Genitalia Flashcards
What process of development can lead to predisposition to development of inguinal hernia or hydrocele?
The processus vaginalis is the tongue of peritoneum that precedes the migrating testis through the inguinal canal - normally it becomes obliterated after birth but sometimes this fails and the predisposition occurs
What sort on inguinal hernias do children get?
Indirect normally always because due to the patent processus vaginalis - therefore comes through inguinal canal
In whom are inguinal hernias more common?
Boys and preterm infants
Which side do inguinal hernias typically occur on?
Typically on the right side
How do inguinal hernias usually present?
Intermittent swelling in groin on crying or straining
Can make it visible by raising intra-abdominal pressure - by placing hand on abdomen or asking them to cough
How else can inguinal hernia present?
Can also present as irreducible lump in groin or scrotum, which is firm and tender
This child can be unwell with irritability and vomiting
Can “irreducible” hernias be reduced
Most can be reduced with opoid analgesia and gentle compression
Then delay surgery for 24-48 hours to allow oedema to go down
What to do if hernia can’t be reduced
Surgery is required as emergency because otherwise bowel can strangulate and can also damage the testis
Surgery to treat inguinal hernia
Ligation and division of hernial sac (processus vaginalis) via inguinal skin crease incision
Usually done as day case
What is a hydrocele?
If processus vaginalis is too narrow to allow bowel through to form an inguinal hernia then fluid can still track down it and go around testis to form hydrocele
Presentation of hydrocele symptomwise
Asymptomatic scrotal swelling. Usually bilateral and may be bluish
Can be tense or lax but non-tender and transilluminate
Presentation of hydrocele time wise
Some are evident at birth but some present in early childhood following viral or GI illness
Most will resolve spontaneously when PV continues to obliterate
Management of hydrocele
Most go automatically
Consider surgery if still present beyond 18-24 months of age
What is cryptorchidism?
Undescended testes
Incidence of undescended testes
4% of term male infants will have unilateral or bilateral undescended testes
When are undescended testes more common?
Preterm infants because descent through inguinal canal occurs in 3rd trimester
What can occur post birth with undescended testes?
Can continue to descend during early infancy and by 3 months of age 1.5% incidence
What can occur to a testes which was fully descended at birth?
Can ascend back into an inguinal position during childhood - will have late presentation of undescended or “ascended” testes
Examination of undescended testes?
In a warm room with warm hands - it is possible to bring testes into a palpable position by gently massaging contents of inguinal canal down
What is retractile testes?
Can be brought down but will be pulled back up into inguinal region by cremasteric muscle
With age testes will permenantly reside in scrotum
What is palpable testes?
Can be palpated in groin but cannot be manipulated into scrotum
What is impalpable testes?
No testis can be felt on examination - can be in inguinal canal, intra-abdominal or absent
Investigations for undescended testes?x 3
Ultrasound
Hormonal - testicular tissue if present will produce rise in serum testosterone after IM injection of HCG
Laparoscopy
Management of undescended testes?
Surgical placement of testis in scrotum - orchidopexy
Reasons for orchidopexy?
Fertility and malignancy risk
Also psychological
Fertility after orchidopexy?
After unilateral undescended testes is close to normal
But reduced to 50% if bilateral palpable undescended testes
If bilateral impalpable undescended testes - usually sterile
Malignancy after orchidopexy?
Risk is greatest for bilateral undescended testes - greatest risk for intraabdominal
Early orchidopexy for unilateral undescended testes reduces risk to almost normal
What is a varicocele?
Variscosities of testicular veins which can develop around puberty
Where are varicoceles normally?
On the left
Association of varicoceles
Associated with reduced fertility
When do you treat varicocele
If symptoms of dragging/aching, if impaired testicular growth or if infertility
Treatment of varicocele?
Obliteration of testicular veins by conventional surgery, laparoscopy or radiological embolisation
Causes of acute scrotal symptoms x5
Testicular torsion Torsion of testicular appendage Viral/bacterial epididymo-orchitis or epididymitis Idiopathic scrotal oedema Incarcerated inguinal hernia
When is testicular torsion most common?
In adolescents but can occur at any age
Presentation of testicular torsion
Pain - not always in scrotum but may be in groin or lower abdomen
Can get atypical presentation therefore suspect in any boy/young pain with inguinal/lower abdominal pain
Time for treatment of testicular torsion
Must be treated within 6-12 hours of onset to maintain testicular viability
Management of testicular torsion
Surgery with fixation of contralateral testis because can be anatomical predisposition to torsion - such as bell clapper testis where testis is not anchored properly
What sort of testis is associated with increased risk of torsion
Undescended testes - also at risk of confusion with incarcerated hernia
What is torsion of testicular appendage
Torsion of the hydratid of Morgagni which is an embroyological remnant on upper pole of testes
When does torsion of testicular appendage typically occur?
It typically occurs in boys just before puberty due to rapid enlargement of hydratid in response to hormones
Presentation of torsion of testicular appendage
Pain may increase over 1-2 days and occasionally torted hydratid can be seen or felt (blue dot sign)
Management of torsion of testicular appendage
Surgical exploration and excision of appendage
What can epididymitis be associated with
UTI
Presentation of idiopathic scrotal oedema
Painless bilateral scrotal swelling and redness in pre-school children
What is hypospadias?
Failure of urethral tubularisation leading to urethral opening not being in normal position on glans but instead being located proximally
Features of hypospadias?
Ventral urethral meatus
Hooded dorsal foreskin
Chordee - ventral curvature of penis shaft most apparent on erection (only marked in more severe forms)
Incidence of hypospadias
Common congenital abnormality
1 in 200 boys
Surgery for hypospadias
Often done before 2 years of age to correct penis for cosmetic and functional reasons
Foreskin retraction in developing penis
At birth foreskin is adherent to the glans
Adhesions separate over time making the foreskin eventually more mobile and retractable
At 1 year - 50% have non-retractable
At 4 years - 10% have non-retractable
At 16 years - 1%
Circumcision recommendations
Not recommended anywhere as routine neonatal procedure - only a few medical indications
3 medical indications for circumcision
Phimosis
Recurrent balanoposthitis
Recurrent UTI
What is phimosis?
Inability to retract foreskin - pathological not physiological
Will have whitish scarring of foreskin
What causes phimosis?
Localised skin disease known as balanitis xerotica obliterans - can also cause meatal stenosis
Age of phimosis?
Rare before age 5
What is balanoposthitis?
Redness and inflammation of foreskin and glans, sometimes with purulent discharge
Management of balanoposthitis?
If occurs once, common and can be treated with warm baths and antibiotics
If recurrent - uncommon and circumcision may be indicated
When is circumcision indicated with UTI
If upper urinary tract problems complicated by recurrent UTI’s
What other than surgery can be used to help irritractable foreskin?
Topical corticosteroids to the prepuce to facilitate retraction
What is paraphimosis
Foreskin trapped in retracted position proximal to a swollen glans
Management of paraphimosis
Adequate analgesia to help reduce foreskin
Problem not usually recurrent
What are labial adhesions
Adhesions of labia minora in midline
Management of labial adhesions
If asymptomatic can be left alone and will often lyse spontaneously
If perineal soreness or urinary irritation - topical oestrogen 2x day for 1-2 weeks
