Inguinal and Scrotal
Pathology
Dr Andre Theron
Paediatric Surgery
Charlotte Maxeke Johannesburg
Academic Hospital
UP TO SPAED 2016
Inguinal and Scrotal Pathology
• Hernia and Hydrocele
• Undescended
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Retractile testis
Canalicular testis
Abdominal testis
Vanished testis
Ectopic Testis
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Torsion of Testis
Torsion of appendix testis
Epididymo-orchitis
Strangulated hernia
Idiopathic scrotal oedema
Haematoma
• Acute scrotum:
• Testicular mass:
– Teratoma
– Orchioblastoma, germ cell tumour; Interstitial cell tumours
(Leydig, Sertoli)
• Inguinal Lymphadenitis
Inguinal and Scrotal Pathology
Anatomy and core embryology
• Congenital inguinal hernia and undescended
testis are related to testicular descent
• The testes develop in the abdomen and
descend into the scrotum under the influence
of hormones, pulling down the processus
vaginalis
• The testes reach the scrotum by the 3rd
trimester
• In +/-90% of children, the processus vaginalis
seals and becomes a thin band of tissue
• If all or any portion of the processus remains
open it may result in a congenital inguinal
hernia, hydrocoele or a communicating
hydrocoele
• Patency of the processus vaginalis decreases
with increasing gestational age
• In girls, hernias are less common than in boys
(1:8)
Inguinal Hernia- Incidence
• Indirect hernia - most
commonly
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– with a patent processus
vaginalis
Direct hernias rare
3% - 5% of term infants
9% - 11% of pre term babies
35% if < 28 weeks
60% right, 25% left, 15% Bilat.
M>F, bilateral. F>M
Increased incidence in patients
on peritoneal dialysis, VP
shunts
• At least 5% bilateral
Inguinal Hernia- Physical
Examination
• A bulge in the groin or the scrotal sac,
worse on straining or crying, cough
impulse
• Rely on history
• “silk string” sign
• Determine difference between a hernia,
hydrocele and communicating hydrocele
• A non-communicating hydrocele usually
presents as a soft, non-tender, fluid-filled
sac in the scrotum which does not change
in size over the course of the day
• Check for testicular descent in boys
Inguinal Hernia - Incarcerated
Hernia
• Incarceration or irreducibility is most common
complication
– 30 % in 1st year of a term baby
– 12% below 12yrs,
• Most commonly bowel, ovary in Female
• Presents as sudden onset of a irreducible swelling in
scrotum or groin, bowel obstruction
• Failure to reduce can lead to strangulation of contents
and ischemia of the testicle
• Sedation required to reduce
– Valeron
– Ileo-inguinal block
Inguinal Hernia - Strangulated
hernia
• May present with bowel
obstruction
• Hot, red, tender, oedematous
• Do not attempt to reduce
• Differential of acute scrotum,
but unable to get above mass
• Urgent surgery
• Bowel and testicular ischaemia
and necrosis common
Inguinal Hernia- Management
• Hydroceles may gradually resolve over the first year
• Persisting hydroceles: surgery
• Hydroceles in older children may follow trauma,
inflammation or tumours of the testis –manage
the underlying condition
• Fluid hernias: operate
• Bowel containing hernias: surgery on next available list –
warn parents of complications
• Incarcerated hernias: reduce, operated before discharge
• Strangulated hernias: resuscitate, urgent surgery
Inguinal Hernia - Surgery
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Hernia, hydrocele fluid hernia can be done as an outpatient surgery, which
is safe, effective, and well tolerated
General anaesthetic
– Caudal block with sedation
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Skin crease incision. Inguinal canal opened. Ilioinguinal and iliohypogastric
nerve identified. Hernia sac identified, dissected from spermatic cord.
High ligation of sac
Limited role for laparoscopic as open performed through small incision in
20 to 30 minutes, associated with little morbidity, almost no mortality, and
prompt return to normal activity
Inguinal Hernia - Complications
• Injury to the ilioinguinal nerve, vas
deferens, and spermatic vessels, are
uncommon after elective hernia repair
• Bleeding is unusual
• Wound infection (1%)
• Scrotal haematoma
• Postoperative hydrocele
• Recurrent inguinal hernia (2%)
Femoral Hernia
Femoral hernias
• Unusual in the paediatric age group
• More common in girls
• Usually present with a bulge below the
groin crease
Undescended Testis
The Normal Descending Testis
• The testicle begins to form just before the 2nd foetal month
• By the 4th month it has migrated from the kidney to the to the
internal inguinal ring
• During month 7 the testicle, accompanied by a small peritoneal
tube passes through internal ring, inguinal canal, and external
ring to the scrotum
• The mechanisms of descent are unknown
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traction on testis by scrotal attachments
differential growth of the body wall
intra-abdominal pressure
maturation of the epididymis
multiple hormonal factors
Undescended Testis
Advantages of Scrotal Location
• Scrotum is 2-3 oC cooler than core important for development of normal
post pubertal testicular structure and
sperm production
• Cosmetic, psychological advantage
• Less amenable to injury
• The most common solid tumour in males
age puberty to 40 yrs is testicular cancer,
scrotal testes can be easily monitored
Undescended Testis - Presentation
• Incidence is 3-5% in full term boys, 1.8%
at 1yr
• About 65% of the testicles typically
descend by 9 months of age
• Clinically an empty scrotum
• Scrotal hypoplasia
Undescended Testis - Classification
• Testicular retraction:
– Most common age 5-6 yrs, from 1-11 yrs, 80% of fully
descended testes can withdraw and leave scrotum empty, due
to hyperactive cremaster, variation of normal. If a testis can
be milked down to bottom of scrotum, it is retractile -no
further treatment needed Usually improves by puberty
• Cannilicular testis:
– Testicle located above the scrotum, but still outside the
abdominal cavity (72%)
• Intra-Abdominal testes:
– Testicle located inside the abdominal cavity in a position along
its pathway of natural descent (8%)
• Ectopic testicle:
– Testicle found in regions not in the usual pathway of descent.
5 major sites are perineum, femoral canal, superficial inguinal
pouch, suprapubic area, and contralateral scrotal pouch
• Absent testicle:
– Can be bilateral, associated with in utero torsion, vascular
insult, or agenesis (4%)
Undescended Testis
Undescended Testis - Imaging
• Generally imaging is not reliable
• Ultrasound can help identify a testicle
located in the inguinal canal, but is of
limited use for intra-abdominal testes
• MRI and CT scan can be useful for intraabdominal testes, but they are often
difficult to use on small children and
have a high false negative rate
Undescended Testis Management
• Avoid intervention before 6 months of age possible spontaneous descent
• Bilateral undescended testes:
– Intersex (females with adrenal hyperplasia) should be
ruled out by hormonal work-up. HCG stimulation test for
testosterone response is performed. Patients with
bilateral anorchia will have no response
• Pharmacotherapy
– Avoids anaesthesia. HCG stimulates Leydig cells to
produce male hormones. The mechanism of action is
unknown, success rates are as low as10%. HCG or GRH
analogues for palpable high-scrotal position of the testis
• Surgical Orchidopexy
– Most will be performed around 1 year.
– There is evidence that early damage to the germ cells
that produce sperm begins at 6 months.
Undescended Testis - Surgery
• Retractile testis – no surgery, monitor
annually
• Cannilicular testis – exploration and
orchidopexy via a hernia incision. After
removal of the hernial sac, the testis is
delivered into the scrotum and anchored
in a sub-dartos pouch
Undescended Testis
Non Palpable testis: Laparoscopy
• Vas and vessels exit abdominal cavity – groin exploration
• Testis low in abdomen and mobile: A laparoscopically
assisted orchidopexy is performed via a small opening in the
scrotum
• High Intra abdominal testis: The testicular artery is divided.
Revascularization occurs and pexy to the scrotum is
performed in a 2nd stage operation in 6 months
• Very abnormal gonad: Biopsy
Undescended Testis - Outcome
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Complications:
– Bleeding
– Infection
– Uncommon
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Fertility:
– is less likely to be normal in 40% of unilateral and 70% of bilateral
undescended testes. Early orchidopexy should optimize this
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Tumorgenesis:
– 20-48 times more likely to undergo malignant degeneration.
Orchidopexy does not alter the risk of malignant transformation. The
incidence is also increased in the unaffected testis. At puberty, boys
should be taught how to perform monthly testicular selfexaminations. Seminoma is most common
Acute scrotum
• Red, Hot, painful, tender
• Pathology
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Torsion of Testis
Torsion of appendix testis
Orchitis / epidydimitis
Strangulated hernia
Idiopathic scrotal oedema
Haematoma
Acute scrotum
Torsion
- Neonatal/extra-vaginal
- Intra-vaginal
• Peak incidence: 13-14yrs
• Left side more common
• Sudden onset
• Extremely tender
• Often “trauma” history
Acute scrotum
Testicular torsion:
• U/S may see torted vessels
• Surgery should not be delayed
• Surgical exploration is only definitive
method
Acute scrotum
Appendix Testis torsion
• ‘Appendix’ is embryonal remnant of
Mullerian structures
• Sudden to progressive onset
• Small blue dot/mass
• If diagnosis certain, can manage
conservatively
• Analgesics for a week
• Surgery definitive
Acute scrotum
Epididymitis: relatively rare
• Slower onset
• Dysuria
• Urinary tract abnormalities
– 47% prepubertal
– Ectopic vas deference,ureters
– Urethral abnormalities.
• Dipstix may be positive
Acute scrotum
Strangulated hernia
• Clinically evident
• Bowel obstruction
• Cant get above mass
• Don’t attempt reduction
• Urgent surgery
Acute scrotum
Idiopathic Scrotal oedema
• <10yr of age
• Unclear etiology
– Eosinophilia, angioneurotic oedema
• Oedematous, generally not painful or tender
• Extends to perineum, inguinal area and opposite
side
• USS: Thickening and oedema of the scrotal wall,
hypervascularity of the scrotum, and normal
appearance of the testes
• Supportive management
Acute scrotum
Haematoma
• Trauma history – straddle, kick
• Bilateral
• Ultrasound
• Conservative
Testicular Mass
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Primary testicular tumours
Lymphoma
TB
Calcified meconium from intra uterine
perforation
• Calcified haematoma
Testicular Tumors
• 2% of Paediatric malignancy
• 0.05 – 2/100 000
• Bimodal distribution
– First 2 years
– Young adult
• 60-77% germ Cell
• Ultrasound
• Appropriate investigations
Thank you
Questions??