Inguinoscrotal Swelling In Pediatrics

By

Khaled Ashour

Causes of Ing.Scrotal swellings

1.
2. 3.

4.
5. 6.

Congenital inguinal hernias. Congenital hydrocele. Undescended testis. Varicocele in children. Malignancies: as lymphoma, testicular tumours, etc. .Others, e.g. Epididymo-orchitis, extensive suppurations, lymphadenopathy, etc.

(1) Congenital inguinal hernia (C.I.H)

Cong. Inguinal Hernia Definition:

It

is herniation of part of the abdominal viscera outside the abdominal cavity through a preformed sac Patent processus vaginalis, which occurs in pediatric age group.

Cong. Inguinal Hernia Incidence:

Inguinal hernitomy is the most common general surgical operation in Pediatrics. Occurs in 0.8% up to 4.4%. Higher in infants than children. Higher in prematures. Male : Female = 7:1. Right side 60%, Left: 32%, Bilateral: 8%.

Cong. Inguinal Hernia Pathogenesis:

The processus vaginalis (P.V.) develops during the third month of Gestation as an outpouching of the peritoneal cavity through the deep ring. During testicular descent at the 7th month, it becomes covered with the P.V., that extends to the scrotum.

Cong. Inguinal Hernia Pathogenesis (Cont.)

During the 9th month, the testicular descent triggers obliteration of PV, although the mechanism of obliteration is not fully understood. Abnormalities of obliteration results in eith hernia or hydrocele according to the caliber of unobliterated PV.

Abnormalities of processus vaginalis obliteration

Cong.Inguinal Hernia Clinical picture:

Infant / child with an inguinoscrotal painless swelling that appears on crying, and disappear spontaneously. Contents: mainly small bowel. Might be associated with maldescended testis. Commonly presented with incarceration.

Cong. Inguinal Hernia Clinical picture

Diagnosis: - History of swelling: Associated with crying and irritability. - On examination: Swelling on straining. No swelling: diagnosis by rolling test: 1) thickening of the cord. Due to: - Presence of sac -Hypertrophy of cremasteric ms. 2) Silk-glove sign: due to the sac leaflets with peritoneal fluid inbetween.

Cong. Inguinal Hernia C/P:

In Female: The inguinal canal is not well developed, carrying the round ligament of the uterus. Indirect inguinal hernia may occur, and is termed: Ing. Hernia of canal of Nuck. The content here is mainly the ovary and fallopian tube.

Cong. Inguinal Hernia Complications

Irreducibility, Obstruction, and strangulation. These complications are commoner than in adults due to narrow hernial neck. C/P: Painful & tender swelling, irreducible, and/ or oedematous red skin overlying.

Isolation of the vas and tesicular vessels

Hernial sac with its contents

Testicle

Hernial sac
Incarcerated Cecum

Testicle

Surgical management

Cong. Inguinal Hernia Management

Elective cases: herniotomy. Emergency cases: irreducible: - Manual reduction. If failed - Operative. Contraindications of manual reduction: - Fever - tender abdomen - Intestinal obstruction. - X ray: air-fluid levels - +Ve local signs of strangulation.

Cong.Inguinal Hernia Management

NO RULE FOR CONSERVATIVE TREATMENT. As the use of ice bags, in irreducible congenital inguinal hernia.

Cong. Inguinal Hernia Surgical treatment

Tips Once the hernia is diagnosed, it should be surgically treated for fear of complications. No repair is needed except in rare cases with evident abdominal wall weakness, eg Bladder exstrophy, Prune-belly syndrome, etc.) in which the canal is very wide and / or abdominal wall muscles are weak. Herniotomy in situ without mobilization of the cord.

The distal part of the sac may be left alone if the hernia is complete.

Hernia of canal of Nuck

Postoperative complications

Scrotal hematoma. Scrotal edema, which resolves spontaneously within days. Testicular atrophy: if dissection affects the vasculature. Iatrogenic ascending undescended testicles. Injury to the vas. Recurrence.

Immediate recurrence

Incision

Congenital (Primary) hydrocele

Congenital Hydrocele

Def.: Accumulation of fluid in relation to processus and / or tunica vaginalis. It occurs also as a result of abnormalities in processus vaginalis (PV) obliteration. When the caliber of the patent P.V is small to admit abdominal viscera but can admit peritoneal fluid.

Congenital Hydrocele presentation

Neonatal presentation. Late presentation. Acute hydrocele: acute inguinoscrotal swelling.

Neonatal Hydrocele Classification

Types of hydrocele in Pediatric age: I. Etiological classification:
1. Congenital hydrocele Primary.

2. Acquired hydrocele Secondary.

Congenital Hydrocele Types

II. Clinical Classification: the most important

1) Tense hydrocele: - Communicating - non-communicating. 2) Soft hydrocele: - Communicating - non-communicating.

Congenital Hydrocele Types

III. Anatomical classification: 1) Complete hydrocele: - Communicating - non-communicating: Tense: testis cannot be palpated Soft: Testis is palpable through hydrocele sac.

III. Anatomical classification (Cont.)

2) Hydrocele of the cord: - Communicating - non-communicating (encysted): * Tense: Non-fluctuant. * Soft : Fluctuant. 3) Infantile hydrocele (Funicular): - Communicating - non-communicating: *Tense * Soft.

III. Anatomical classification (Cont.)

4) Combined hydrocele: Hydrocele of the cord + complete or funicular one. 5) Hydrocele of the hernial sac.

Congenital Hydrocele Clinical Picture

Inguinoscrotal painless cystic swelling, that shows diurnal & nocturnal variations in size. Commonly soft cystic, but sometimes tense. In hydrocele of the cord, a cystic supratesticular mass may be felt, with positive testicular traction test. +Ve translucency.

Congenital hydrocele

* Transillumination

Congenital Hydrocele Management

1) Neonatal presentation: - tense: operative. - Soft : follow-up, many possibilities might occur (Mentioned next slide). 2) Late presentation. Less than one year: as above. More than one year: Operative. 3) Acute hydrocele: Operative to exclude acute scrotum.

Congenital Hydrocele Management

In follow-up strategy for the soft neonatal presentations, the following possibilities might occur: 1) Turn into tense. from fluctuant into non 2) Becomes softer. 3) Completely disappears ??? 4) Hydrocele of hernial sac.

Congenital Hydrocele Surgery

Via a small lower abdominal crease incision, as in cong. Ing. Hernia, the communication is attacked if present. Disconnection of the patent processus vaginalis, as in hernia, with transfixion of the proximal end (hydrocelectomy), + near complete excision of the tunica.

3) Maldescended testis

Maldescended testis
1) Arrested: in the superficial inguinal pouch - At the neck of scrotum. - Associated with inguinal hernia. - Acute swelling if torsion occurred. 2) Retractile, ascending, ectopic: presented with inguinal swelling

4) Varicocele in Pediatrics

Varicocele in Pediatrics Definition

Dilatation,

elongation and tortuousity of the pampiniform plexus of veins.

Varicocele in Pediatrics incidence

Very rare under the age of 10 year-old. Above this age, the incidence rises to become near the adult onset (5-12%) Left side: 80% - 90%.

Varicocele in Pediatrics pathophysiology

Venous dilatation, with reversal of blood flow causes disturbance of the countercurrent heat exchange mechanism of the spermatic cord. Local increase in temperature due to blood stagnation

Varicocele in Pediatrics pathophysiology

Local increase in temperature due to blood stagnation leads to : 1) Dartos muscle relaxation: loss of scrotal wrinkles. 2) Cremasteric muscle relaxation: low-lying testis.

Varicocele in Pediatrics Etiology

Primary varicocele: The left side is commoner due to : 1} Right angle fusion of the left testicular vein to the left renal vein. 2} Longer course left Test. vein,. 3} Pressure effect of the loaded sigmoid 4} Nut-cracker mechanism of the aorta with the superior mesenteric artery.

Varicocele in Pediatrics Etiology (Cont.)

5} Vascular spasm at the origin of the vein by adrenaline coming from the adrenal gland. 6} Higher incidence of congenital absence of valves on the left side 40% left, 23% right.

Varicocele in Pediatrics Etiology

Secondary varicocele: Secondary to: A) Renal enlargement: Wilms tumour, neuroblastoma, hydronephrosis. B) Retroperitoneal malignancies.

Varicocele in Pediatrics Clinical picture

Young boy with mainly affection of the left side . Mild dragging pain on the affected side. Loss of scrotal wrinkles on the affected side. The left side is hanging down more than the right.

Varicocele in Pediatrics Clinical Picture

Varicocele may be classified by size into: Grade I: evident only by Valsalva maneuver.
Grade II: evident without Valsalva.

Grade III: Visible as a scrotal spaceoccupying lesion

Varicocele in Pediatrics Complications

Thrombophlebitis. Testicular

dysfunction. troubles.

Psychological

Varicocele in Pediatrics Treatment

Indications for surgery: @ Chronic pain and discomfort @ demonstrable testicular atrophy in adolescence. @ Infertility in adults.
@ Difference in orchidometry (testicular measurement) > 15% between both sides.

Varicocele in Pediatrics Surgery

Three approaches: 1) Low inguinal approach 2) High ing. Approach 3) Retroperitoneal approach Open Laparoscopic

Uncommon causes of scrotal/inguinoscrotal swellings

Other causes
* Testicular tumours * Epidydimo-orchitis * Testicular torsion * Hematocele * Scrotal haematoma * Idiopathic scrotal oedema

Primary testicular tumours

Testicular teratoma

2nd Testicular tumours

Leukaemic infiltration