inguinoscrotal swellings- a problem oriented approach
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INGUINOSCROTAL SWELLINGS
A PROBLEM ORIENTED APPROACH
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INGUINOSCROTAL SWELLINGS
Dr.B.SELVARAJ MS;Mch;FICS;
ASSOCIATE PROFESSOR IN PEDIATRIC SURGERY
PONDICHERRY INSTITUTE OF MEDICAL SCIENCES
PONDICHERRY- 605014; INDIA
A PROBLEM ORIENTED APPROACH
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INGUINOSCROTAL SWELLINGS
A PROBLEM ORIENTED APPROACH
Appropriate surgical referral
Recognise various conditions
Clinch correct diagnosis
Appropriate investigations
Appropriate early treatment
OBJECTIVES
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INGUINOSCROTAL SWELLINGS
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
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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- 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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Torsion of Testicular Appendages
Bluedot sign
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Explore & Excise torsed appendages
In delayed cases >48 hrs conservative treatment with antibiotics
Torsion of Testicular Appendages
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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