Inguinal Hernias & Hydroceles Flashcards
(141 cards)
1
Q
What is one of the most common operations performed by pediatric surgeons?
A
Inguinal hernia repair
2
Q
What is the male-to-female ratio for inguinal hernias?
A
M:F → 5:1 (1:1 in prematures)
This indicates that the condition is more common in males, but the ratio equalizes in premature infants.
3
Q
Inguinal hernias are most common on which side?
A
Right (60%)
4
Q
Which conditions are associated with inguinal hernias?
A
1) Cystic Fibrosis
2) Hydrocephalus (VP Shunts)
3) Peritoneal Dialysis
4) Undescended testes
5) Connective tissue disorders (Ehlers–Danlos syndrome)
5
Q
The anterior wall of the inguinal canal consists of:
A
External oblique aponeurosis
6
Q
The inferior wall of the inguinal canal consists of:
A
1) Inguinal ligament
2) Lacunar ligament (medial third)
3) Iliopubic tract (lateral third)
7
Q
The superior wall of the inguinal canal consists of:
A
1) Internal oblique
2) Transversus abdominis muscles
8
Q
The posterior wall of the inguinal canal consists of:
A
1) Transversalis fascia
2) Conjoint tendon
9
Q
What are the contents of the inguinal canal in males?
A
1) Ilioinguinal nerve
2) Spermatic cord
10
Q
What are the contents of the inguinal canal in females?
A
1) Ilioinguinal nerve
2) Round ligament
11
Q
What are the spermatic cord structures?
A
1) Cremasteric muscle
2) Testicular artery
3) Pampiniform plexus
4) Lymphatic channels
5) Vas
6) Genital branch of Genitofemoral nerve
7) Processus vaginalis
12
Q
What artery is found in the spermatic cord?
A
Testicular artery
13
Q
What is the Processus Vaginalis (PV)?
A
A parietal peritoneal diverticulum extending through the internal inguinal ring into the inguinal canal
14
Q
Where is the Processus Vaginalis located in males?
A
Beside the descending testicle
15
Q
Where is the Processus Vaginalis located in females?
A
Beside the elongated round ligament
16
Q
The round ligament connects:
A
The uterus to the labia majora
17
Q
What structure does the Processus Vaginalis extend through?
A
The internal inguinal ring
18
Q
True or False: The Processus Vaginalis is present only in males.
A
False
The PV is present in both males and females.
19
Q
Where do the gonads form?
A
On the anteromedial nephrogenic ridges in the retroperitoneum
20
Q
What structure attaches the gonads to the scrotum?
A
The gubernaculum
The gubernaculum plays a crucial role in the descent of the testes.
21
Q
How are the gonads attached to the labia majora?
A
Via the round ligament
The round ligament is essential for the proper positioning of the female gonads.
22
Q
The processus vaginalis in the inguinal canal:
A
Obliterates after birth
23
Q
The processus vaginalis in the scrotum:
A
Forms the tunica vaginalis around the testis
24
Q
The female analogue of the processus vaginalis is:
A
The canal of Nuck
25
What results in indirect inguinal hernia in children?
Failure of the processus vaginalis to close
26
How do you diagnose an indirect inguinal hernia?
Clinically (asymptomatic, but you find bulging)
27
What are some maneuvers that may help demonstrate the hernia?
1) Raise the head while supine
2) Blowing up a balloon
3) Standing upright
28
What is acceptable as an indication of operation for indirect inguinal hernias?
Good History
29
What is a hydrocele?
Accumulation of peritoneal fluid surrounding the testicle
30
A Non-communicating Hydrocele is accumulation of peritoneal fluid in the:
Tunica vaginalis (after PV obliteration)
31
A Communicating Hydrocele is accumulation of peritoneal fluid in the:
The tunica vaginalis (due to a patent PV)
32
An Encysted Hydrocele is accumulation of peritoneal fluid in the:
Non-obliterated portion of the PV
33
Next best step for an asymptomatic Non-communicating Hydrocele?
Observe for 1-2 years of age (90% resolve by 1 year of age)
34
Indications of surgery for Non-communicating Hydrocele?
1) When it fails to resolve
2) If a clinical hernia is apparent
3) If symptomatic (pain)
35
Next best step for an asymptomatic Communicating Hydrocele?
Observe for 1-2 years of age (65% resolve by 1 year of age)
36
Indications of surgery for Communicating Hydrocele?
1) When it fails to resolve
2) If a clinical hernia is apparent
3) If symptomatic (pain)
37
Most surgeons will repair which type of hydrocele despite age?
Encysted hydroceles (Hydroceles of the cord)
38
What is the surgical treatment for hydroceles?
Evacuation of fluid + High ligation
39
What may be done with large or thick hydrocele sacs?
They may be everted behind the cord (Bottle Procedure)
40
The method known as the ______ procedure involves everting large or thick hydrocele sacs behind the cord.
Bottle
41
What is the surgical treatment for inguinal hernias?
Open Repair Technique (high ligation of processus vaginalis)
42
Open exploration of the clinically-free contralateral side is justified in:
1) Prematurity
2) Younger age
3) Female gender
4) Left-sided unilateral hernia
43
Is mesh required in children?
No
44
Which hernia DOES need mesh in children?
Recurrent hernias in children with connective tissue disorders or mucopolysaccharidoses
45
What are the pros of laparoscopic inguinal hernia repair?
1) No difference in recurrence (< 0.5%)
2) Lower incidence of metachronous hernia (recurrent hernia)
3) Lower operation time for bilateral repairs
46
What are the cons of laparoscopic inguinal hernia repair?
Increased operation time for unilateral repair
47
Risk factors for incarcerated inguinal hernias?
1) Younger age
2) Prematurity
48
Early Signs & Symptoms of incarcerated inguinal hernias?
1) Inconsolable infant
2) Intermittent abdominal pain
3) Vomiting
4) Tender and erythematous irreducible mass in the groin
49
Late Signs & Symptoms of incarcerated inguinal hernias?
1) Abdominal distention
2) Bloody stools
3) Peritoneal signs (strangulation)
50
What is the first step in the treatment of incarcerated inguinal hernia in the ER?
Trial of manual reduction
51
What type of sedation is used during the trial of reduction for incarcerated inguinal hernia?
Monitored conscious sedation
52
How do you manually reduce an incarcerated inguinal hernia?
Firm and continuous pressure around the incarceration
53
Under what circumstances should you not attempt reduction of an incarcerated inguinal hernia?
1) Signs of peritonitis
2) Septic shock
54
If the incarcerated inguinal hernia is reduced, what is your next step?
Admit for elective surgery same or next day
55
What is Reduction en masse?
When the hernia contents are reduced into the peritoneal cavity but the bowel remains incarcerated internally in the hernia sac
56
If the incarcerated inguinal hernia reduction failed, questionable (reduction en masse*), incomplete, or contraindicated, what is your next step?
Admit for emergent surgery
57
What are the complications of inguinal hernia & hydrocele surgical repair?
1) Recurrence
2) Injury to the Spermatic Cord or Testis
3) Wound infection
4) Hematoma
5) Persistent hydrocele
6) Chronic pain
7) Loss of domain (due to a huge hernia)
8) Iatrogenic cryptorchidism
58
Recurrence after inguinal hernia & hydrocele surgical repair is higher in:
1) Premature infants
2) Children with incarcerated hernias
3) Associated diseases (e.g., connective tissue disorder, VPS)
59
Undescended testes is a common abnormality that carries ___ and ___ implications
Fertility; malignancy
60
Majority of testes complete descending within:
The first 6 to 12 months of life
61
What is more common: Non-palpable UDT or Palpable UDT?
Palpable UDT
62
What is a peeping testis?
When a previously palpable testis falls back into the abdomen through the open inguinal ring
OR
An intra-abdominal testis that can be felt at the upper inguinal canal
(Basically when you feel it at the inguinal area, it moves up into the abdomen)
63
What is a retractile testis?
NORMALLY descended testis that retracts into the inguinal canal as a result of the cremasteric contraction
(Overactive cremasteric muscle)
64
What is an ascending testis (ACQUIRED UDT)?
A testis that was previously descended on examination, but at a later time can no longer be brought down into the scrotum
65
Possible causes of ascending testis (ACQUIRED UDT)?
1) Secondary to a retractile testis
2) Change in position with growth of the child
3) Iatrogenic after inguinal surgery
66
Undescended testes can be associated with which anomalies?
1) Patent processus vaginalis
2) Epididymal abnormalities
67
Specific syndromes with higher rates of undescended testes include:
1) Prune-belly syndrome
2) Gastroschisis
3) Bladder exstrophy
4) Prader–Willi, Kallman, Noonan syndromes
5) Testicular dysgenesis
6) Androgen insensitivity syndromes
68
How can undescended testes present?
1) Empty hemiscrotum
2) Mobile testis (moving upward)
69
Is there good Hemiscrotal
development in low inguinal hernias?
No
70
You suspect Testicular agenesis. What is your next best step?
Diagnostic laparoscopy to confirm
71
You suspect abdominal UDT. What is your next best step?
1) Diagnostic laparoscopy
2) Primary or staged orchidopexy
72
You suspect Retractile testis. What is your next best step?
1) Observe till puberty for possible spontaneous resolution (90%)
2) Orchidopexy (10%)
73
When should you perform an Orchidopexy for retractile testes?
1) Painful
2) Not growing
3) Upward most of the time
4) Became ascending testis
74
You suspect Low inguinal UDT. What is your next best step?
1) Observe until 1-2 years of age
2) Open primary orchidopexy (if didn’t descend completely)
75
What are the benefits of orchidopexy?
1) Reduces the risk of malignancy and infertility
2) Reduces the risk of torsion
3) Facilitates testicular examination
4) Improves endocrine function of the testis
5) Creates a normal-appearing scrotum
76
What hormonal treatment can we give for undescended testes?
1) Buserelin (LHRH agonist)
2) Low-dose hCG
77
Patients with a history of UDT have a ___ semen analyses
Subnormal
78
Infertility rate of men with a history of unilateral UDT is:
Equivalent to normal population (10%)
79
Infertility rate of men with a history of bilateral UDT is:
6 times more than the normal population
80
Delayed orchiopexy at 3 years versus 9 months results in:
Impaired testicular catch-up growth
81
Abdominal testes had ___(higher/lower) fertility than those with inguinal testes
Lower
82
UDT appears to be associated with x2-x8
increased risk of:
Malignancy
83
Among men with testicular cancer, up to
10% have a history of:
Undescended testes
84
Which malignancy is associated with abdominal testes?
Seminomas
85
Malignancies arising after successful orchidopexy (regardless of original location) are most frequently:
Non-seminomatous germ cell tumors
86
Orchidopexy facilitates subsequent testicular examination and ____.
Cancer detection
87
What is Acute Scrotum?
Acute scrotal pain with or without swelling and erythema
88
What is the most serious differential to keep in mind when presented with acute scrotum?
Torsion of the testis
89
What is the most common differential to keep in mind when presented with acute scrotum?
Torsion of the appendix testis/epididymis
90
Prepubertal boys with acute scrotum are more likely to have:
Torsion of the appendix testis/epididymis
91
Neonates and adolescents with acute scrotum are more likely to have:
Testicular torsion
92
How does testicular torsion happen?
Twisting of the spermatic cord → compromises testicular vasculature
→ testicular infarction
93
What are the two types of testicular torsion?
1) Intravaginal
2) Extravaginal
94
Intravaginal testicular torsion is more common in:
Children and adolescents
95
What is an intravaginal testicular torsion?
When the spermatic cord twists within the tunica vaginalis
96
What is an extravaginal testicular torsion?
When the spermatic cord twists proximal to the tunica vaginalis
97
Which congenital abnormality increases the risk of intravaginal testicular torsion?
Bell-clapper deformity
98
How does the bell-clapper deformity work?
It allows the testis to swing freely, like a bell clapper, within the tunica vaginalis.
99
Extravaginal testicular torsion is more common:
Perinatally
100
When is prenatal torsion noticed?
At birth
101
Prenatal torsion results in a hard, ___(tender/nontender) scrotal mass.
Nontender
102
What findings do you see in prenatal torsion?
1) Discoloration
2) Fixation of the skin to the mass
103
What findings do you see in postnatal torsion?
1) Acutely inflamed scrotum
2) Erythema and tenderness
104
Postnatal torsion scrotum is reported as ___ at delivery
Normal
105
Which type of torsion needs emergency surgery: Prenatal or Postnatal torsion?
Postnatal torsion
106
Testicular torsion typically occurs at which ages?
1) Before age of 3 years
2) After puberty
107
Testicular torsion is LESS common at which ages?
1) Prepubertal boys
2) After age of 25 years
108
How does testicular torsion typically present?
1) Sudden onset of severe, continuous, unilateral testicular pain
2) Lower thigh, or lower abdominal pain
3) Nausea and vomiting
109
Incomplete torsion with spontaneous detorsion presents as:
Intermittent testicular pain
110
Physical examination of torted testis will show:
1) Enlargement
2) Retracted up
3) Transverse orientation
4) Anteriorly located epididymis
5) Absent cremasteric reflex
111
If you order a urinalysis and it reveals pyuria and bacteriuria, what would your top differential diagnosis be?
Infectious epididymitis/orchitis
112
What imaging should you do if you suspect testicular torsion?
1) US with color flow Doppler
2) Radionuclide imaging
113
What will you see on imaging for testicular torsion?
1) Testicular blood flow
2) Coiling of the spermatic cord
114
If clinical features STRONGLY point to testicular torsion, what is your immediate next step?
Emergent exploration under general anesthesia
115
Emergent exploration reveals viable torted testes. What are your next steps?
1) Detorsion
2) Place warm moist sponges to help blood flow
3) Fixation (orchidopexy)
116
Emergent exploration reveals non-viable torted testes. What are your next steps?
Remove to avoid potential damage to the contralateral testis
117
How can a non-viable testicular torsion cause damage to the other testicle?
Through formation of antisperm antibodies
118
There's a high chance of salvaging the torted testes if we operate within:
6 hours
119
Torsion of the appendix testis or appendix
epididymis most commonly occurs between ages:
7-10 years
120
How does torsion of the appendix testis or appendix epididymis present?
1) Sudden onset of pain and nausea
2) Normal urinalysis
3) Appendage can be palpated & focally tender
4) ‘Blue dot’ sign
5) Edema and erythema
121
What is the blue dot sign?
Ischemic appendage seen through the scrotal skin as a blue-colored mass
122
Torsion of the appendix testis or appendix epididymis is suspected. What is your next best step?
It is a self-limited disease;
1) NSAIDs
2) Restricted activity
3) Warm compresses
123
In bacterial epididymitis, scrotal pain and swelling typically have a ___(slow/fast) onset
Slow
124
Which organisms are implicated in bacterial epididymitis in younger children?
Common urinary pathogens (coliforms and Mycoplasma sp.)
125
Which organisms are implicated in bacterial epididymitis in older and sexually active children?
Neisseria gonorrhoeae and Chlamydia
126
What is the treatment for bacterial epididymitis?
Antibiotics
127
Which organisms are implicated in viral epididymitis?
1) Mumps orchitis
2) Adenovirus
3) Enterovirus
4) Influenza
5) Parainfluenza
128
What is the treatment for viral epididymitis?
Supportive (self-limited)
129
What is Idiopathic Scrotal Edema?
Scrotal swelling of unknown etiology
130
Idiopathic Scrotal Edema typically affects which ages?
Boys 5 to 9 years of age
131
Idiopathic Scrotal Edema is characterized by:
1) Insidious onset of swelling and erythema
2) Pruritus
132
Idiopathic Scrotal Edema begins in the __ then spreads to the:
Perineum/inguinal region; hemiscrotum
133
Does Idiopathic Scrotal Edema present with tenderness?
No
134
What do you see on US Doppler in Idiopathic Scrotal Edema?
Normal testicular blood flow
135
What is the treatment for Idiopathic Scrotal Edema?
1) Anti-histamines
OR
2) Topical corticosteroids
136
What are the signs and symptoms of Henoch–Schönlein Purpura (HSP)?
1) Scrotal & spermatic cord pain, erythema, and swelling
2) Skin purpura, joint pain, and hematuria
137
What do you see on US Doppler in Henoch–Schönlein Purpura (HSP)?
Normal blood flow to the testis
138
What is the treatment for Henoch–Schönlein Purpura (HSP)?
1) Supportive measures
2) Systemic corticosteroids
139
If you're presented with testicular trauma, you need to think of:
Sexual abuse
140
What should you evaluate on US Doppler in testicular trauma?
Rupture of the tunica albuginea
141
What is the treatment for testicular trauma?
Exploration +/- repair of the ruptured
tunica albuginea
