Paeds: Inguinoscrotal disorders

Question 1

Inguinoscrotal disorders
Embryology:
Testis is formed from

Answer 1

The urogenital ridge on the posterior abdominal wall close to the developing kidney.

Question 2

Gonadal induction to form a testis is regulated by

Answer 2

genes on the Y chromosome.

Question 3

During gestation, the testis

Answer 3

1. migrates down towards the inguinal canal, guided by mesenchymal tissue known as the gubernaculum, probably under the influence of anti-Mullerian hormone.

Question 4

Inguinoscrotal descent of the testis requires

Answer 4

the release of testosterone from the fetal testis.

Question 5

What preceds the migrating testis through the inguinal canal

Answer 5

A tongue of peritoneum, the processus vaginalis,

Question 6

This peritoneal extension, what happens to it

Answer 6

normally becomes obliterated after birth failure of this process may lead to the development of an inguinal hernia or hydrocele

Question 7

Inguinal hernia:

Types

Answer 7

Inguinal hernias in children are almost always indirect and due to patient processus vaginalis

Question 8

Inguinal hernia:Aetiology

Answer 8

More frequent in boys and particularly common in premature infants.

Question 9

Inguinal hernia: Presentation

Answer 9

More common on the right due to later descent of the right testis
1 in 50 boys will develop an inguinal hernia.

Question 10

Inguinal hernia: Signs and symptoms

Answer 10

• An intermittent swelling in the groin or scrotum on crying or straining
• Presents as an irreducible lump in the groin or scrotum.
• Firm and tender lump
Infant may be unwell and vomiting

Question 11

Inguinal hernia: Diagnosis

Answer 11

• Diagnosis relies on history and the identification of thickening of the spermatic cord (or round ligament in girls).
The groin swelling may become visible on raising the intra-abdominal pressure by gently on the abdomen or asking the child to cough.

Question 12

Inguinal hernia: Examination

Answer 12

• Most ‘irreducible’ hernias can be successfully reduced following opioid analgesia and sustained gentle compression
• Does not transluminate
• Often increases in size when the child is crying
• Testis is palpable, distinct form the swelling
• Reduction of the swelling is diagnostic
No pain unless incarcerated

Question 13

Inguinal hernia: Management

Answer 13

• Most ‘irreducible’ hernias can be successfully reduced following opioid analgesia and sustained gentle compression
• Surgery is delayed for 24-48 hours to allow resolution oedema
• If reduction impossible, emergency surgery is required because of the risk of strangulation of bowel and damage to the testis.
A hernia associated with an undescended testis should be operated early to minimise risk to the testis.

Question 14

Inguinal hernia: Incarcerated

Answer 14

30% risk of testicular infarction due to pressure on the gonadal vessels.

Question 15

Inguinal hernia: Surgical reduction

Answer 15

• Carried out via an inguinal skin crease incision and involves ligation and division of the hernia sac (processus vaginalis).
Except in small infants, this can usually be undertaken as a day-case procedure, provided there is appropriate anaesthetic and surgical support.

Question 16

Hydrocele:

Definition and process of formation

Answer 16

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

Question 17

Hydrocele:

Presentation

Answer 17

• Symptomatic scrotal swellings, often bilateral and sometime with a bluish discolouration
May be tense of lax but are non-tender and transluminate

Question 18

Hydrocele: Prognosis

Answer 18

• Majority resolve spontaneously as the processes continues to obliterate, but surgery is considered if it persists beyond 18-24 months of age
A hydrocele of the cord forms a non-tender mobile swelling in the spermatic cord.

Question 19

Female:

Inguinal hernias

Answer 19

• Much less common in girls
• Ovary becomes incarcerated in the hernia sac and can be difficult to reduce
• Rarely, androgen insensitivity syndrome (testicular feminisation) can present as a hernia in a phenotypic female who actually has a male genotype.

Question 20

Labial adhesions

Answer 20

• Labia minora are adherent in the midline, appearance of no vagina but a translucent midline raphe partially or totally occluding the vaginal opening.

Question 21

Labial adhesions Management:

Answer 21

1. Asymptomatic – left alone and will often lyse spontaneously.
2. If perineal soreness or urinary irritation, treatment with topical oestrogen treatment applied sparingly twicSe a day for 1-2 weeks often dissolves the adhesions.
3. Active separation of the adhesions under anaesthesia is sometimes required.