This document discusses various pediatric inguinal-scrotal swellings including inguinal hernia, maldescended testes, hydrocele, and torsion testis. It provides details on the anatomy, presentation, examination, differential diagnosis, investigations, and management of each condition. The key points are that inguinal hernias and hydroceles often present as palpable scrotal swellings in infants and children. Maldescended testes can occur in ectopic locations and require surgery. Torsion testis is a surgical emergency due to risk of testicular necrosis from interrupted blood flow. Prompt surgical exploration is needed to detorse and assess viability of the testis in suspected cases of torsion.

1. INGUINO-SCROTAL SWELLINGS
PEDIATRIC SURGERY DEPARTMENT
2015
PROF. ALY HASSIB
PROF. SHERIF KADDAH

2. INGUINO-SCROTAL SWELLING
• Inguinal hernia
• Maldescended testes
• Hydrocele

3. ANATOMY

4. INGUINAL HERNIA
Inguinal hernia is a type of ventral
hernia that occurs when an intra
abdominal structure, such as
bowel or omentum, protrudes
through a defect in the
abdominal wall
The processus vaginalis is an out
pouching of peritoneum attached
to the testicle that trails behind
as it descends retroperitoneally
into the scrotum.
When obliteration of the
processus vaginalis fails to occur,
inguinal hernia results.

5. INGUINAL HERNIA
Presentation ;
•The infant or child with an
inguinal hernia generally
presents with an obvious bulge
at the internal or external ring
or within the scrotum.
•The parents typically provide
the history of a visible swelling
or bulge, commonly
intermittent, in the
inguinoscrotal region in boys
and inguinolabial region in girls.
•The bulge commonly occurs
after crying or straining and
often resolves during the night
while the baby is sleeping.

6. INGUINAL HERNIA
Examination ;
• examination of a child with an inguinal hernia typically reveals a
palpable smooth mass originating from the external ring lateral to
the pubic tubercle
• Occasionally, the examining physician may feel the loops of
intestine within the hernia sac.
• Silk sign: When the hernia sac is palpated over the cord structures,
the sensation may be similar to that of rubbing 2 layers of silk
together. This finding is highly suggestive of an inguinal hernia.

7. • In girls, a visible swelling in the inguinolabial region is felt
• feeling the ovary in the hernial sac is not unusual

8. INGUINAL HERNIA
Complications ;
• Incarceration: The bowel can become swollen, edematous,
engorged, and trapped outside of the abdominal cavity
• Obstruction
• Strangulation
• Testicular (ovarian) atrophy

9. Management ;
• Inguinal hernias do not heal spontaneously and must be surgically repaired
• Elective surgical repair should be performed very soon after the diagnosis is
confirmed.
• When an incarceration is encountered, manual reduction should be
attempted if there are no signs of systemic toxicity or strangulation
• Elective operation is scheduled within 24-72 hours following successful
reduction because recurrent incarceration is quite common.
• Urgent surgical intervention is planned with incarceration and failed
manual reduction , and with strangulation presenting from the start

10. INGUINAL HERNIA

11. HYDROCELE
A hydrocele is a
collection of serous
fluid that results from
a defect or irritation in
the tunica vaginalis of
the scrotum.
Hydrocele also may
arise in the spermatic
cord or the canal of
Nuck.

12. HYDROCELE
Types;
•Communicating (congenital)
hydrocele, a patent processus
vaginalis permits flow of
peritoneal fluid into the
scrotum.
•Non communicating
hydrocele, a patent processus
vaginalis is present, but no
communication with the
peritoneal cavity occurs.
•Hydrocele of the cord, the
closure of the tunica vaginalis
is defective. The distal end of
the processus vaginalis closes
correctly, but the mid portion
of the processus remains
patent. The proximal end may
be open or closed in this type
of hydrocele.

13. HYDROCELE
Presentation ;
In neonates,
differentiating between
a hernia and a hydrocele
is not always easy.
Painless firm bluish
cystic, scrotal, and or
inguinoscrotal swelling
Transillumination , rectal
examination !!!

14. HYDROCELE
Management ;
•Hydrocele in neonates:
This is the only exception
in which surgical treatment
is delayed.
•The connection with the
peritoneal cavity (via the
processus vaginalis) may
close
•Fluid in the hydrocele
from the peritoneal cavity
is gradually absorbed if the
communication has closed.
•If hydrocele persists after
this observation period(18
months), operative repair
is indicated

15. MALDESCENDED TESTES
•Cryptorchidism is the most common
abnormality of male sexual
development.
•In this condition, the testis is not located
in the scrotum.
•The testis can be ectopic, incompletely
descended, retractile, and absent or
atrophic
•The testis remains in a retroperitoneal
position until 28 weeks' gestation, at
which time inguinal descent of the
testicle begins
•Most testes have completed their
descent into the scrotum by 40 weeks'
gestation

16. MALDESCENDED TESTES
Presentation ;
History; Determining if the testis was palpable in the
scrotum at any time is important
Physical examination is most important tool in the
diagnostic evaluation of cryptorchidism
Determining if the testis is palpable is essential. If the
testis is palpable, ascertain retractibility of the testicle.
The retractile testis should stay in the dependent
portion of the scrotum after manipulation.
Look for hemiscrotal asymmetry and for contralateral
testicular hypertrophy; both are partial indicators of an
absent testis.
Examination of potential ectopic sites such as penile,
femoral, and perineal areas is important if the testicle
cannot be felt in the inguinal area

17. MALDESCENDED TESTES
Investigations ;
Imaging studies have little or no role in the diagnosis of cryptorchidism.
Ultrasonography, CT ,MRI
Diagnostic laparoscopy is the most effective and efficient modality to
identify an intra-abdominal testis.

18. MALDESCENDED TESTES
Treatment ;
• Orchiopexy should be considered after 4-12 months of life, as the
rate of descent diminishes considerably after this point.
• Hormonal therapy !!!
• In patients with cryptorchidism, the risk of testicular cancer is 3%-
5%, a 4-7–fold increased risk compared with the 0.3%-0.7% risk in
the healthy population.
• Orchiopexy is not protective against subsequent testis cancer but
does place the testis in a favorable position for routine self-
examination

19. ACUTE SCROTAL SWELLINGS IN
INFANTS AND CHILDREN
Common acute scrotal swellings in infancy and
childhood include;
 Torsion testis
 Strangulated hernia

20. ACUTE SCROTAL SWELLINGS IN
INFANTS AND CHILDREN
TORSION TESTIS;
• Torsion of the testis, is a surgical emergency
because it causes strangulation of gonadal blood
supply with subsequent testicular necrosis and
atrophy.

21. EMERGENCIES IN INFANTS AND
CHILDREN
TORSION TESTIS;
• Torsion of the spermatic cord interrupts blood flow to the testis and
epididymis.
• The extent and duration of torsion prominently influence both the
immediate salvage rate and late testicular atrophy.
• Testicular salvage most likely occurs if the duration of torsion is less
than 6-8 hours.
• If 24 hours or more elapse, testicular necrosis develops in most
patients

22. ACUTE SCROTAL SWELLINGS IN
INFANTS AND CHILDREN
• Types;
Extra vaginal
Intra vaginal

23. Extra vaginal torsion
Extra vaginal testicular torsion is commonly seen in perinatal case
The tunica vaginalis takes about 6 weeks after birth to adhere to the surrounding
tissues,
Large birth weight, difficult labor, breech presentation, maldescended testis ,
and over reactive cremasteric reflex have been proposed as possible causes for
perinatal torsion

24. Intra vaginal torsion
Intra vaginal testicular torsion, represents almost all torsion events in older boys
Predisposing factors, such as horizontal lie, bell clapper deformity may be the cause of
torsion

25. TORSION TESTIS
Clinical presentation; severe scrotal pain, scrotal
swelling and erythema ,and Nausea and vomiting
Examination; severe tender, high-riding testis, abnormal
(transverse) orientation ,scrotal swelling and edema

26. TORSION TESTIS
Differential diagnosis;
• Torsion of testicular or epididymal appendage
• Epididymitis, orchitis, epididymo-orchitis
• Hydrocele
• Tumor

27. TORSION TESTIS
Investigations ; should not be allowed to delay
treatment in cases suspicious for acute
testicular torsion.
• Urine analysis
• Ultrasonography
• Duplex

28. TORSION TESTIS
Treatment: Goals of surgical exploration are as follows
• Confirmation of the diagnosis of torsion
• Detorsion of the involved testis
• Assessment of the viability of the involved testis
• Removal (if nonviable) or fixation (if viable) of the involved testis
• Fixation of the contralateral testis, when appropriate

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