Inguinoscrotal

Question 1

What is physiological phimosis and when is it normal until?

Answer 1

80% have non-retractile foreskin at birth. Usually retracts from age 2-6, if not retracted after this could still be normal just taking longer

Question 2

What is smegma in a child?

Answer 2

Physiological substance that is produced to build up under foreskin to help stretch the foreskin. Will self resolve in a few years

Question 3

Ammoniacal dermatitis?

Answer 3

Urine can irritate the glans therefore avoid wet nappies, avoid urine too long in glans, withdraw to wash if possible (not forced) - then immediately replace to prevent paraphimosis

Question 4

Causes and treatment of balanitis?

Answer 4

Irritation from: urine, soaps, children fiddling/infection (including forced retraction)
Infection: bacterial, STI, fungal - candida nappy rash in infants
Dermatologic: psoriasis, eczema, lichen sclerosis

Tx: 1% hydrocortison if irritation, topical antibiotic if infection (although ?if effective; oral if severe)
Soak in warm water can ease discomfort, avoid triggers, antifungal cream if required

Question 5

Treatment of phimosis?

Answer 5

No treatment required unless causing repeated irritation/infection or problems with urine stream
Topical steroids (low-medium dose just as effective as high-dose)

Question 6

Residual phimosis?

Answer 6

Sometimes does not retract evenly and can have small residual areas - this is normal. Can lead to a day or two of soreness and dysuria.

Question 7

Ballooning and treatment?

Answer 7

Not an issue except sometimes can cause residual urine to be trapped and increase the risk of balanitis or spotting on underpants
Treatment is longer than for regular phimosis: 0.05% betamethasone tds 6-12 weeks - success rate 90%, recurrence rate 17%

Question 8

When would circumcision be indicated?

Answer 8

• If recurrent issues with physiological phimosis - balanitis/infection/days off school - try to avoid before age 5/6 as usually naturally resolves
• If scarring not responsive to topical steroids

Question 9

What is pathologic phimosis and what is its treatment?

Answer 9

• Small ring of scarring visible, from repeated infections or trauma.
• Problems with physiological phimosis in children

Betamethasone 0.05% 2-3 times daily for 2-4 weeks and review. If good response, 6-12 weeks. If no improvement, refer - could respond in early stages but if not then will progress
Balanitis Xerotica Obliterans is rare in <8 year olds - an aggressive scarring condition that needs circumcision

Question 10

Treatment for labial adhesions?

Answer 10

Can leave alone if asymptomatic, self-resolves. Otherwise Premarin 0.1% E with glove or cotton bud once daily for 2/52 on adhesions

Question 11

What would be your approach if there is a palpable non descended testis at 6/52

Answer 11

May take up to 3 months to descend in many infants (occurs in 50% with undescended testes), therefore reexamine at 3-4 months (more common in prematurity)

Question 12

What would be your approach if there is a palpable non descended testis at 3/12

Answer 12

Send referral - it is rare for it to descend after 3/12

Question 13

What is the best time to do an orchidopexy?

Answer 13

Controversial but about from 6-12 months (definitely not before 6 months) - to maximise fertility

Question 14

What is congenital adrenal hyperplasia and how does it present?

Answer 14

Defect in adrenal glands in utero causing them to release androgens rather than cortisone. Results in ambiguous genitalia in a genotype female, occasionally if severe can cause normal male genitalia with undescended testes (ovaries inside abdomen)

Question 15

What are the differential diagnoses of bilateral non palpable testes at 6/52 and what would you do?

Answer 15

Bilateral undescended testes; CAH. Needs

• karyotype
• serum electrolytes (looking for low sodium)
• US (?presence of testes, ?morphology of internal genitalia)

Question 16

What is your management plan if initial undescended testes are now palpable at 3/12?

Answer 16

No further intervention but ongoing follow up as those with delayed testicular descent in the first three months are at increased risk of acquired undescended testes - review at 2, 4, 6 years of age.

Question 17

What does a hypoplastic scrotum suggest?

Answer 17

Given the scrotum enlarges to accomodate the testes this suggests that the testis has never been in it

Question 18

What is the prognosis if orchidopexy is performed before one year of age?

Answer 18

Excellent

Question 19

What causes a retractile / ascended testis?

Answer 19

A processus vaginalis that instead of obliterating to become the tunica vaginalis, leaves a small fibrous remnant which then fails to elongate with the child’s growth (if tunnel remains widely patent then an inguinal hernia forms, if partially then a hydrocoele)

Question 20

History of intermittently palpable testis. What history/examination should be performed?

Answer 20

Confirm that testes were in scrotum at birth (nil concerns from hospital staff, blue book, etc. Exam:

• testis palpable
• can it be manipulated into the scrotum and does it stay there
• size of contralateral testis

Question 21

What does an enlarged unilateral testis indicate? What should be done with this?

Answer 21

Bigger than the size of the glans (or >2mL), that there is compensatory hypertrophy e.g. has there been perinatal torsion and atrophy.
US to ensure not a tumour

Question 22

Differential diagnosis of previously palpable testis now impalpable?

Answer 22

Likely: retractile testis, rare: torsion and atrophy (check other side for size)

Question 23

What is the natural history of a rectractile testis?

Answer 23

About half will have the remnant obliterate and resolve, and half will not and will become worse to become an acquired undescended testis

Question 24

What is the management plan for a retractile testis?

Answer 24

The aim of management is to determine which group the patient is in - resolve or not resolve. It is best to refer to a paediatric surgeon to follow and decide on this (often if stays in groin after manipulation will follow, if doesn’t then will operate).

Question 25

What is the GP’s role in the management of the retractile testis that is being monitored?

Answer 25

Examine the scrotum opportunistically to assess for acquired undescended testis (or if testis no longer resides in scrotum after manipulation)

Question 26

When do retractile testis appear?

Answer 26

2-6 years of age

Question 27

Should an US be done for a testis that was previously present and now cannot be palpated?

Answer 27

No. Poorly sensitive. A specialist should be able to feel the testis on examination, if not will need laparoscopic exploration.

Question 28

What is the natural history of an acquired undescended testis?

Answer 28

About half will descend in adolescence when the hormonal surge causes final obliteration of the processus vaginalis remnant. The concern is that the testis has been out of the scrotum for an extended period of time (potentially 10 years) which can lead to infertility.

Question 29

What is the management of acquired undescended testis?

Answer 29

Immediate referral for orchidopexy

Question 30

What is testicular cancer risk related to?

Answer 30

Congenital undescended testes after 1 year as germ cells develop during the first year of life (not so much for acquired undescended testes)

Question 31

DDx groin lump? Differentiating between?

Answer 31

Hernia (mostly indirect in babies), hydrocoele, hydrocoele of the cord. Can you get above it? Transillumination not so helpful in small babies (bowel wall is so thin hernias will also transilluminate)

Question 32

Management for hernias?

Answer 32

If <6/52 then needs phone call as will promptly repair; otherwise refer (<2/52 for <6/12, <2/12 for >6/12)

Question 33

Concern about non reducible inguinal hernias in girls?

Answer 33

?ovarian or fallopian tube tissue present - therefore don’t try to reduce as could damage - will operate, risk of torsion