Inguinoscrotal - Paed Surg

Question 1

What is the scrotum derived from embryologically?

Answer 1

Embryologically derived from genital swellings. Fuse in midline during development at scrotal raphe.

Question 2

What are the contents of the scrotum?

Answer 2

3 major paired structures:

1) Testis: sperm production
2) Epididymis: siutated at the head of each testicle. Functions as storage reservoir for sperm.
3) Spermatic cord: collection of muscle fibres, vessels, nerves and ducts that run to and from the testis.

Question 3

Where do testes develop?

Answer 3

Gonadal ridge in lumbar position of posterior abdominal wall

Question 4

What attaches testes to the abdominal wall?

Answer 4

1) Posterior gonadal ligament

2) gubernaculum

Question 5

How does the gubernaculum assist with testicular descent?

Answer 5

as body grows, gubernaculum does not therefore testes drawn down

Question 6

What are the phases of testicular descent?

Answer 6

Migrate to internal inguinal ring above the scrotum between month 3 and term
• Testicular descent has 2 phases:
1. Transabdominal descent: dependent on insulin like hormone 3
2. Inguinoscrotal descent: dependent on androgens

Question 7

Proportion of infants with descended testicles at birth and 12 months?

Answer 7

• Full term newborn boys - 97% have bilateral descended testes
• Further descent may occur during the first 3 months after birth
By 12 months, 99% testes will be in scrotum

Question 8

How is inguinal hernia reduced?

Answer 8

• Place towel under baby’s bottom to straighten out the inguinal canal
• Two handed approach
• Left hand with fingers at external ring (halfway btwn ASIS and pubic tubercle)
• Right hand fingers compress mass gently and slowly
• Often a gurgle feel as hernia is reduced
  Reduce all contents and keep reduced with finger at external ring

Question 9

What is the importance of checking for complete testicular descent?

Answer 9

• 1. Higher temperature outside the scrotum (i.e. in the body) lead to failure of germ cell maturation and may lead to oligospermia or azospermia
• 2. Testes in the inguinal region are more prone to torsion or trauma
• 3. Risk of seminoma in undescended testis is 5-10x the normal rate

Question 10

What is an orchidopexy?

Answer 10

• Aim: identify the testis, divide the processus vaginalis, preserve blood supply and vas, place the testis in a good scrotal position
• Elective, day case surgery
• General anaesthesia, may have caudal or inguinal block
• Inguinal skin crease incision and find testis
• Deliver cord, dissect processes vaginalis from cord, divide and tie it off
• Create a passage from the groin to scrotum, scrotal incision
• Pass testis to scrotum and secure
• Close the wounds
  Follow-up in 4 weeks, 6 months and at puberty

Question 11

What is an undescended testis?

Answer 11

Arrested along its normal path of descent. May be abdominal, inguinal or prescrotal.

Question 12

What are the possible locations of an ectopic testis?

Answer 12

• Prepenile
• Superficial ectopic
• Transverse scrotal
• Femoral
• Perineal

Question 13

What is a retractile testis?

Answer 13

Testes are pulled out of the scrotum by the action of cremasteric muscle. Cremasteric muscle is more active when the testosterone levels are low (between 3 months to puberty)

Question 14

How does a retractile testis present?

Answer 14

• may be brought down to the base of the scrotum on examination and will stay
  If manipulation tight then might be cord

Question 15

What is ascending testis?

Answer 15

Previously descended in first year then is ascends during childhood. Thought to be due to failure of elongation of the spermatic cord.

Question 16

Why is a retractile testis monitored?

Answer 16

A retractile testis is monitored to ensure it does not develop into an ascended testis

Question 17

What is the Ddx of impalpable testis?

Answer 17

Majority of undescended testes (80%) will be palpable - feel but not in the right spot.
Impalplable testes DDx
• Atrophy
• Intra-bdominal
• Inguinal canal
•  Ectopic

Question 18

Mx inguinal hernias in kids?

Answer 18

• Inguinal hernias never go away by themselves
• The contents may become incarcerated, impairing their own blood supply
• Incarcerated hernia may impair the blood supply to the testis
• Requires surgical repair: inguinal herniotomy to reduce the hernia

*the younger the child, the earlier the surgery needed. Op pre discharge.

Question 19

What is a hydrocele?

Answer 19

• Same anatomy as inguinal hernia but the processus vaginalis only allows fluid through (smaller)
Fluid may be around the testis, in the tunica vaginalis, within the inguinal canal, encysted as a hydrocele of the cord

Question 20

PEx features hydrocele?

Answer 20

PEx
• Non reducible
• Can get above the testis -able to palpate above the swelling below the external ring (location of the narrowing of processus vaginalis)
• Testis may be able to be felt separately
Transilluminable (but so is bowel)

Question 21

What is a varicocele?

Answer 21

Collection of abnormally enlarged spermatic cord veins, found in teenage boys. Mostly on the left.

Question 22

What are the PEx features of a varicocele?

Answer 22

Mass of varicose veins (“bag of worms”) above testicle. Non tender, more prominent when standing.

Question 23

What are the hx features of testicular torsion?

Answer 23

Sudden onset testicular pain and swelling; occasionally N/V.

Question 24

PEx features of testicular torsion?

Answer 24

• Discolouration of scrotum;
• exquisitely swollen and tender tests.
• Riding high.
• Cremasteric reflex usually absent.