Genital Flashcards
Migration of the testis physiology
Originates on posterior abdominal wall
Testosterone acts on peripheral tissues
Migration guided by mesenchymal gubernaculum
Layers are collected from abdominal wall and guided through inguinal canal
Scrotal contents
Testis
Vas
Blood vessels
Labial content
Attachment of the round ligament of the uterus
Features inguinal hernia
Common
Risk factor: prematurity
Persistently patent processus vaginalis
Emerges through deep inguinal ring through inguinal canal (indirect)
Lump in the groin which may extend to the scrotum or labium
Asymptomatic and intermittent
Thickened cord structure palpable in the groin
Features of strangulated hernia
Tender lump
Irritability
Vomiting
Greater risk in infants
Mx Hernias
Most successfully reduced by taxis
Surgery planned for time when oedema has settled and child is well
Emergency surgery required if strangulated
Surgery: ligation and division of processes vaginalis (hernial sac)
Surgery performed >3m old
Feature hydrocele
Asymptomatic Sometimes appear blue Testis still papable Hydrocele is separate from testis -differentiates from hernia Transilluminates
Mx hydrocele
Resolves spontaneously: patent vaginalis closes
Surgery is persisting beyond 2y
Features varicocele
Scrotal swelling
Dilated varicose testicular veins (bag of worms)
Common in boys, especially at puberty
Due to valvular incompetence
Commoner on left : drainage of gondal vein into renal vein (catecholamine from left adrenal)
Dull ache
Bluish colour
Testis may be smaller or softer than normal
Mx Varicocele
Conservative if asymptomatic
Occlusion of gonadal vein by surgical ligation
-laparoscopic through groin
-radiological embolisation
Features undescended testis
5% newborn term infants but more common in preterm
Most resolve by 3 months (1% still undescended)
Identified on routine examination of the newborn
Testis examination for undescended testis
Warm room and warm hands
Testis felt in scrotum or delivered by gentle pressure along inguinal canal
May be palpable or impalpable
Location of undescended testis
Groin
Below the external inguinal ring, outside scrotum (ectopic)
impalpable: in abdomen or absent
Mx bilateral undescended testis
Karotype to exclude disorders of sex development
Features retractile testis
Can be manipulated into the scrotum with ease and without tension
Action of the cremaster muscle pulls up the testis
More prominent when warm and relaxed
Mx Undescended testis
Referral by 3m, surgical appt by 6m
Procedure performed at 1y
Surgical placement of testis in the scrotum (orchidopexy)
-groin approach
-opening inguinal canal and mobilising testis
Functions of orchidopexy
Cosmetic with possible testis prosthesis when older
Reduced risk of torsion and trauma
-lying transversely on attachment to spermatic cord (clapper ball testis)
Fertility
Malignancy
Features Torsion of the Testis
Typically post-pubertal boys Can occur at any age Very painful Redness and odema of scrotal skin Pain localised to groin or abdomen
Mx Torsion of the testis
Must be treated within hours
Surgical exploration is mandatory
Fixation of contralateral testis
Testicular loss in delay (esp. perinatal torsion)
Features torsion of appendix testis
Hydatid or Margani is Mullerian remnant located in upper pole of testis Affects pre pubertal boys More common than testis torsion Pain evolves over days Blue dot is pathognomonic
Mx Appendix testis torsion
Surgical exploration and excision of appendix (in case of torsion)
If proven- control pain with analgaesia
Features Epidiymitis
Inflammed epidiymis
Commoner in infants and small children
Associated with pre-exciting urological or rectal malformation
Small hydrocele and swollen testis
Mx epidymitis
Usually surgical exploration in case of torsion
US of flow pattern allows differentiation from torsion
Pus sent for microbiology
Empirical antibiotics
Features idiopathic scrotal oedema
Redness and swelling
Extending beyond scrotum into the thigh, perineum and surapubic area
Testis normal and non-tender
Mx idiopathic scrotal oedema
Analgesia and review
Red Flag Vaginal discharge
Blood vaginal discharge
dDx: vaginal rhabdomyosarcoma
Rare
Occurs in pre-school girls
Features labial adhesions
Fusion of the labial minora
Can cause local irritation
Usually adequate orifice for passage of urine
Transluscent/bluish flimsy tissue between labia
Mx labial adhesions
Non required
Topical corticosteroids or oestrogens may lyse lesions
Re-adhesion is common
Formal division of adhesions undertaken rarely
Features true obstruction of vagina
Rare
Primary amenorrhea in adolescents
Cyclical abdo or pelvic pain
Bulging introitus that appears blue (imperforate hymen)
No imperforate hymen: problem of vaginal canalisation
Mx imperforate hymen
Hymenectomy under anaesthesia
Features normal foreskin retraction
Does not retract in infancy
50% non-retractile at 1y
Sub-preputial smegma: lump growing under foreskin
Ballooning of foreskin: incomplete lysis of preputial adhesions
Features balanoposthitis
Extensive redness Sore prputial opening Purulent discharge Occurs 3% of boys Peak incidence 3y
Mx balanoposthitis
Anibiotics
Topical corticosteroids
Features non-retractile foreskin
Preputial opening does not evert on retraction of the foreskin
Most commonly caused by balanitis (progressive scarring)
Indications for circumscision
Balanitis causing true phimosis
Recurrent balanoposthitis causing refractory symptoms
Prophylaxis as UTI
Access required for intermittent catherterisation
Possible protection against HIV and HPV
Cx circumcision
Post-op bleeding (2%) Infection in the skin margin Ulceration of exposed granular skin Meatal stenosis (most common in Hx balanitis)- require subsequent surgery Urethral fistula
Features paraphimosis
Usually post-pubertal boys Retracted foreskin not reduced easily Ring of narrower skin Glans swelling Compromise to glans blood supply
Mx paraphimosis
Surgical emergency
Reduction of foreskin surgically under GA
Circumcision in balanitis
Features Hypospadius
Common (1/200)
Failure of development of ventral tissue of penis
Ventral urethral meatus
Ventral curvature of shaft of the penis (more apparent on errection)
Hooded appearance of foreskin (deficiency of ventral skin)
Mx hypospadius
Surgery not indicated if penis and urinary stream are straight
function or cosmetic indications
Surgery performed within 2-3y of life
Cannot be circumcised before repair incase prepuce is required for repair
Cx hypospadius surgery
Breakdown of repair
Meatal narrowing
Location of hypospadius
Glanular (Most common)
Coronal
Midshaft
Penoscrotal
