Kids inguinoscrotal conditions – When wait and see isn’t a good idea

Timely treatment of inguinal and testicular problems is critical and delays in surgical intervention may affect future fertility. This overview aims to cover common inguinoscrotal conditions seen in children and provide guidelines on optimal times and ages to seek a Paediatric Surgeon’s advice.

Inguinal hernia

Affects 1-4% children and more common in boys. Over half will present under 12 months of age and incarceration (hernia is stuck and cannot easily reduce to normal position),  is common under 6 months of age. Up to 25% of babies will suffer incarceration if treatment is delayed beyond 4 weeks from onset. If incarcerated and reduced by firm manipulation, chance of re-incarceration, within days or weeks, is high. Irreducible or strangulated hernia requires prompt surgical treatment, and delay beyond several hours risks ischaemia (lack of blood supply), potential infarction (death of tissue) of bowel, testis,or ovary.  Prolonged strangulated hernia has been known to cause infant death.

Key messages- baby hernia < 6months of age = urgent referral -Incarcerated hernia (reduced or not) = urgent referral

Hydrocele

Again affects 1-4% children and more common in boys. Ninety percent undergo spontaneous resolution by 1 year and beyond this very small hydroceles may resolve before 2 years. Diagnosis is anatomical assessment: trans illuminable scrotal swelling that does not extend above scrotal skin with thin cord felt above at external ring next to pubic tubercle. Ultrasound is not necessary with obvious hydrocele anatomy and absence of inflammation or symptoms. Beware confounding clinical presentations such as transullimination of fluid filled herniated bowel in the young baby. Gonadal tumours are uncommon 0.5/100 000 and will not transilluminate. Cystic hydrocele of cord and large inguino scrotal hydrocele may mimic hernia. Usually history of persistent swelling without fluctuation over several days or weeks in a well baby would indicate hydrocele and in these situations ultrasound provides reassurance. Refer for surgical treatment if obvious hydrocele remains beyond 12 months. Surgical repair in young childhood is highly successful and simple ligation of patent processus vaginalis. If not treated, gradual enlargement over several years leads to large hydrocele and this has increased recurrence risk after surgery.

Key message = hydrocele wait and see for 12 months, >12 months refer clinically obvious hydrocele

Undescended testis

2-5 % boys will have undescended testis at birth.  Eighty percent will undergo spontaneous descent in the first 12 weeks (52 weeks gestation). If not surgery for orchidopexy for palpable undescended testes (90% of undescended testes) or laparoscopy for absent testis is recommended between 6 and 18 months of age for optimum testicular function and future spermatogenesis.  Changes in testis are seen after 12 months with decrease in number and size of Leydig cells, decreased size of seminiferous tubules and general atrophy. Reasons for orchidopexy are to achieve a normal appearance, improve fertility, reduce risk of torsion and enable early detection of tumour (undescended testes have increased risk in early adulthood).

If not treated, 98% of undescended testes have abnormal spermatogenesis after puberty. Ascending testes are more common if postnatal descent and this group require observation and annual review until school-age.

Key message = refer before 6 months if not descended by 3 months of age

Ascending testis vs Retractile testis

Retractile testes present in early childhood, not before 6 months, are down in scrotum at birth and during warm conditions.  Scrotal shape is normal and testes can be manipulated to base of scrotum without cord tension. Spontaneous resolution is expected. Ascending testis will become evident in 1-2% usually before 5 years of age.

Ascending testes are descended at, or shortly after, birth, and caused by tight fibrous remnant of processus vaginalis.  Testes are not witnessed low in scrotum, transient reduction into scrotum is possible, often with discomfort or tight cord and immediately return to superficial inguinal region.

Acute scrotum

Torsion of testis is more common in second decade and characterised by sudden onset of testicular pain, sometimes with abdominal pain and vomiting.  Differential diagnosis includes torsion of hydatid of Morgagni, epididymo-orchitis, idiopathic scrotal oedema and Henoch-Schönlein Purpura.  Decision for operation is based on clinical assessment. Ultrasound is not necessarily reliable.  If performed, optimally without delay and by experienced sonographer who examines the length of spermatic cord for twists.  Testicular perfusion can continue in early torsion

If detorsion is delayed beyond 6 hours, atrophy risk is 50% and after 24 hours atrophy occurs in 70%.  Ischaemia then reperfusion of the torted testis is known to injure the contralateral testis and associated with infertility.

Varicocele

Left-sided varicocele is common in adolescents (10-15%) and seen in 35-40% of men assessed for infertility. Dilation of pampiniform plexus and counter current heat exchange with increased testicular temperature is proposed mechanism leading to testicular dysfunction.  Testicular hypotrophy can occur in 30-40% of palpable or visible varicoceles.  Monitoring testicular growth and consistency is advised.  Testicular hypotrophy is reason to consider treatment.  Catch up growth is seen in up to 70% after varicocele correction.  Management options include laparoscopic ligation of testicular vein, retroperitoneal mass ligation of testicular artery and vein, high inguinal ligation or interventional radiology and selective embolisation.

Key message =Adolescent varicocele with smaller or softer testis-refer for assessment