Swellings in the groin and scrotum

Question 1

Differential

Answer 1

Lymphadenopathy Testicular torsion Inguinal hernia Hydrocele

Question 2

What happens to an inguinal hernia when a child cries

Answer 2

Gets bigger

Question 3

What is diagnostic of an inguinal hernia

Answer 3

Reduction of the swelling

Question 4

What age group is testicular torsion found

Answer 4

Pubertal

Question 5

At what age does a hydrocele generally resolve

Answer 5

Resolution typically by 12 months

Question 6

Differential diagnosis for impalpable testes

Answer 6

Retractile testes Undescended Ectopic

Question 7

How to examine a child when considering retracted testes

Answer 7

Warm hands cross legged, or squatting

Question 8

In what demographic are undescended testes more common

Answer 8

premature

Question 9

What does orchidexy by 1 year help prevent with undescended

Answer 9

Torsion Infertility Malignancy

Question 10

Where might you find ectopic testes

Answer 10

Superficial inguinal pouch or on perineum

Question 11

Key points with scrotal swellings

Answer 11

Incarcerated hernias and torsion are emergencies Hydroceles usually resolve spontaneously and are present from birth Undescended testicles must be referred before age 1

Question 12

Physical examination of the swelling

Answer 12

Observation->pain, comfortable Palpation->tender, mass separate from the testes Transillumination Reducible General examination->infection

Question 13

Bilateral inguinal hernias in a girl should raise the possibility of what

Answer 13

That they are undescended testes in an undervirilised boy with ambiguis genitalia

Question 14

What might bilateral impalpable testes be a manifestation of

Answer 14

Virilised female->congenital adrenal hyperplasia Perform pelvic US immediately

Question 15

Impalpable testes + micro-penis

Answer 15

Severe anterior pituitary dysfunction

Question 16

How to assess acute scrotum

Answer 16

1. 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

Question 17

Important history in acute scrotum

Answer 17

Features on history: age of the child: neonatal, prepubertal, adolescent onset and severity trauma fever sexual activity prior genitourinary surgeries / known urological abnormality

Question 18

Features on examination:

Answer 18

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?

Question 19

Investigations in acute scrotum

Answer 19

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

Question 20

When would you consider an USS in acute scrotum

Answer 20

Once a testicular torsion and incarcerated hernia has been excluded by surgical consultation ultrasound may be considered if the diagnosis remains unclear.

Question 21

Management of testicular torsion

Answer 21

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

Question 22

With torsion, when does testicular infarction occur

Answer 22

Within 8-12 hours

Question 23

Features of testicular torsion

Answer 23

High riding Exquisitely tender Discolouration of scrotum Cremasteric reflex absent

Question 24

Findings in torsion of appendix, and acute management

Answer 24

Blue dot sign Analgesia Rest Pain resolves 2-12 days, lessens w/i 2 days

Question 25

Findings in epididymo-orchitis on history and examination

Answer 25

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.

Question 26

Acute management of EO

Answer 26

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

Question 27

Findings in incarcerated hernia

Answer 27

History of intermittent inguinoscrotal bulge, with associated irritability Firm, tender, irreducible, inguinoscrotal swelling Needs reduction surgically

Question 28

Presentation and management of idiopathic scrotal swelling

Answer 28

Rapid onset painless, notable swelling Bland, violaceous edema, extending to perineum + penic, may be bilateral, not tender Usually resolves in a few days

Question 29

Examination findings in hydrocele and management

Answer 29

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.

Question 30

Findings in testicular rupture and management

Answer 30

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.

Question 31

Assessment and management of congenital undescended testes

Answer 31

Seen by pediatric surgeon at 3-6 months and surgical management by 6-12 months to improve fertility

Question 32

Which side is more common for inguinal hernia

Answer 32

1. Right side more common than left

Question 33

In what age is inguinal hernia more likely to become incarcerated

Answer 33

1. The earlier it presents the more likely it will become incarcerated

Question 34

Timing of repair of inguial hernia <40 CGA, >44 CGA, older

Answer 34

1. <40 CGA on that visit
2. >44 weeks, within a week
3. In older->urgent OP referral

Question 35

Management post-repair of hernia

Answer 35

1. Regular post-operative care, may be admitted overvight
2. R/V with pediatrician in six months to ensure no testicular atrophy