Inguinoscrotal Swelling In Inguinoscrotal Swelling In PediatricsPediatrics

By

Khaled Ashour

Causes of Ing.Scrotal Causes of Ing.Scrotal swellingsswellings

1. Congenital inguinal hernias.2. Congenital hydrocele.3. Undescended testis.4. Varicocele in children.5. Malignancies: as lymphoma, testicular

tumours, etc.6. .Others, e.g. Epididymo-orchitis, extensive

suppurations, lymphadenopathy, etc.

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

Cong. Inguinal HerniaCong. Inguinal HerniaDefinition: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 HerniaCong. Inguinal HerniaIncidence: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 HerniaCong. Inguinal HerniaPathogenesis: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 HerniaCong. Inguinal HerniaPathogenesis (Cont.)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 HerniaCong.Inguinal HerniaClinical picture: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 HerniaCong. Inguinal HerniaClinical pictureClinical 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 HerniaCong. Inguinal HerniaC/PC/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 HerniaCong. Inguinal HerniaComplicationsComplications

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

Incarcerated Cecum

Hernial sac

Testicle

Surgical managementSurgical management

Cong. Inguinal HerniaCong. Inguinal HerniaManagementManagement

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 HerniaCong.Inguinal HerniaManagementManagement

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

Cong. Inguinal HerniaCong. Inguinal HerniaSurgical treatmentSurgical 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 complicationsPostoperative 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.

Incision

Immediate recurrence

Congenital (Primary) Congenital (Primary) hydrocelehydrocele

Congenital HydroceleCongenital 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 HydroceleCongenital Hydrocelepresentationpresentation

Neonatal presentation.Late presentation.Acute hydrocele: acute inguinoscrotal

swelling.

Neonatal HydroceleNeonatal HydroceleClassificationClassification

Types of hydrocele in Pediatric age:

I. Etiological classification:

1. Congenital hydrocele “Primary”.

2. Acquired hydrocele “ Secondary”.

Congenital HydroceleCongenital HydroceleTypesTypes

II. Clinical Classification:the most important

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

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

Congenital HydroceleCongenital HydroceleTypesTypes

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.)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.)III. Anatomical classification (Cont.)

4) Combined hydrocele:- Hydrocele of the cord + complete or

funicular one.- 5) Hydrocele of the hernial sac.

Congenital HydroceleCongenital HydroceleClinical PictureClinical 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 hydroceleCongenital hydrocele

*Transillumination

Congenital HydroceleCongenital HydroceleManagementManagement

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 HydroceleCongenital HydroceleManagementManagement

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 HydroceleCongenital HydroceleSurgerySurgery

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 testis3) Maldescended testis

Maldescended testisMaldescended 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 Pediatrics4) Varicocele in Pediatrics

Varicocele in PediatricsVaricocele in PediatricsDefinitionDefinition

Dilatation, elongation and tortuousity of the pampiniform plexus of veins.

Varicocele in PediatricsVaricocele in Pediatricsincidenceincidence

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 PediatricsVaricocele in Pediatricspathophysiologypathophysiology

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 PediatricsVaricocele in Pediatrics pathophysiology 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 PediatricsVaricocele in PediatricsEtiologyEtiology

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 sigmoid4} Nut-cracker mechanism of the aorta with

the superior mesenteric artery.

Varicocele in PediatricsVaricocele in PediatricsEtiology (Cont.)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 PediatricsVaricocele in PediatricsEtiologyEtiology

Secondary varicocele:

Secondary to:

A) Renal enlargement: Wilms’ tumour, neuroblastoma, hydronephrosis.

B) Retroperitoneal malignancies.

Varicocele in PediatricsVaricocele in PediatricsClinical pictureClinical 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 PediatricsVaricocele in PediatricsClinical PictureClinical 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 space-

occupying lesion

Varicocele in PediatricsVaricocele in PediatricsComplicationsComplications

Thrombophlebitis.

Testicular dysfunction.

Psychological troubles.

Varicocele in PediatricsVaricocele in PediatricsTreatmentTreatment

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 PediatricsVaricocele in PediatricsSurgerySurgery

Three approaches:

1) Low inguinal approach

2) High ing. Approach

3) Retroperitoneal approach

Open Laparoscopic

Uncommon causes of Uncommon causes of scrotal/inguinoscrotal swellingsscrotal/inguinoscrotal swellings

Other causesOther causes

*Testicular tumours

*Epidydimo-orchitis

*Testicular torsion

*Hematocele

*Scrotal haematoma

*Idiopathic scrotal oedema

Primary testicular tumoursPrimary testicular tumours

Testicular teratoma

22ndnd Testicular tumours Testicular tumours

Leukaemic infiltration