Does Your Child have a Hernia ? Inguino Genital Conditions in Children By Dr. Vivek Rege. Lot of silent conditions that may require surgical intervention at the right time by the doctor. For info log on to www.healthlibrary.com

1. Dr. Vivek M. Rege
Inguino Genital ConditionsInguino Genital Conditions
in Childrenin Children
Dr. Vivek M. RegeDr. Vivek M. Rege
Pediatric Surgeon & Pediatric UrologistPediatric Surgeon & Pediatric Urologist
B J Wadia Hospital for ChildrenB J Wadia Hospital for Children
Bhatia HospitalBhatia Hospital
Saifee HospitalSaifee Hospital
Fortis HospitalsFortis Hospitals

2. ProblemsProblems
• Most of these conditions areMost of these conditions are silentsilent
• Children are neverChildren are never botheredbothered about themabout them
• Some conditions need to be corrected inSome conditions need to be corrected in timetime
• Parents are notParents are not awareaware about these conditionsabout these conditions
• Parents may notParents may not noticenotice these conditionsthese conditions
• ParentsParents ignoreignore them as they are afraid ofthem as they are afraid of
surgerysurgery
Dr. Vivek M. Rege

3. ImportanceImportance
• EarlyEarly detectiondetection & consult& consult properproper surgeonsurgeon
• Good clinicalGood clinical examinationexamination
• Good clinicalGood clinical judgmentjudgment
• RelevantRelevant investigationsinvestigations
• EarlyEarly interventionintervention if necessaryif necessary
• GoodGood resultsresults and earlyand early recoveryrecovery
• Most cases can be done asMost cases can be done as day care/ssday care/ss
Dr. Vivek M. Rege

4. Dr. Vivek M. Rege
Inguinal HerniaInguinal Hernia
PresentationsPresentations
• Inguinal / Inguino - scrotal swellingInguinal / Inguino - scrotal swelling
• Increases on crying, strainingIncreases on crying, straining
• Sudden increase / decrease in sizeSudden increase / decrease in size
• Swelling reducible, usually gurgle++Swelling reducible, usually gurgle++
• Age from birth to infancy to childhoodAge from birth to infancy to childhood

5. Dr. Vivek M. Rege
Inguino Scrotal SwellingInguino Scrotal Swelling

6. Dr. Vivek M. Rege
Sudden increase in size of swellingSudden increase in size of swelling

7. Dr. Vivek M. Rege
Sudden increase in size of swellingSudden increase in size of swelling

8. Dr. Vivek M. Rege
Inguinal HerniaInguinal Hernia
Indications for surgeryIndications for surgery
• Presence of a hernia(50% may have/developPresence of a hernia(50% may have/develop
opposite side)opposite side)
• Age / Sex / Weight – no barAge / Sex / Weight – no bar
ComplicationsComplications
• IrreducibilityIrreducibility
• IncarcerationIncarceration
• Intestinal ObstructionIntestinal Obstruction
• Intestinal GangreneIntestinal Gangrene
• Testicular InfarctionTesticular Infarction

9. Dr. Vivek M. Rege
inguinal herniainguinal hernia
Sac
Cord structures

10. Dr. Vivek M. Rege
Open sac after the intestines have been pushed
inside the abdomen
Sac
Inguinal hernia - surgery

11. Open sac after the intestines have
been pushed inside the abdomen

13. Aryan – 1 month old – Bilateral HerniaAryan – 1 month old – Bilateral Hernia

14. Bilateral Herniotomy doneBilateral Herniotomy done

15. Dr. Vivek M. Rege
Complication of inguinal hernia
Groin & scrotal swelling in a 12 day old child withGroin & scrotal swelling in a 12 day old child with
excessive crying, pain when touched, non reducibleexcessive crying, pain when touched, non reducible
swelling – suggestive of obstruction of intestines -gangreneswelling – suggestive of obstruction of intestines -gangrene

16. Dr. Vivek M. Rege
Black TestisBlack Testis
Prolonged uncorrected obstructed hernia leads to pressureProlonged uncorrected obstructed hernia leads to pressure
on the testicular artery – cutting off of the blood supply toon the testicular artery – cutting off of the blood supply to
the testis and infarction of the testisthe testis and infarction of the testis
OBSTRUCTED HERNIA

17. 6 month old girl with inguinal swelling

21. Dr. Vivek M. Rege
HYDROCELEHYDROCELE

22. Dr. Vivek M. Rege
HydroceleHydrocele
PresentationPresentation
• Scrotal/ing. SwellingScrotal/ing. Swelling
• No impulse on cryingNo impulse on crying
• No sudden changeNo sudden change
• Diurnal variationDiurnal variation
• Non reducibleNon reducible
IndicationsIndications
• Persists after 1 yearPersists after 1 year
• Large size scrotumLarge size scrotum
• Difficulty walkingDifficulty walking

23. Dr. Vivek M. Rege
HERNIOTOMY FOR HYDROCELEHERNIOTOMY FOR HYDROCELE
Inguinal crease incision, canal opened. Sac and cordInguinal crease incision, canal opened. Sac and cord
identified, sac separated from cord. The sac is looped andidentified, sac separated from cord. The sac is looped and
held with hemostats away from the cord structures.held with hemostats away from the cord structures.
Sac

24. Dr. Vivek M. Rege
HERNIOTOMHERNIOTOM
Fluid

25. Dr. Vivek M. Rege
HERNIOTOMY FOR HYDROCELEHERNIOTOMY FOR HYDROCELE
The distal sac is laid open after draining the fluid from itThe distal sac is laid open after draining the fluid from it
and the edges of the sac are cauterised without excising it .and the edges of the sac are cauterised without excising it .
Later hemostasis is achieved and closure done in layersLater hemostasis is achieved and closure done in layers
with continuous sutures.with continuous sutures.
Open sac

26. Dr. Vivek M. Rege
HERNIOTOY FOR HYDROCELEHERNIOTOY FOR HYDROCELE
The sac is then dissected from cord till the internal ring isThe sac is then dissected from cord till the internal ring is
reached and the preperitoneal fat is seen. The sac is thenreached and the preperitoneal fat is seen. The sac is then
twisted transfixed, ligated and the excess sac is excised.twisted transfixed, ligated and the excess sac is excised.
Base of sac
Cord

27. Dr. Vivek M. Rege
Absent testis on one sideAbsent testis on one side
Possibilities are:Possibilities are:
• Retractile testisRetractile testis
• Ectopic testisEctopic testis
• Undescended Palpable testisUndescended Palpable testis
• Undescended non palpable testisUndescended non palpable testis
• Absent testisAbsent testis

28. Dr. Vivek M. Rege
RETRACTILE TESTES

29. Dr. Vivek M. Rege
RETRACTILE TESTES
Testis in scrotumTestis in scrotum

30. Dr. Vivek M. Rege
CLASSIFICATION
Palpable
Palpable
Nonpalpable

31. Dr. Vivek M. Rege
Swelling at base of penisSwelling at base of penis

32. Swelling noticed
Empty Scrotum
Proper examination

33. Dr. Vivek M. Rege
Problems of Undescended TestisProblems of Undescended Testis
• Infertility: Decrease in germ cell numberInfertility: Decrease in germ cell number
• Trauma to testisTrauma to testis
• Torsion of testisTorsion of testis
• Hernia associated with udt – 65 – 70%Hernia associated with udt – 65 – 70%
• Tumour of testis 22 times more commonTumour of testis 22 times more common
• Psychological effect on childPsychological effect on child

34. Dr. Vivek M. Rege
Ideal age for surgeryIdeal age for surgery
• Not before age of 6 monthsNot before age of 6 months
• Not later than a yearNot later than a year
• Any age if hernia visibleAny age if hernia visible
• Any age if h/o suspected torsionAny age if h/o suspected torsion

35. Dr. Vivek M. Rege
UNDESCENDED PALPABLE
TESTIS
Empty
scrotum
Testis in
scrotum

36. Dr. Vivek M. Rege
UNDESCENDED PALPABLE
LEFT TESTIS
Inguinal
incision
Penis

37. Dr. Vivek M. Rege
Testis with sac delivered into incision

38. Dr. Vivek M. Rege
Gubernaculum
Testis
Epididymis

39. Dr. Vivek M. Rege
The testis with the cord is pulled into the scrotum
after making an incision and a subdartos pouch.

40. Dr. Vivek M. Rege
Inguinal incision is also closed with continuous
sutures –subcuticular skin sutures.

41. Bilateral Orchiopexy(20%) can be
done simultaneously

42. Dr. Vivek M. Rege
Non Palpable testis
Laparoscopy –Diagnostic
No structures seen Testis seen Cord structures seen
Absent testis Blood vessels length Testis in canal
Mobilise vessels Clip vessels Inguinal exploration

43. Dr. Vivek M. Rege
Internal ring
Vas
Vessels
Laparoscopic view
Bladder
Ligament

44. Dr. Vivek M. Rege
Internal ring
Gubernaculum
Testis
Right Undescended Testis Laparosopy

45. Dr. Vivek M. Rege
Vas
TestisTestis
GubernaculumGubernaculum

46. Dr. Vivek M. Rege
After the testis has been
brought out from scrotum

47. Dr. Vivek M. Rege
Clinical examination & judgement

48. Dr. Vivek M. Rege
Testicular torsion of undescended testis
Infarcted testisInfarcted testis

49. Dr. Vivek M. Rege
Acute Pain & Swelling -Acute Pain & Swelling -
ScrotumScrotum
Commonest PossibilitiesCommonest Possibilities
• Testicular torsion – Surgery onlyTesticular torsion – Surgery only
• Epididymo orchitis – Medical therapyEpididymo orchitis – Medical therapy
onlyonly
DifferentiationDifferentiation
• Clinical examinationClinical examination
• Doppler examination: blood flowDoppler examination: blood flow
• Exploration – safest in all casesExploration – safest in all cases

50. Dr. Vivek M. Rege
Acute Scrotal Swelling & Pain

51. Dr. Vivek M. Rege
Differential DiagnosisDifferential Diagnosis
•Torsion testisTorsion testis
• EpididymoorchitisEpididymoorchitis

52. Dr. Vivek M. Rege
Neonatal testicular torsion & infarctionNeonatal testicular torsion & infarction

53. Dr. Vivek M. RegeTwist in cord seen clearlyTwist in cord seen clearly

54. Dr. Vivek M. Rege
History of painHistory of pain
No traumaNo trauma
Minimal rednessMinimal redness
Minimal swellingMinimal swelling
Tenderness ++Tenderness ++

55. Dr. Vivek M. Rege
Testis – dusky colourTestis – dusky colour

56. Dr. Vivek M. Rege
Epididymis bluish colourEpididymis bluish colour

57. Dr. Vivek M. Rege
Gangrenous testis excised – post torsionGangrenous testis excised – post torsion

58. Dr. Vivek M. Rege
Scrotal & penile edemaScrotal & penile edema

59. Dr. Vivek M. Rege
Clinical examination & judgement

60. Dr. Vivek M. Rege
Perineal abscess prior to drainagePerineal abscess prior to drainage

61. Dr. Vivek M. Rege
PHIMOSISPHIMOSIS
Inability to retract the prepeuce such that the
external urethral opening is not seen

62. Dr. Vivek M. Rege
Abnormal pigmentation of the
prepeucial skin along with phimosis
Balanitis Xerotica

63. Dr. Vivek M. Rege
BALANOPOSTHITIS & PHIMOSISBALANOPOSTHITIS & PHIMOSIS
Swelling

64. Dr. Vivek M. Rege
SMEGMA BALLSMEGMA BALL
After retraction of the prepeuce - reveals theAfter retraction of the prepeuce - reveals the
“swelling” to be a collection of the smegma“swelling” to be a collection of the smegma
that has accumulatedthat has accumulated

66. Dr. Vivek M. Rege
REDUNDANT PREPEUCEREDUNDANT PREPEUCE
Extremely long & redundant prepeuce
predisposes to residual urine in the
prepeucial sac and recurrent urinary
infections

67. Dr. Vivek M. Rege
Indications for Circumcision
• Symptomatic phimosisSymptomatic phimosis
• Ballooning of prepeuceBallooning of prepeuce
• Recurrent balanoposthitisRecurrent balanoposthitis
• Long redundant prepeuceLong redundant prepeuce
• Paraphimosis in pastParaphimosis in past
• Injury – zipper most commonInjury – zipper most common
• Boys with diagnosed urinary anomalies-VURBoys with diagnosed urinary anomalies-VUR

68. Dr. Vivek M. Rege
PARAPHIMOSISPARAPHIMOSIS
Forcible retraction of phimotic prepeuce,
later inability to replace it as before – tight
ring of compression at glans base

69. Dr. Vivek M. Rege
After reduction of the paraphimosis a lot ofAfter reduction of the paraphimosis a lot of
edema of the prepeucial skin occurs andedema of the prepeucial skin occurs and
remains for a few days. Circumcision isremains for a few days. Circumcision is
indicated for excision of the prepeucial skinindicated for excision of the prepeucial skin
electively after few weekselectively after few weeks

70. ZIPPER INJURYZIPPER INJURY
The skin of the prepeuce is accidentally caught in
the zip of the pant being worn without an
underwear
Zipper
Prepeuce

71. ZIPPER INJURYZIPPER INJURY
After release of the prepeuce from the zipper, the
skin is damaged permanently and requires
circumcision later electively

75. CIRCUMCISION
Final result after suturing

76. Complications can occur

78. Dr. Vivek M. Rege
Ventral curvature of the penis very obvious. The urethral
opening is at the tip of the penis. The ventral curve is
Chordee – but there is no associated Hypospadias
Chordee

79. Dr. Vivek M. Rege
Degloving of the penile skin done to cut the skin chordee.Degloving of the penile skin done to cut the skin chordee.
Artificial erection done to confirm that the chordeeArtificial erection done to confirm that the chordee
correction is complete or not. Care taken to see that therecorrection is complete or not. Care taken to see that there
is no short urethra.is no short urethra.

80. Dr. Vivek M. Rege
Final result 8 days after surgery – after the catheter isFinal result 8 days after surgery – after the catheter is
removed and the dressing is kept open. The chordeeremoved and the dressing is kept open. The chordee
correction is complete – no short urethra seencorrection is complete – no short urethra seen
BeforeBefore
AfterAfter

81. HYPOSPADIASHYPOSPADIAS
Urethral opening abnormally situated away from the tip
Absence of a length of the urethral tube from birthDr. Vivek Rege

82. Dr. Vivek M. Rege
Types ofTypes of
HypospadiasHypospadias

83. Dr. Vivek M. Rege
HypospadiasHypospadias
TypesTypes
• GlanularGlanular
• CoronalCoronal
• Distal PenileDistal Penile
• Mid PenileMid Penile
• Proximal PenileProximal Penile
• Peno-scrotalPeno-scrotal
• ScrotalScrotal
• PerinealPerineal
Surgical CorrectionSurgical Correction
• Ideal age 9 - 1 2 mnthsIdeal age 9 - 1 2 mnths
• Single stage CorrectionSingle stage Correction
• Two stage CorrectionTwo stage Correction
• Catheter stent – 8/10 daysCatheter stent – 8/10 days
• Compression dressingCompression dressing

84. Dr. Vivek M. Rege
ONE STAGE CORRECTION
Meatus
Tourniquet

85. Dr. Vivek M. Rege
Degloving of skin
– Prepeucial skin
2 layered – inner
skin for urethral
tube. Inner tube
raised off the
outer prepeucial
skin

86. Dr. Vivek M. Rege
Outer prepeucialOuter prepeucial
skin flap separatedskin flap separated
from the innerfrom the inner
Inner layer
tube

87. Dr. Vivek M. Rege
Meatus

88. Dr. Vivek M. Rege
Post Operative result: Child now passes urine from the tip
of the penis with a good stream. The penis looks almost
normal except that it is circumcised.
Common
Complications:
Fistula
Meatal stenosis
Stricture
Diverticulum

89. Dr. Vivek M. Rege
Urethral
Meatus
Glans
Perineal Hypospadias

90. Dr. Vivek M. Rege
Incision
Circumferential incsion taken – chordee correction
Meatus

91. Dr. Vivek M. Rege
Final result – meatus at the tip of penis
BeforeBefore

92. Dr. Vivek M. Rege
Meatus
Original
opening

93. Perineal Hypospadias – Bifid ScrotumPerineal Hypospadias – Bifid Scrotum
Dr. Vivek Rege Pediatric Urologist

94. Final Result with opening at tipFinal Result with opening at tip
Dr. Vivek Rege Pediatric Urologist

95. Dr. Vivek M. Rege
Urethral & vaginal opening not seen

96. Dr. Vivek M. Rege
After separation – urethral & vaginal
opening visible and normal

97. Dr. Vivek M. Rege

98. Dr. Vivek M. Rege

99. Dr. Vivek M. Rege
Neonate with distended abdomen – cystic
mass palpable – suprapubic region

100. Dr. Vivek M. Rege
Imperforate hymen with accumulation ofImperforate hymen with accumulation of
blood in the uterus & vaginal cavitiesblood in the uterus & vaginal cavities

101. Dr. Vivek M. RegeImperforate Hymen – older girlImperforate Hymen – older girl
Clinical examination & judgement

102. Dr. Vivek M. Rege
Ambiguous genitaliaAmbiguous genitalia
PhallusPhallus
PalpablePalpable
gonadsgonadsPerinealPerineal
hypospadiashypospadias

103. Dr. Vivek M. Rege
Ambiguous genitaliaAmbiguous genitalia
LabioscrotalLabioscrotal
foldsfolds
PerinealPerineal
hypospadiashypospadias
PhallusPhallus

104. Dr. Vivek M. Rege
Ambiguous genitalia
Phallus notPhallus not
seen, one sideseen, one side
scrotalscrotal
swelling seenswelling seen
with awith a
palpablepalpable
gonad withingonad within

105. Dr. Vivek M. Rege

106. Dr. Vivek M. Rege
MCUMCU
•Bladder seen anteriorlyBladder seen anteriorly
•Uterus seen posteriorlyUterus seen posteriorly
•Urethra seen-shortUrethra seen-short
BladderBladder
U
terus
U
terus

107. Dr. Vivek M. Rege
Herniotomy exploration of contents – ovaryHerniotomy exploration of contents – ovary
& Fallopian tube as well as a testis& Fallopian tube as well as a testis
OvaryOvary
F.T.F.T.
Testis &Testis &
EpididymisEpididymis

108. Dr. Vivek M. Rege
Normal Female Anatomy

109. Abnormal anatomy of anal opening

110. Anal opening
Fourchette
Anteriorly placed Anus

111. Suturing of the anal opening

112. Dr Vivek M Rege
Anal
opening
Vestibular anus

113. Recto Vaginal fistula –pre op
2 Openings in the perineum only

114. Post operative
result after pull
thru with normal
appearing anal
opening in the
right position

115. Dr Vivek M Rege
Cloacal AnomalyCloacal Anomaly

118. Vagina & urethra TUM with suturingVagina & urethra TUM with suturing

119. 1010thth
Post operative day resultPost operative day result

120. Dr. Vivek M. Rege