Genitalia Disorders

Question 1

Give 3 examples of acute scrotal disorders in children

Answer 1

Testicular torsion = Most common around puberty

Irreducible inguinal hernia = Most common in children < 2 years old

Epididymitis = Rare in prepubescent children

Question 2

What is testicular torsion? features

Answer 2

Basics

• twist of the spermatic cord resulting in testicular ischaemia and necrosis.
• most common in males aged between 10 and 30 (peak incidence 13-15 years)

Features

• pain is usually severe and of sudden onset
• the pain may be referred to the lower abdomen
• nausea and vomiting may be present
• on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened
• cremasteric reflex is lost
• elevation of the testis does not ease the pain (Prehn’s sign)

Question 3

How do we treat testicular torsion?

Answer 3

More viable within 4-6 hr sx onset

If suspected → admit ASAP urology/paediatric surgery

• IV fluids, antiemetics, analgesia

Non-neonates

• immediate urological consultation for operative repair
• w/ supportive care = morphine sulfate and ondansetron
• decision about orchidectomy vs orchidopexy based on extent of damage to testicular tissue
• contralateral testicle fixed to posterior wall

Neonates

• born with torsion = ?surgical intervention (risk of anaesthesia)
• born with normal testes but develop torsion = urgent surgical exploration
• supportive care = morphine sulfate and ondansetron

Manueal de-torsion if surgery not available within 6 hours

Supportive care

• pain relief and sedation
• anti-emetics

Question 4

Where is undescended testis more common?

Answer 4

Undescended testis occurs in around 2-3% of term male infants, but is much more common if the baby is preterm. Around 25% of cases are bilateral.

Question 5

Complications of undescended testis

Answer 5

infertility

torsion

testicular cancer

psychological

Question 6

How do we manage undescended testis? aka Cryptorchism

Answer 6

< 3 months

• If possibility of disorder of sexual development (e.g. ambiguous genitalia or hypospadias)
• Urgently refer to a senior paediatrician within 24 hours as genetic or endocrine testing may be necessary

If undescended testes are bilateral at birth

• Urgently refer to a senior paediatrician within 24 hours as genetic or endocrine testing may be necessary

If unilateral undescended testis

At birth - arrange review at 6-8 weeks

At 6-8 weeks`:

• If both testes are descended, no further action is necessary
• If unilateral undescended testis, re-examine at 3 months

At 3 months

• If both testes are descended, no further action is needed
• If both testes are in the scrotum, but one or both are retractile, advise the parents that annual follow up is needed throughout childhood as there is a risk of ascending testes
• If the testis is still undescended, refer the child to a paediatric surgeon before 6 months of age

If uncertain between undescended or retractile - referral for clarification of diagnosis

Surgery

Undescended palpable testis → Orchidopexy (placement of testis in the scrotum) is performed for the following reasons:

• Cosmetic
• Reduced risk of trauma and torsion
• Fertility (particularly important if bilateral)
• Malignancy (increased risk in an undescended testis) (Ideally, surgery should be performed <1 year of age)

Undescended non-palpable testis → Laparoscopic inguinal surgical exploration with subsequent orchidopexy/orchidectomy

• Orchidolysis- by 12 months
• Orchidopexy- by 18 months
• In 10% of impalpable testis, they have regressed in development and are absent

Summary

If undescended by 3 months, refer to paediatric surgery (before 6 months)

Orchidopexy should be considered from 3 months

Question 7

Ambigious genitalia: physiology on how genitalisa form and most common cause of ambiguous genitalia in newborns

Answer 7

Basic physiology

• initially gonads in fetus are undifferentiated
• on the Y chromosome there is a sex-determining gene (SRY gene) which causes differentiation of the gonad into a testis
• if absent (i.e. in a female) then the gonads differentiate to become ovaries

Most common cause in newborns is congenital adrenal hyperplasia. Other causes include:

• true hermaphroditism
• maternal ingestion of androgens

Question 8

What is phimosis and how do we manage it?

Answer 8

non-retractile foreskin and/or ballooning during micturition in a child under 2

• will resolve in time
• personal hygiene

Over 2 years + recurrent balanoposthitis (inflammation of glans penis and prepuce) or UTI

• consider treatment