Paeds: Inguinoscrotal disorders Flashcards Preview

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Flashcards in Paeds: Inguinoscrotal disorders Deck (21)

Inguinoscrotal disorders
Testis is formed from

The urogenital ridge on the posterior abdominal wall close to the developing kidney.


Gonadal induction to form a testis is regulated by

genes on the Y chromosome.


During gestation, the testis

1. migrates down towards the inguinal canal, guided by mesenchymal tissue known as the gubernaculum, probably under the influence of anti-Mullerian hormone.


Inguinoscrotal descent of the testis requires

the release of testosterone from the fetal testis.


What preceds the migrating testis through the inguinal canal

A tongue of peritoneum, the processus vaginalis,


This peritoneal extension, what happens to it

normally becomes obliterated after birth failure of this process may lead to the development of an inguinal hernia or hydrocele


Inguinal hernia:

Inguinal hernias in children are almost always indirect and due to patient processus vaginalis


Inguinal hernia:Aetiology

More frequent in boys and particularly common in premature infants.


Inguinal hernia: Presentation

More common on the right due to later descent of the right testis
1 in 50 boys will develop an inguinal hernia.


Inguinal hernia: Signs and symptoms

• An intermittent swelling in the groin or scrotum on crying or straining
• Presents as an irreducible lump in the groin or scrotum.
• Firm and tender lump
Infant may be unwell and vomiting


Inguinal hernia: Diagnosis

• Diagnosis relies on history and the identification of thickening of the spermatic cord (or round ligament in girls).
The groin swelling may become visible on raising the intra-abdominal pressure by gently on the abdomen or asking the child to cough.


Inguinal hernia: Examination

• Most ‘irreducible’ hernias can be successfully reduced following opioid analgesia and sustained gentle compression
• Does not transluminate
• Often increases in size when the child is crying
• Testis is palpable, distinct form the swelling
• Reduction of the swelling is diagnostic
No pain unless incarcerated


Inguinal hernia: Management

• Most ‘irreducible’ hernias can be successfully reduced following opioid analgesia and sustained gentle compression
• Surgery is delayed for 24-48 hours to allow resolution oedema
• If reduction impossible, emergency surgery is required because of the risk of strangulation of bowel and damage to the testis.
A hernia associated with an undescended testis should be operated early to minimise risk to the testis.


Inguinal hernia: Incarcerated

30% risk of testicular infarction due to pressure on the gonadal vessels.


Inguinal hernia: Surgical reduction

• Carried out via an inguinal skin crease incision and involves ligation and division of the hernia sac (processus vaginalis).
Except in small infants, this can usually be undertaken as a day-case procedure, provided there is appropriate anaesthetic and surgical support.


Definition and process of formation

A patent processus vaginalis, which is sufficiently narrow to prevent the formation of an inguinal hernia may still allow peritoneal fluid to track down around the testis to form a hydrocele.



• Symptomatic scrotal swellings, often bilateral and sometime with a bluish discolouration
May be tense of lax but are non-tender and transluminate


Hydrocele: Prognosis

• Majority resolve spontaneously as the processes continues to obliterate, but surgery is considered if it persists beyond 18-24 months of age
A hydrocele of the cord forms a non-tender mobile swelling in the spermatic cord.


Inguinal hernias

• Much less common in girls
• Ovary becomes incarcerated in the hernia sac and can be difficult to reduce
• Rarely, androgen insensitivity syndrome (testicular feminisation) can present as a hernia in a phenotypic female who actually has a male genotype.


Labial adhesions

- Labia minora are adherent in the midline, appearance of no vagina but a translucent midline raphe partially or totally occluding the vaginal opening.


Labial adhesions Management:

1. Asymptomatic – left alone and will often lyse spontaneously.
2. If perineal soreness or urinary irritation, treatment with topical oestrogen treatment applied sparingly twicSe a day for 1-2 weeks often dissolves the adhesions.
3. Active separation of the adhesions under anaesthesia is sometimes required.

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