;1042. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/38415505/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/38415505/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaha OA, Aldossary N, Alqarni A et al. Knowledge and awareness of screening for children with cryptorchidism in Al-Qunfudhah Governorate, Saudi Arabia: a nationwide cross-sectional study. \u003cem\u003eJ Pediatr Urol\u003c/em\u003e. 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/38846244/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/38846244/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrump T, Elbakry AA, Al-Omar O. Referral patterns for undescended testis: a comparative analysis before and after guideline publication. J Pediatr Urol. 2021;17(5):736. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ee1-736.e6\u003c/span\u003e\u003cspan address=\"http://e1-736.e6\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchneuer FJ, Holland AJ, Pereira G, et al. Timing of orchidopexy in children with cryptorchidism and risk of adverse outcomes. Pediatrics. 2018;142(2):e20180687.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolon TF, Herndon CDA, Baker LA et al. Guidelines on management of cryptorchidism. \u003cem\u003eJ Urol\u003c/em\u003e. 2014. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.auanet.org/guidelines-and-quality/guidelines/cryptorchidism-guideline\u003c/span\u003e\u003cspan address=\"https://www.auanet.org/guidelines-and-quality/guidelines/cryptorchidism-guideline\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Factors associated with correct knowledge and practices regarding ATM\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"691\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorrect knowledge (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026gt;35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.20\u0026ndash;2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026le;35 years\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e24%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecialty\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePediatricians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.30\u0026ndash;3.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eGeneral practitioners\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e29%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e31%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.10\u0026ndash;2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e5\u0026ndash;15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e27%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026gt;15 years\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e39%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRoutine testicular examination\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.50\u0026ndash;3.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e26%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReferral to pediatric surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e39%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.15\u0026ndash;2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eNo / Observation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e27%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePediatric surgery rotation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e34%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.90\u0026ndash;1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Abnormal testicular migration (ATM)- Primary care physicians- Pediatric care-Knowledge, attitudes, practices (KAP)- Early detection- Surgical referral","lastPublishedDoi":"10.21203/rs.3.rs-8862118/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8862118/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAbnormal testicular migration (ATM), or cryptorchidism, is a common congenital condition in boys, with early detection and timely surgical referral crucial to prevent long-term complications such as infertility and testicular cancer. Primary care physicians (PCPs) play a key role in identifying and managing ATM, but their knowledge and practices in Tunisia remain poorly understood.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e This national cross-sectional survey, conducted from December 2022 to June 2023, assessed the knowledge, attitudes, and practices of 504 PCPs involved in pediatric care across Tunisia using a structured electronic questionnaire. Sociodemographic data, knowledge of ATM, and clinical practices were collected, and associations between variables were analyzed using chi-square tests (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAlthough nearly all participants reported familiarity with ATM, only 30.2% correctly defined the condition. Knowledge of optimal timing for surgical correction was limited, with fewer than 10% recognizing that surgery before one year of age aligns with international guidelines. Misconceptions persisted regarding spontaneous testicular descent and long-term risks. Routine testicular examinations were inconsistently performed, and ultrasounds were frequently requested despite guideline recommendations. Most physicians referred patients to pediatric surgeons, yet referral timing varied. Higher knowledge scores were significantly associated with pediatric specialization, longer clinical experience, urban practice, and routine genital examination.\u003c/p\u003e\u003ch2\u003eConclusion :\u003c/h2\u003e \u003cp\u003eIn conclusion, while awareness of ATM is widespread among Tunisian PCPs, gaps remain in detailed knowledge and adherence to evidence-based practices. Strengthening continuing medical education and improving collaboration with pediatric surgical services could enhance early detection and standardize management, ultimately reducing the risk of adverse outcomes for affected children.\u003c/p\u003e","manuscriptTitle":"Bridging the Gap in Cryptorchidism Care: Knowledge and Practices of Primary Care Physicians in Tunisia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-16 06:43:52","doi":"10.21203/rs.3.rs-8862118/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-22T21:43:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5249227916515392435025967763566210051","date":"2026-04-17T15:24:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152952715698892006980087081153620208559","date":"2026-04-15T01:16:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-07T18:52:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-10T19:05:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T02:26:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-16T02:25:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2026-02-12T12:20:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fe976154-1a97-4d29-97bb-d2599c92b38e","owner":[],"postedDate":"April 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-16T06:43:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-16 06:43:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8862118","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8862118","identity":"rs-8862118","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}