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What process of development can lead to predisposition to development of inguinal hernia or hydrocele?

The processus vaginalis is the tongue of peritoneum that precedes the migrating testis through the inguinal canal - normally it becomes obliterated after birth but sometimes this fails and the predisposition occurs


What sort on inguinal hernias do children get?

Indirect normally always because due to the patent processus vaginalis - therefore comes through inguinal canal


In whom are inguinal hernias more common?

Boys and preterm infants


Which side do inguinal hernias typically occur on?

Typically on the right side


How do inguinal hernias usually present?

Intermittent swelling in groin on crying or straining
Can make it visible by raising intra-abdominal pressure - by placing hand on abdomen or asking them to cough


How else can inguinal hernia present?

Can also present as irreducible lump in groin or scrotum, which is firm and tender
This child can be unwell with irritability and vomiting


Can "irreducible" hernias be reduced

Most can be reduced with opoid analgesia and gentle compression
Then delay surgery for 24-48 hours to allow oedema to go down


What to do if hernia can't be reduced

Surgery is required as emergency because otherwise bowel can strangulate and can also damage the testis


Surgery to treat inguinal hernia

Ligation and division of hernial sac (processus vaginalis) via inguinal skin crease incision
Usually done as day case


What is a hydrocele?

If processus vaginalis is too narrow to allow bowel through to form an inguinal hernia then fluid can still track down it and go around testis to form hydrocele


Presentation of hydrocele symptomwise

Asymptomatic scrotal swelling. Usually bilateral and may be bluish
Can be tense or lax but non-tender and transilluminate


Presentation of hydrocele time wise

Some are evident at birth but some present in early childhood following viral or GI illness
Most will resolve spontaneously when PV continues to obliterate


Management of hydrocele

Most go automatically
Consider surgery if still present beyond 18-24 months of age


What is cryptorchidism?

Undescended testes


Incidence of undescended testes

4% of term male infants will have unilateral or bilateral undescended testes


When are undescended testes more common?

Preterm infants because descent through inguinal canal occurs in 3rd trimester


What can occur post birth with undescended testes?

Can continue to descend during early infancy and by 3 months of age 1.5% incidence


What can occur to a testes which was fully descended at birth?

Can ascend back into an inguinal position during childhood - will have late presentation of undescended or "ascended" testes


Examination of undescended testes?

In a warm room with warm hands - it is possible to bring testes into a palpable position by gently massaging contents of inguinal canal down


What is retractile testes?

Can be brought down but will be pulled back up into inguinal region by cremasteric muscle
With age testes will permenantly reside in scrotum


What is palpable testes?

Can be palpated in groin but cannot be manipulated into scrotum


What is impalpable testes?

No testis can be felt on examination - can be in inguinal canal, intra-abdominal or absent


Investigations for undescended testes?x 3

Hormonal - testicular tissue if present will produce rise in serum testosterone after IM injection of HCG


Management of undescended testes?

Surgical placement of testis in scrotum - orchidopexy


Reasons for orchidopexy?

Fertility and malignancy risk
Also psychological


Fertility after orchidopexy?

After unilateral undescended testes is close to normal
But reduced to 50% if bilateral palpable undescended testes
If bilateral impalpable undescended testes - usually sterile


Malignancy after orchidopexy?

Risk is greatest for bilateral undescended testes - greatest risk for intraabdominal
Early orchidopexy for unilateral undescended testes reduces risk to almost normal


What is a varicocele?

Variscosities of testicular veins which can develop around puberty


Where are varicoceles normally?

On the left


Association of varicoceles

Associated with reduced fertility