Genitalia

Question 1

Are most disorders of the genitalia in childhood in boys or girls?

Answer 1

Boys

Question 2

What are some inguinoscrotal disorders in boys?

Answer 2

Inguinal hernia
Hydrocele
Undescended testis
Varicocele

Question 3

What causes an inguinal hernia?

Answer 3

They are almost always indirect and due to a patent processus vaginalis.

Question 4

In which children are inguinal hernias more common and which side?

Answer 4

Much more frequent in boys and are particularly common in premature infants. They are more common on the right side

Question 5

How do inguinal hernias usually present in children?

Answer 5

Intermittent swelling in the groin or scrotum on crying or straining. The groin swelling may become visible on raising the intra-abdominal pressure by gently pressing on the abdomen or asking the child to cough.

Question 6

How do inguinal hernias present in infants?

Answer 6

An irreducible lump in the groin or scrotum. The lump is firm and tender. The infant may be unwell with irritability and vomiting.

Question 7

How would you manage an inguinal hernia?

Answer 7

Most ‘irreducible’ hernias can be successfully reduced following opiod analgesia and sustained gentle compression. Surgery is delayed for 24-48 hours to allow resolution of oedema. If reduction is impossible, emergency surgery is needed

Question 8

Why does an inguinal hernia need to be reduced quickly?

Answer 8

Because of the risk of strangulation of bowel and damage to the testis. A hernia associated with undescended testis should be operated early to minimise risks to the testis.

Question 9

What is a hydrocele?

Answer 9

A patent processus vaginalis, which is sufficiently narrow to prevent formation of an inguinal hernia, may still allow peritoneal fluid to track down around the testis to form a hydrocele.

Question 10

How do hydrocele’s present?

Answer 10

They are asymptomatic scrotal swellings, often bilateral and sometimes with a blueish discolouration. They may be tense of lax but are non-tender and transilluminate.

Question 11

What might stimulate a presentation of a hydrocele?

Answer 11

Some are not evident at birth but present early in childhood after a viral or gastrointestinal illness.

Question 12

How would you manage a hydrocele?

Answer 12

The majority resolve spontaneously as the processus continues to obliterate, but surgery is considered if it persists beyond 18-24 months of age..

Question 13

What is undescended testis?

Answer 13

An undescended testis has been arrested along its normal pathway of descent. It can be unilateral or bilateral

Question 14

In which infants is undescended testis more common?

Answer 14

Preterm infants, descent occurs through the third trimester and may continue into early infancy

Question 15

How would you examine an undescended testis?

Answer 15

It should be carried out in a warm room, with warm hands and a relaxed child. The testis can then be brought down into a palpable position by gently massaging the contents of the inguinal canal towards the scrotum

Question 16

How would you classify undescended testis?

Answer 16

Retractile - can be manipulated into the bottom of the scrotum without tensions but subsequently retracts
Palpable - can be palpated in the groin but cannot be manipulated into the scrotum
Impalpable - no testis can be felt on detailed examination

Question 17

What investigations would you perform on an undescended testis?

Answer 17

US
Hormonal (in bilateral impalpable testes - the presence of testicular tissue is proven by rise in testosterone after IM injections of hCG)
Laparoscopy - used in impalpable testis

Question 18

How would you treat undescended testis?

Answer 18

Surgical placement of the testis in the scrotum (orchidopexy) to correct infertility, increased risk of malignancy and cosmetic and psychological factors

Question 19

What is a varicocele?

Answer 19

Varicosities of the testicular veins may develop in boys around puberty. They are usually on the left side and their is an association with subfertility

Question 20

How do you treat varicocele?

Answer 20

Surgery to improve symptoms (dragging, aching), impaired testicular growth and, in later life, for infertility

Question 21

What are some acute disorders of the scrotum?

Answer 21

Torsion of the testis
Torsion of the testicular appendage
Infection

Question 22

When is testicular torsion most common?

Answer 22

In adolescents, but it may occur at any age, including the perinatal period

Question 23

How does testicular torsion present?

Answer 23

The pain is not always centred on the scrotum but may be in the groin or lower abdomen. There may be a history of previous self-limiting episodes. Atypical presentation is not unusual

Question 24

When should testicular torsion be treated?

Answer 24

Within 6-12 hour of the onset of symptoms for there to be a good chance of testicular viability.

Question 25

How do you treat testicular torsion?

Answer 25

Surgical exploration is mandatory unless torsion can be excluded. Fixation of the contralateral testis is essential because there may be an anatomical predisposition to torsion.

Question 26

What is torsion of the testicular appendage and when does it occur?

Answer 26

A hydatid of Morgagni is an embryological remnant found on the upper pole of the testis. Torsion of this appendage characteristically affects boys just prior to puberty

Question 27

How does torsion of the testicular appendage present?

Answer 27

The pain may increase over 1 or 2 days and occasionally the touted hydatid can be seen or felt (the blue dot sign)

Question 28

How would you treat torsion of the testicular appendage?

Answer 28

Surgical exploration and excision of the appendage leads to rapid resolution of the problem

Question 29

What infection may cause an acute scrotum in infants and toddlers?

Answer 29

Viral or bacterial epididymo-orchitis or epididymitis

Question 30

What are some abnormalities of the penis?

Answer 30

Hypospadias
Circumcision
Paraphimosis

Question 31

What is hypospadias?

Answer 31

In the male fetus, urethral tubularisation occurs in a proximal to distal direction under the influence of fetal testosterone. Failure to complete this process leaves the urethral opening proximal to the normal meatus on the glans and this is termed hypospadias

Question 32

What are the presenting features of hypospadias?

Answer 32

It may be solely cosmetic concerns but it may cause functional problems including an inability to micturate in a normal direction and erectile disformity

Question 33

When is surgery for hypospadias performed?

Answer 33

Correction is often undertaken before 2 years of age, often as a single-staged operation.

Question 34

Should infants with hypospadias be circumcised?

Answer 34

No, the foreskin if often needed for later reconstructive surgery

Question 35

What physiological thing can a non-retractile foreskin often lead to?

Answer 35

Ballooning on micturition

Question 36

What are some medical indications for circumcision?

Answer 36

Phimosis (inability to retract foreskin)
Recurrent balanoposthitis (redness and inflammation of the foreskin)
Recurrent UTIs

Question 37

What is paraphimosis?

Answer 37

The foreskin becomes trapped in the retracted position proximal to a swollen glans. The foreskin can usually be reduced, but adequate analgesia is needed to achieve this.

Question 38

What are some genital disorders in girls?

Answer 38

Inguinal hernias
Labial adhesions
Vulvovaginitis/vaginal discharge

Question 39

What happens in inguinal hernias in girls?

Answer 39

Much less common than in boys. The ovary becomes incarcerated in the hernial sac and can be difficult to reduce.

Question 40

What are the causes of vaginal discharge in young girls?

Answer 40

Infection (bacterial or fungal)
Specific irritants
Poor hygiene
Sexual abuse