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Paeds > Scrotum > Flashcards

Scrotum Flashcards

1
Q

Age ranges scrotal pathology

A

Torsion
Infancy and puberty less than 3 and from beginning of puberty

Hydatid
7-10 years

Idiopathic scrotal oedema
5-9 years

Infection
Infancy and puberty

Mumps
Rare before 10

HSP
3-15 years of age

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2
Q

Retraction foreskin and age ranges

A 
Oster Danish study 1965
1968 danish schoolboys
8% 6-6 year olds
6% 10-11 year olds
1% 16-17 year olds
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3
Q

Testicular descent embryology
At inguinal ring
In scrotum

A

Transabdominal descent week 10-15

Inguinoscrotal week 25-35

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4
Q

UDT prevalence

Right vs bilateral

A 
3% newborns
1% at 6 months
30% premature 
Right 70%
Bilateral 30%
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5
Q

UDT impalpable locations

A 
80% palpable 
20% impalpable of which
50% in canal
40% abdomen
10% absent
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6
Q

Ascending testicle risk if retraction and all testes

A

50 % retraction and 2% all testes May ascend

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7
Q

Age of orchidopexy

Complications

A 
6 months- 18 months
At 1 year risk of anaesthetic lower
Complications BAUS
Groin scrotal swelling pain 10-50%
2-10 %
Infection
Removal
High riding position
0.004-2%
Bleeding
Atrophy
Fertility 
Chronic pain
Repeat procedure
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8
Q

Risks of hydrocele PPV repair

A 
Recurrence 1-3% for neonate, 1% older kids
Iatrogenic UDT 1%
Injury to vas 0.33%
Atrophy up to 10% 
No change swelling almost all
Bleeding requiring treatment 2-10%
Infection 0.004-2%
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9
Q

Testicular survival with orchidopexy procedures

A

Groin 98%
One stage 70%
Two stage 90%

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10
Q 
Risk malignancy UDT
General RR
% of testicular cancer with UDT
RR if fixed 0-6 years old
RR if fixed over 13 years
A

Testicular cancer of which 10-15 % have UDT
RR is 3
RR is 2 if fixed 0-6 years old
RR 5 if fixed over 13

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11
Q

Circumcision complications

A 
Bleeding 1.5%
Local sepsis 8.5%
Oozing 36%
Discomfort more than 7 days 26%
Meatal scabbing or stenosis
Removal of too much or too little skin
Urethral injury
Amputation of glam
Inclusion cyst
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12
Q

Testicle development MIH secretion week

A

Week 7 by pre sertoli cells
Regression of Müllerian ducts begin week 8 in response to MIS and complete by 10-12 weeks
Testosterone allows each mesoneprhic duct develop into epididymis, vas and seminal vesicles

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13
Q

incidence of UDT

A

3-5% at term

born less than 37 weeks 30% incidence of UDT

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14
Q

2 nd stage descent of testes

A

25-35 weeks

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15
Q

risk factors for UDT

A

maternal smoking
dad or brother - family history first degree relative
low birth weight or IUGR

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16
Q

when will testes not descend further

% of boys at 6 months with UDT

A

6 months of age
most likely to descend within first 3 months
premature babies descent can occur any time 1st year of life
1% of boys at 6 months have UDT
1.5% of 3 months have UDT, not much change in this figure by 1 year

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17
Q

ectopic locations

A 
penile
contralateral scrotum
pre prenile
superficial inguinal pouch
perineum
femoral region
anterior abdominal wall
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18
Q

incidence bilateral UDT

right vs left

A

25%
right more common than left
right 70%
left 30%

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19
Q

semen parameters with UDT

paternity rate with unliat and bilat UDT

A

Oligospermia or azoospermia occurs in 75% of patients with bilateral UDT and 40% of unilateral UDT
Paternity in patients with unilateral UDT is similar to general population

Paternity rates 80-90% with history of unilateral UDT
Paternity rate 45-65% with history of bilateral UDT
Prospects fertility enhanced by early orchidopexy under 2 years

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20
Q

UDT and risk malignancy

A

RR 2 x to 10x vs normally descended testicle
higher risk if intrabdominal
early orchidopexy may reduce risk malignancy but not eliminate entirely
Nordic concensus and SRs - advise into scrotum 6-12 months

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21
Q

Fowler stephens success rate
when to do second stage
complications

A

60%
at 6 months, either open or with laparoscopic assitance

Atrophy 5% for inguinal up to 27% of two stage
Reascent
Injury Vas 1-2%

Testicular atrophy – 8% when testis lay beyond the external ring, 13% when in inguinal canal, 27% two stage fowler stphens, 5% for inguinal orchidopexy
Reascent of testis
Injury vas 1-2% - post ichaemic obliteration vas resulting from damage to blood supply likely unrecognised
Testicular volume influenced by initial position of gonad rather than age at surgery performed

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22
Q

surgery for UDT NICE, EAU

A

BAPS 6-18 months
EAU by 12 months
Nordic consensus statement 6-12 months

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23
Q

retractile testes age range most common

A

In clear-cut cases parents may be reassured that retractile testes are common, particularly between the ages of 3 and 7 years, and that surgical intervention is rarely required.

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24
Q

testicular descent

transadbominal

A

abdomen week 10-15

inguinoscrotal week 25-35

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25
Q

co existing conditions with UDT

A 
hypospadias,
SB
100% prune belly
CP
exomphalos
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26
Q

causes of maldescent of testicle 4

A

Physical ob to descent
Lack of intrabdominal pressure
Hypopituitarism
Mesenchymal defects

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27
Q

most common ectopic location

where is this

A

superficial inguinal pouch

between scarpa fascia and external oblique fascia

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28
Q

normal size pre pubertal testes

A

smaller than a malteaser sweet

29
Q

definition retractile testicle

A

Retractile testes are those that move spontaneously out of the scrotum on a regular basis and or on initial examination but will return either spontaneously or with manipulation to a dependent scrotal position and remain there for a finite but ill defined period

30
Q

cremasteric reflex and testosterone

A

reflex suppressed by T so absent in first six months due to perinatal T surge

31
Q

risk of ascending testicle with retractile testes

follow up of retractile testicle

A

50% of retractile may ascend
2% of all testes may ascend
Arrange yearly review until puberty is established as significant risk of ascent by urology or GP if willing
May have 50% ascend

32
Q

anaesthetic concern under age 1

A

Anaesthetic risk under 1 year equal to those over 70s should be undertaken by paediatric anaesthetist
Testicular survival concerns before age of 1 have not been realised

33
Q

benefits of early orchidopexy for UDT (5)

A

Reduced distance testes have to move outweighs risk to delicate vessels
Early orchidopexy improves testicular growth
cosmesis
higher risk torsion
malignancy (before 13) Pettersson NEJM
fertility (before 2)
risk hernia

34
Q

management bilateral impalpable testes

A

20 times more common to have bilateral intra ab testis than bilateral absent testes
Recommended to have laparoscopy than trying to assess whether testicular tissues with GnRH stimulation test

35
Q

inguinal orchidopexy success rate

A

98%
Single stage Fowler stephens 70%
Two stage 60%

36
Q

malignancy outcomes UDT

A

7/100,000 testicular cancer so still uncommon
5-10% in those with UDT
RR = 3,

Influence by syndromes, position, and dysplasia
Maybe increased risk in CL testis
Responsibility not to cause undue anxiety
Reassure risk small
Encourage monthly examination both testis from adolescence

37
Q

malignancy paper age before or after 13

A

Pettersson NEJM 2007 Swedish
The relative risk of testicular cancer among those who un-derwent orchiopexy before reaching 13 years of age was

2.23 (95% confidence inter-val [CI], 1.58 to 3.06), as compared with the Swedish general population;

for those treated at 13 years of age or older, the relative risk was 5.40 (95% CI, 3.20 to 8.53)

38
Q

fertility outcomes UDT

A

Historical data unilateral UDT does not affect paternity rates
But is reduced for bilateral UDT
Time to conception equal 3 gourps
Sperm densities different but morphology and motility similar
Early orchidopexy allows neonatal gonadocytes to adult dark spermatogonia which may improve sperm density in adulthood
96% normal semen parameters if orchidopexy under 12 months
66% if 12-24 months

39
Q

differentiation of gonads

testicular descent phase 1 and 2 hormones

A

6th weeks undifferentiated
6-7 weeks under influence of SRY genes testes differentiate
testicular descent under MIH occuring by 12 weeks from urogenital ridge to internal inguinal opening
then
second phase from 25-30 weeks under T, inguingal canal to scrotum

40
Q

differentiation of gonads

testicular descent phase 1 and 2 hormones

A

6th weeks undifferentiated
6-7 weeks under influence of SRY genes testes differentiate
testicular descent under MIH occuring by 12 weeks from urogenital ridge to internal inguinal opening
then
second phase from 25-30 weeks under T, inguingal canal to scrotum

41
Q 
stages of spermatogenesis
draw diagram
growth phase
multiplication phase
maturation phase
A

in neonatal gonocytes
ages of 3 and 12 months give rise adult dark spermatogonia
these then develop adult pale spermatogonia
meiosis I transform into primary spermatocytes
then meiosis II into secondary spermatocytes
progress to spermatids then rise to spermatozoa

42
Q

complications inguinal orchidectomy

A

10-50%
Swelling of the groin and scrotum lasting several days

2-10%
1/10 to 1/50
Infection, removal, lie high in scrotum

0.004-2%
1/50 to 1/250

Bleeding
No guarantee or reduced fertility
Atrophy
Repeat procedure
Chronic pain
Anaesthetic risk
43
Q

Fowler stephens laparoscopy

risk of testicular loss with 2 stage procedure

A

air flow 2 pressure 10

20%

44
Q

patency of PPV at birth

A

90% patent at birth

in up to 80% of males and 60% of females, the process vaginalis is still present at birth

45
Q

when does PPV obliterate

A

By 8 weeks of age, 63% of males will have a persistent processus vaginalis with obliteration occurring any time up until the age of two years.

After this age, up to 40% of males continue to have a persistent process vaginalis with around half remaining asymptomatic throughout life.

46
Q

incidence of neonatal hernia

when is risk of obstruction highest

A

1-5% of children

in neonate

47
Q

management of incarcerated hernia

A

resuscitate,
Analgesia
Try to reduce hernia
Try to control ext ring, put pressure on swelling and feel hernia reduce
If unable to reduce despite maximal morphine analgesia, then proceed to emergency repair
If hernia is reduced, quite common to wait 48 hours, let oedema settle and then expediated basis

48
Q

rate of resolution of hydrocele

when to do surgery

A

90% resolve in 1st year spontaneously

fix over 2 years old

49
Q

complications PPV ligation

A 
Complications
Recurrence in older child 1%
Neonate 1-3% recurrence rate
UDT in 1% iatrogenic
Testicular atrophy more common in neonate up to 10%
Injury to vas 0.33%
50
Q

peak times testicular torsion

incidence torsion

A

<3 and shortly after puberty 13-15

incidence 4.5 per 100,000 in age 1-25 years

51
Q

contralateral bell clapper deformity

A

A recent study of 27 pubertal TT cases indicated that the contralateral testis was affected in 78% of the boys

52
Q

testicular appendage torsion age group

A

7-10 years

53
Q

mumps orchitis

A

usually after puberty
rare before 10
4-5 days after mumps infection parotitis
affects scrotum in 10-30% of patients who have mumps
conservative treatment
can result in testicular atrophy, reduced size seen in half of post pubertal patients with abnormalities of semen in a quarter, may be as a result of pressure necrosis
effect on endocrine difficult to establish

54
Q

idiopathic scrotal odema age range

association

A

5-9 YEARS
testicle not tender, skin may be tender
association with worms treat child and family

55
Q

when do second stage fowler stephens

A

6 months later

56
Q

HSP

A

3-15 years
May rarely cause acute scrotum
Painless rash, weals blotches petechiae,
May get joint pain, VH, abdominal pain, can get intussepction, vasculitis of scrotum
No need explore
Conservative will get better

57
Q

what are salvage rates of torsion after time frame

A

study

58
Q

what is it called when near internal ring at laparoscopy

A

peeping testicle

59
Q

examination of scrotum in UDT

A

look for underdeveloped scrotum if testicle never was there

60
Q

when would do next stage of FS procedure

risk of need to remove testicle

A

6 months
liklihood of survival 70% successful
20% risk removal

61
Q

mumps orchitis percentage after mumps infection
time interval
rate testicular atrophy and semen abnormality

A

15-30% will get mumps orchitis in post pubertal boys occurs 4-8 days after parotitis
half will have testicular atrophy
quarter abnormal semen analysis
sterility is rare

62
Q

incidence UDT

A

2-4% of boys at full term

30% premature

63
Q

incidence 1 month

incidence 1 year

A

1% at 1 month

0.8.% at 1 year

64
Q

UDT familial risk

A

father affect 4.6 x RR

brother affected 6.9 x RR

65
Q

principle of fertility in fixing UDT

A

Early orchidopexy allows neonatal gonadocytes to adult dark spermatogonia occuring at 3-6 months which may improve sperm density in adulthood
96% normal semen parameters if orchidopexy under 12 months
66% if 12-24 months

66
Q

extravaginal torsion

A

neonatal torsion

testis and coverings twist entirely within the scrotum

67
Q

intravaginal torsion

A

children and older adults

within the TA

68
Q

resolving PPV by 1 year %

A

90% resolve by 1 year

surgery if persists over 2 yo

69
Q

when intervene varicocele

A

if more than 20% size difference on US

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