inguinoscrotal swellings- a problem oriented approach

INGUINOSCROTAL SWELLINGS

A PROBLEM ORIENTED APPROACH


Dr.B.SELVARAJ MS;Mch;FICS;

ASSOCIATE PROFESSOR IN PEDIATRIC SURGERY

PONDICHERRY INSTITUTE OF MEDICAL SCIENCES

PONDICHERRY- 605014; INDIA


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Appropriate surgical referral

Recognise various conditions

Clinch correct diagnosis

Appropriate investigations

Appropriate early treatment

OBJECTIVES

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Causes

Hernia Hydrocele

Torsion Testis &

Testicular Appendages Epididymo-orchitis

Testicular Tumor Inguinal Lymphadenitis

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INGUINAL HERNIA

Persistent patent Processus Vaginalis- always indirect

Male:Female ratio 9:1

Peak incidence in 1st year of life-common in premies

Rt side- 60%

Lt side-25%

Bilateral-15%

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INGUINAL HERNIA

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Inguinal swelling when baby cries

Silk glove sign+

Simple hernia� reducible

Obstructed hernia� Not reducible

Strangulated hernia� Tense & Tender

Bilious vomiting in obstructed & strangulated hernia

INGUINAL HERNIA

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INGUINAL HERNIA- Complications

Incarceration – Premature Neonates<1yr 50%

In huge hernia – Testicular atrophy in boys

-- Ovarian atrophy in girls

-- Mature Neonates < 1yr 30%

-- Mature Neonates > 1yr 15%

Strangulation -- Gangrenous bowel +

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INGUINAL HERNIA

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INGUINAL HERNIA- Operative

Management

Inguinal skin crease incision

Incise External oblique aponeurosis and extend into superficial ring

Dissect off hernial sac from cord structures

High ligation of sac ��Herniotomy

Close wound in layers

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INGUINAL HERNIA- Operative

Management

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INGUINAL HERNIA-

Postop complications

Injury to Vas deferens & vessels

Testicular atrophy due to testicular artery injury

Recurrence due to failure of high ligation

Wound infection in obstructed & strangulated hernia

Hydrocele when distal hernial sac around testis hasn’t been left open

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HYDROCELE

Peritoneal fluid collection in processus vaginalis

Diurnal variation in size

Positive fluctuation & Transillumination

Regression & spontaneous closure of processus vaginalis by 1 to 1.5 yrs

Get above the swelling+ve

Traction test +ve in Encysted Hydrocele

Huge Hydrocele �Pressure atrophy of Testis

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HERNIA&HYDROCELE-Types

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HYDROCELE

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HYDROCELE- Operation

High ligation of processus vaginalis- Herniotomy

In Encysted Hydrocele in addition incise and evacuate fluid; Don’t close incision

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TORSION TESTIS

Twisting of Testis� Strangulation�Necrosis

Common in Neonates & at puberty

Affects Left side more

An Undescended Testis undergoes torsion frequently

Swollen hemiscrotum with edema & erythema

Tender Testis

Cremasteric reflex- Absent

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TORSION TESTIS-TYPES

In Neonates In Adolescents Very rare

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TORSION TESTIS

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TORSION TESTIS-

Differential Diagnosis

Epididymo orchitis

Incarcerated Hernia

Idiopathic scrotal edema

Hydrocele

Torsion of Testicular

Appendages

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TORSION TESTIS-

Doppler Study

Central testicular blood flow� Normal Testis

No Central testicular blood flow but excessive peripheral

blood flow

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TORSION TESTIS-Management

Ipsilateral side�Exploration,Detorsion and Fixation orchiopexy

Contralateral side� Exploration and Fixation orchiopexy

In doubtful cases & Nonavailability of Doppler scan� Better to explore rather than delay treatment

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Torsion of Testicular Appendages

Hydatid of testis & epididymis�Remnant of obliterated Mullerian ducts

Sudden Swelling and redness of hemiscrotum

Tender Testis

‘Bluedot sign’ +ve

Cremastric reflex intact

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Testicular Appendages

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Bluedot sign

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Explore & Excise torsed appendages

In delayed cases >48 hrs conservative treatment with antibiotics


Management

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EPIDIDYMOORCHITIS

Inflammation of epididymis & Testis due to infection or trauma

Sudden onset of pain in a hemiscrotum

Commonly associated with UTI

Thickened & Tender epididymis

Pain relief by elevation of hemiscrotum� Prehn’s sign

Can be treated conservatively with antibiotics and antiinflammatory drugs

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EPIDIDYMOORCHITIS

USG Scrotum

Thickened Epididymis

Reactive Hydrocele

Thick Scrotal wall

Doppler Scan

Excessive blood flow to Epididymis

Normal Testicular parenchymal blood flow

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TESTICULAR TUMORS

Account for 1% of all pediatric malignant tumors

Most are germinal in origin & Malignant

Present before the age of 3 yrs

Endodermal sinus tumor� Commonest malignant tumor

Teratoma�Commonest benign tumor

Rhabdomyosarcoma� Arise from paratesticular tissues

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TESTICULAR TUMORS

Present with painless hard testicular swelling

Scrotal skin is usually free

Estimation of Alfa-feto-protein & Human chorionic gonadotrophin- Tumor markers

Needle biopsy- contraindicated

High orchidectomy with retroperitoneal lymph node dissection

Pot op Radiotherapy or adjuvant chemotherapy

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TESTICULAR TUMORS

USG Testis

Anterior Hypoechoic area�Testicular Tumor

Doppler Scan

Hypovascular intratesticular tumor

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TESTICULAR TUMORS

High Orchidectomy

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INGUINAL LYMPHADENITIS

Look for any primary focus of infection or neoplasia in drainage area – from umbilicus to toes

Most are due to reactive hyperplasia and responds to antibiotics

Some may be due to Koch’s or Lymphoma

In persistent cases always do Excisional Biopsy

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inguinoscrotal swellings- a problem oriented approach

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