Surgery - genitalia Flashcards
How do inguinal hernias and hydrocoeles form in boys?
The processus vaginalis is a peritoneal extension, which in these pathologies does not become completely obliterated. In a hydrocoele, there is a slight opening
What are the clinical features of inguinal hernias in young boys?
How are they different from hydrocoeles?
Almost always indirect. 1 in 50 boys.
Intermittent swelling in groin on crying or straining. May also be shown by gently pressing on abdomen.
Irreducible lump in groin or testis.
Firm and tender.
Irritable
Vomiting
Can mostly be reduced with analgesia (if not, may indicate strangulation and requires surgery)
HYDROCOELE
Peritoneal fluid which goes back during the night - reduced each morning, greatest in the evening
Asymptomatic Often bilateral Non-tender Transillluminate Majority resolve spontaneously as processus vaginalis obliterates, however if 24months of age, SURGERY
What are the risks of having an inguinal hernia?
INCARCERATION
Predisposes to strangulation of bowel
There is a risk of damage to the testis (especially if undescended)
What are the causes of the acute scrotum? TORSION
Pain can be referred - inguinal/lower abdo
Anatomical predisposition (“bell clapper” - not properly anchored)
Undescended testis
Trauma/sport
What are the causes of the acute scrotum? (EPIDIDYMO-ORCHITIS)
Infants and toddlers
Most are due to infection:
UTI (e.coli - tracks down vas deferens. mostly >35 years)
STI (chlamydia and gonorrhoea - mostly urethritis, but can track down vas deferens: young men)
mumps (very uncommon now due to MMR)
Urethral surgery - may introduce bacteria
Can also be a side-effect of amiodarone
What are the differentials for the acute scrotum?
Torsion (neonates and post-pubertal). Abrupt.
Torsion of testicular appendage (hydatid of Morgagni can tort prior puberty)
Epididymitis (prepubertal) - slower onset
Epididymo-orchitis
Incarcerated inguinal hernia
Idiopathic scrotal oedema (painless, bilateral swelling and redness, pre-school)
Surgical exploration is required if there is any doubt that torsion cannot be excluded, because there is only 6-12h to operate before viability is compromised!!!
What is the natural history of non-retractile foreskin?
At birth, foreskin is adherent to glans due to adhesions. These disappear with time.
By 1 year, 50% have non-retractile.
By 4 years, 10%.
By 16 years, 1%
Most non-retractile foreskins are thus physiologically normal
What are the medical indications of circumcision?
No medical associated currently advocates routine circumcision.
Phimosis - pathological only if there is white-ish scarring of the foreskin, usually >5 years. Caused by BXO (balanitis xerotica obliterans)
Recurrent balanoposthitis - inflammation of the glans and foreskin (single episode is common and resolves with warm bath and broad-spectrum AB).
Recurrent UTI - if there are upper urinary tract anomalies.
What are the possible complications of circumcision?
EARLY:
Bleeding (can be significant if coagulation disorder)
Infection
Pain
Major early complications:
Hypospadias
Glanular necrosis/amputation
LATE: Epidermal inclusion cyst Penile adhesions chordee Meatitis/meatal stenosis
Describe the conservative treatment of bacterial balanitis in children (<16)
Oral flucloxacillin 7 days
If allergic, oral erythromycin/clarithromycin
Take sub-preputial swabs and adjust treatment according to results.
If inflammation severe, can prescribe 1% hydrocortisone cream for up to 14 days
What is the natural course of balanitis
Inflammation of glans of the penis.
Can be acute, chronic (>weeks) or recurrent.
What are some causes of balanitis?
Non-specific dermatitis due to poor retractibility + poor hygiene and smegma.
Infection - candida albicans, group A beta-haemolytic streptococci
Irritant or allergic contact dermatitis (such as soap)
What is balanitis xerotica obliterans and how can it be recognised?
Localised skin disease leading to scarring. Appears as white-ish patches on foreskin, sometimes with preputial stenosis.
Early is mostly asymptomatic. Symptoms include from early to late: Pruritus Burning Dysuria
Phimosis (unable to retract) and paraphimosis (unable to return to retracted)
How is an inguinal hernia managed?
Reduced with gentle compression after opioid analgesia (mostly succeeds, even if it seems irreducible at first). It prevents incarceration
Allow 24-28hours for reduction of oedema. Then operate
If irreducible, emergency operation is required (possible strangulation).
Elective herniorrhaphy. There are 3 techniques in children and all can be done laparoscopically
What is the classification of undescended testis?
Palpable (in groin or ectopic eg. femoral triangle/perineum)
Impalpable (can be in inguinal canal, intra-abdominal or absent)
