Swellings in the groin and scrotum Flashcards
Differential
Lymphadenopathy Testicular torsion Inguinal hernia Hydrocele
What happens to an inguinal hernia when a child cries
Gets bigger
What is diagnostic of an inguinal hernia
Reduction of the swelling
What age group is testicular torsion found
Pubertal
At what age does a hydrocele generally resolve
Resolution typically by 12 months
Differential diagnosis for impalpable testes
Retractile testes Undescended Ectopic
How to examine a child when considering retracted testes
Warm hands cross legged, or squatting
In what demographic are undescended testes more common
premature
What does orchidexy by 1 year help prevent with undescended
Torsion Infertility Malignancy
Where might you find ectopic testes
Superficial inguinal pouch or on perineum
Key points with scrotal swellings
Incarcerated hernias and torsion are emergencies Hydroceles usually resolve spontaneously and are present from birth Undescended testicles must be referred before age 1
Physical examination of the swelling
Observation->pain, comfortable Palpation->tender, mass separate from the testes Transillumination Reducible General examination->infection
Bilateral inguinal hernias in a girl should raise the possibility of what
That they are undescended testes in an undervirilised boy with ambiguis genitalia
What might bilateral impalpable testes be a manifestation of
Virilised female->congenital adrenal hyperplasia Perform pelvic US immediately
Impalpable testes + micro-penis
Severe anterior pituitary dysfunction
How to assess acute scrotum
- Scrotal swelling 2. Generalised edema->Y Nephrotic 3. Pain 4. Trauma? Y Hematocele, hematoma, rupture, epididymitis, torsion 5. No Trauma, tender testes-> Torsion, epididymitic, orchitis, torsion of appendix, tumor 6. No trauma, not tender->torsion of appendix, hernia, HSP, Kawasaki 7. No pain, enlarged testis->Tumor/Leukemia, antenatal torsion 8. No pain, not enlarged ->Reducible swelling= hernia ->Scrotal wall swelling->Idiopathic edema, HSP, kawasaki ->No scrotal wall swelling, transilluminable->hydrocele, hernia w/ hydrocele, spermatocele ->No scrotal wall swelling, not transilluminable->varicocele, hernia
Important history in acute scrotum
Features on history: age of the child: neonatal, prepubertal, adolescent onset and severity trauma fever sexual activity prior genitourinary surgeries / known urological abnormality
Features on examination:
observation of the patients gait and resting position natural position of the testis in the scrotum while standing presence or absence of cremasteric reflex (this is absent in torsion) palpation of lower abdomen, inguinal canal and cord palpation of scrotum and contents, compare with unaffected hemiscrotum transillumination Is the swelling reducible?
Investigations in acute scrotum
Features on investigations: 1. Check urinalysis, and send sample for M & C. 2. Blood tests are not useful in the acute setting. 3. Doppler ultrasound is not useful in the acute setting. However, colour Doppler flow ultrasound can assess anatomy and blood flow. Swelling and fluid collections can be localised. 4. USS generaly useless->if thinking torsion->must explore
When would you consider an USS in acute scrotum
Once a testicular torsion and incarcerated hernia has been excluded by surgical consultation ultrasound may be considered if the diagnosis remains unclear.
Management of testicular torsion
Brief history Examination Inform senior IV access->give analgesia, start fluids, take bloods->FBC, UEC Urine dipstick Keep NBM, Consent and book for orchidopexy +/- orchiectomy depending on findings, RSI, explore
With torsion, when does testicular infarction occur
Within 8-12 hours
Features of testicular torsion
High riding Exquisitely tender Discolouration of scrotum Cremasteric reflex absent
Findings in torsion of appendix, and acute management
Blue dot sign Analgesia Rest Pain resolves 2-12 days, lessens w/i 2 days
Findings in epididymo-orchitis on history and examination
Onset may be insidious; fever, vomiting, urinary symptoms; rare in pre-pubertal boys, unless underlying genitourinary anomaly, when associated with UTI. Mumps orchitis occurs from 4 to 6 days after parotitis manifests. Red, tender, swollen hemiscrotum; tenderness most marked posteriolateral to testis. Pyuria may be present.
Acute management of EO
Urine MCS, PCR for chlamydia and gonorrhea in adolescents. Antibiotics->outpatient usually with co-trimoxazole Slow to resolve, several weeks gradually subsiding discomfort and scrotal swelling
Findings in incarcerated hernia
History of intermittent inguinoscrotal bulge, with associated irritability Firm, tender, irreducible, inguinoscrotal swelling Needs reduction surgically
Presentation and management of idiopathic scrotal swelling
Rapid onset painless, notable swelling Bland, violaceous edema, extending to perineum + penic, may be bilateral, not tender Usually resolves in a few days
Examination findings in hydrocele and management
Soft, non-tender swelling adjacent to testis; testis can be felt to be normal in simple hydrocele; transilluminates brightly. Will often resorb and the tunica vaginalis close spontaneously in the first year. If still present at 2 years, surgical referral should be made for consideration of repair.
Findings in testicular rupture and management
Tender swollen testis. Bruising, oedema, haematoma, or haematocele may be present. Surgical evaluation should be undertaken in all testicular trauma, unless the testis clearly can be felt to be normal and without significant tenderness.
Assessment and management of congenital undescended testes
Seen by pediatric surgeon at 3-6 months and surgical management by 6-12 months to improve fertility
Which side is more common for inguinal hernia
- Right side more common than left
In what age is inguinal hernia more likely to become incarcerated
- The earlier it presents the more likely it will become incarcerated
Timing of repair of inguial hernia <40 CGA, >44 CGA, older
- <40 CGA on that visit
- >44 weeks, within a week
- In older->urgent OP referral
Management post-repair of hernia
- Regular post-operative care, may be admitted overvight
- R/V with pediatrician in six months to ensure no testicular atrophy
