Inguinoscrotal Swelling in Pediatrics
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Transcript of Inguinoscrotal Swelling in Pediatrics
Inguinoscrotal Swelling In Inguinoscrotal Swelling In PediatricsPediatrics
By
Khaled Ashour
Causes of Ing.Scrotal Causes of Ing.Scrotal swellingsswellings
1. Congenital inguinal hernias.2. Congenital hydrocele.3. Undescended testis.4. Varicocele in children.5. Malignancies: as lymphoma, testicular
tumours, etc.6. .Others, e.g. Epididymo-orchitis, extensive
suppurations, lymphadenopathy, etc.
(1) Congenital inguinal hernia (1) Congenital inguinal hernia (C.I.H)(C.I.H)
Cong. Inguinal HerniaCong. Inguinal HerniaDefinition:Definition:
It is herniation of part of the abdominal viscera outside the abdominal cavity through a preformed sac “Patent processus vaginalis”, which occurs in pediatric age group.
Cong. Inguinal HerniaCong. Inguinal HerniaIncidence:Incidence:
Inguinal hernitomy is the most common general surgical operation in Pediatrics.
Occurs in 0.8% up to 4.4%.Higher in infants than children.Higher in prematures.Male : Female = 7:1.Right side 60%, Left: 32%, Bilateral: 8%.
Cong. Inguinal HerniaCong. Inguinal HerniaPathogenesis:Pathogenesis:
The processus vaginalis (P.V.) develops during the third month of Gestation as an outpouching of the peritoneal cavity through the deep ring.
During testicular descent at the 7th month, it becomes covered with the P.V., that extends to the scrotum.
Cong. Inguinal HerniaCong. Inguinal HerniaPathogenesis (Cont.)Pathogenesis (Cont.)
During the 9th month, the testicular descent triggers obliteration of PV, although the mechanism of obliteration is not fully understood.
Abnormalities of obliteration results in eith hernia or hydrocele according to the caliber of unobliterated PV.
Abnormalities of processus vaginalis obliteration
Cong.Inguinal HerniaCong.Inguinal HerniaClinical picture:Clinical picture:
Infant / child with an inguinoscrotal painless swelling that appears on crying, and disappear spontaneously.
Contents: mainly small bowel.Might be associated with maldescended
testis.Commonly presented with incarceration.
Cong. Inguinal HerniaCong. Inguinal HerniaClinical pictureClinical picture
Diagnosis:- History of swelling:
Associated with crying and irritability.- On examination:
• Swelling on straining.• No swelling: diagnosis by “rolling test”:
1) thickening of the cord. Due to:- Presence of sac -Hypertrophy of cremasteric ms.
2) Silk-glove sign: due to the sac leaflets with peritoneal fluid inbetween.
Cong. Inguinal HerniaCong. Inguinal HerniaC/PC/P::
In Female:
The inguinal canal is not well developed, carrying the round ligament of the uterus.
Indirect inguinal hernia may occur, and is termed: “Ing. Hernia of canal of Nuck”.
The content here is mainly the ovary and fallopian tube.
Cong. Inguinal HerniaCong. Inguinal HerniaComplicationsComplications
Irreducibility, Obstruction, and strangulation.
These complications are commoner than in adults due to narrow hernial neck.
C/P: Painful & tender swelling, irreducible, and/ or oedematous red skin overlying.
Isolation of the vas and tesicular vessels
Hernial sac with its contents
Testicle
Incarcerated Cecum
Hernial sac
Testicle
Surgical managementSurgical management
Cong. Inguinal HerniaCong. Inguinal HerniaManagementManagement
Elective cases: herniotomy. Emergency cases: irreducible:
- Manual reduction.
If failed - Operative.• Contraindications of manual reduction:
- Fever - tender abdomen
- Intestinal obstruction. - X ray: air-fluid levels
- +Ve local signs of strangulation.
Cong.Inguinal HerniaCong.Inguinal HerniaManagementManagement
NO RULE FOR CONSERVATIVE TREATMENT. “As the use of ice bags”, in irreducible congenital inguinal hernia.
Cong. Inguinal HerniaCong. Inguinal HerniaSurgical treatmentSurgical treatment
Tips Once the hernia is diagnosed, it should be
surgically treated for fear of complications. No repair is needed except in rare cases with
evident abdominal wall weakness, eg Bladder exstrophy, Prune-belly syndrome, etc.) in which the canal is very wide and / or abdominal wall muscles are weak.
Herniotomy in situ without mobilization of the cord.
The distal part of the sac may be left alone if the hernia is complete.
Hernia of canal of Nuck
Postoperative complicationsPostoperative complications
Scrotal hematoma.Scrotal edema, which resolves
spontaneously within days.Testicular atrophy: if dissection affects the
vasculature.Iatrogenic ascending undescended testicles.Injury to the vas.Recurrence.
Incision
Immediate recurrence
Congenital (Primary) Congenital (Primary) hydrocelehydrocele
Congenital HydroceleCongenital Hydrocele
Def.: Accumulation of fluid in relation to processus and / or tunica vaginalis.
It occurs also as a result of abnormalities in processus vaginalis (PV) obliteration.
When the caliber of the patent P.V is small to admit abdominal viscera but can admit peritoneal fluid.
Congenital HydroceleCongenital Hydrocelepresentationpresentation
Neonatal presentation.Late presentation.Acute hydrocele: acute inguinoscrotal
swelling.
Neonatal HydroceleNeonatal HydroceleClassificationClassification
Types of hydrocele in Pediatric age:
I. Etiological classification:
1. Congenital hydrocele “Primary”.
2. Acquired hydrocele “ Secondary”.
Congenital HydroceleCongenital HydroceleTypesTypes
II. Clinical Classification:the most important
1) Tense hydrocele: - Communicating - non-communicating.
2) Soft hydrocele: - Communicating - non-communicating.
Congenital HydroceleCongenital HydroceleTypesTypes
III. Anatomical classification:
1) Complete hydrocele:
- Communicating
- non-communicating:• Tense: testis cannot be palpated• Soft: Testis is palpable through hydrocele
sac.
III. Anatomical classification (Cont.)III. Anatomical classification (Cont.)
2) Hydrocele of the cord: - Communicating
- non-communicating (encysted):* Tense: Non-fluctuant. * Soft : Fluctuant.3) Infantile hydrocele (Funicular):
- Communicating - non-communicating:*Tense * Soft.
III. Anatomical classification (Cont.)III. Anatomical classification (Cont.)
4) Combined hydrocele:- Hydrocele of the cord + complete or
funicular one.- 5) Hydrocele of the hernial sac.
Congenital HydroceleCongenital HydroceleClinical PictureClinical Picture
Inguinoscrotal painless cystic swelling, that shows diurnal & nocturnal variations in size.
Commonly soft cystic, but sometimes tense.In hydrocele of the cord, a cystic
supratesticular mass may be felt, with positive testicular traction test.
+Ve translucency.
Congenital hydroceleCongenital hydrocele
*Transillumination
Congenital HydroceleCongenital HydroceleManagementManagement
1) Neonatal presentation:- tense: operative.- Soft : follow-up, many possibilities might
occur (Mentioned next slide).2) Late presentation. Less than one year: as above.More than one year: Operative.3) Acute hydrocele: Operative to exclude acute
scrotum.
Congenital HydroceleCongenital HydroceleManagementManagement
In follow-up strategy for the soft neonatal presentations, the following possibilities might occur:
1) Turn into tense. “from fluctuant into non”
2) Becomes softer.
3) Completely disappears ???
4) Hydrocele of hernial sac.
Congenital HydroceleCongenital HydroceleSurgerySurgery
Via a small lower abdominal crease incision, as in cong. Ing. Hernia, the communication is attacked if present.
Disconnection of the patent processus vaginalis, as in hernia, with transfixion of the proximal end (hydrocelectomy), + near complete excision of the tunica.
3) Maldescended testis3) Maldescended testis
Maldescended testisMaldescended testis
1) Arrested: in the superficial inguinal pouch
- At the neck of scrotum.
- Associated with inguinal hernia.
- Acute swelling if torsion occurred.
2) Retractile, ascending, ectopic: presented with inguinal swelling
4) Varicocele in Pediatrics4) Varicocele in Pediatrics
Varicocele in PediatricsVaricocele in PediatricsDefinitionDefinition
Dilatation, elongation and tortuousity of the pampiniform plexus of veins.
Varicocele in PediatricsVaricocele in Pediatricsincidenceincidence
Very rare under the age of 10 year-old.Above this age, the incidence rises to
become near the adult onset (5-12%)Left side: 80% - 90%.
Varicocele in PediatricsVaricocele in Pediatricspathophysiologypathophysiology
Venous dilatation, with reversal of blood flow causes disturbance of the countercurrent heat exchange mechanism of the spermatic cord.
Local increase in temperature due to blood stagnation
Varicocele in PediatricsVaricocele in Pediatrics pathophysiology pathophysiology
Local increase in temperature due to blood stagnation leads to : -
1) Dartos muscle relaxation: loss of scrotal wrinkles.
2) Cremasteric muscle relaxation: low-lying testis.
Varicocele in PediatricsVaricocele in PediatricsEtiologyEtiology
Primary varicocele:The left side is commoner due to : -1} Right angle fusion of the left testicular
vein to the left renal vein.2} Longer course left Test. vein,.3} Pressure effect of the loaded sigmoid4} Nut-cracker mechanism of the aorta with
the superior mesenteric artery.
Varicocele in PediatricsVaricocele in PediatricsEtiology (Cont.)Etiology (Cont.)
5} Vascular spasm at the origin of the vein by adrenaline coming from the adrenal gland.
6} Higher incidence of congenital absence of valves on the left side “40% left, 23% right”.
Varicocele in PediatricsVaricocele in PediatricsEtiologyEtiology
Secondary varicocele:
Secondary to:
A) Renal enlargement: Wilms’ tumour, neuroblastoma, hydronephrosis.
B) Retroperitoneal malignancies.
Varicocele in PediatricsVaricocele in PediatricsClinical pictureClinical picture
Young boy with mainly affection of the left side .
Mild dragging pain on the affected side.Loss of scrotal wrinkles on the affected
side.The left side is hanging down more than the
right.
Varicocele in PediatricsVaricocele in PediatricsClinical PictureClinical Picture
Varicocele may be classified by size into: -
Grade I: evident only by Valsalva maneuver.
Grade II: evident without Valsalva.
Grade III: Visible as a scrotal space-
occupying lesion
Varicocele in PediatricsVaricocele in PediatricsComplicationsComplications
Thrombophlebitis.
Testicular dysfunction.
Psychological troubles.
Varicocele in PediatricsVaricocele in PediatricsTreatmentTreatment
Indications for surgery:
@ Chronic pain and discomfort
@ demonstrable testicular atrophy in adolescence.
@ Infertility in adults.@ Difference in orchidometry (testicular
measurement) > 15% between both sides.
Varicocele in PediatricsVaricocele in PediatricsSurgerySurgery
Three approaches:
1) Low inguinal approach
2) High ing. Approach
3) Retroperitoneal approach
Open Laparoscopic
Uncommon causes of Uncommon causes of scrotal/inguinoscrotal swellingsscrotal/inguinoscrotal swellings
Other causesOther causes
*Testicular tumours
*Epidydimo-orchitis
*Testicular torsion
*Hematocele
*Scrotal haematoma
*Idiopathic scrotal oedema
Primary testicular tumoursPrimary testicular tumours
Testicular teratoma
22ndnd Testicular tumours Testicular tumours
Leukaemic infiltration