ED: Timely treatment of inguinal and testicular problems is critical and delay in surgical intervention can affect future fertility.
Inguinal hernia, while more common in boys, affects 1-4% of children. One third will present under six months of age and incarceration is common under 12 months of age. Up to 25% of infants will suffer incarceration if treatment is delayed beyond four weeks from onset.
The risk of hernia and incarceration is greater in premature infants. If incarcerated, at any age, and reduced by firm manipulation, reincarceration risk is high. Irreducible or strangulated hernia requires prompt surgical treatment and delay risks infarction of bowel, testis (ovary) or death.
Also, more common in boys, Hydrocele affects 1-4% of children where 90% undergo spontaneous resolution by age one and small hydroceles may resolve before two 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 of confounding clinical presentations such as trans-illuminating, fluid-filled herniated bowel in a young baby. Gonadal tumours are uncommon 0.5/100 000 and will not trans-illuminate. Cystic hydrocele of cord and large inguino scrotal hydrocele may mimic hernia. History of persistent swelling without fluctuation over several days or weeks in a happy baby would indicate hydrocele. 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 involving simple ligation of patent processus vaginalis. If not treated, gradual enlargement over several years increases the risk of recurring after surgery.
Undescended testes
This occurs in 2-5% of boys at birth. Spontaneous descent is seen in 80% in the first 12 weeks (full gestation). If not, orchidopexy for palpable undescended testes (90% of cases) or laparoscopy for absent testis is recommended between six and 12 months of age. This timing achieves optimum testicular function and spermatogenesis.
Delay in treatment is associated with testicular hypotrophy, decrease in number and size of Leydig cells and decreased size of seminiferous tubules. Testicular abnormality in high testes increases over time. If not treated, 98% of undescended testes have abnormal spermatogenesis after puberty.
Testicular maldescent is associated with malignant change in early adulthood. Orchidopexy enables earlier detection.
Ascending testes are more common if postnatal descent and this group requires observation and annual review until school-age.
Retractile testes present in early childhood, not before six months. Testes are in the 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 five years of age.
Ascending testes are descended at, or shortly after, birth, and caused by a tight fibrous remnant of processus vaginalis. Testes are not witnessed low in the 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 the 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. The decision to operate is based on clinical assessment. Ultrasound is not necessarily reliable unless performed, optimally without delay, by an experienced sonographer who examines the length of spermatic cord for twists. Testicular perfusion can continue in early torsion
If de-torsion is delayed beyond six 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 is associated with infertility.
<subhead>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 the 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 messages
- Urgently refer Hernia in < 12 months or incarcerated hernia (reduced or not)
- Hydrocele wait and see for 12 months, refer if clinically obvious over 12 months
- If incomplete testicular descent by three months, refer before six months
- Monitor delayed descent for ascending testis and refer if suspected
- Refer adolescent varicocele with smaller or softer testis
References available on request.
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Author competing interests: nil relevant disclosures.
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