Acute scrotum : sudden onset scrotal pain without or without swelling and erythema

Torsion of the Testis or Epidydimal

Appendage
Torsion of the appendix testis/epididymis is most common in prepubertal boys; testicular
torsion is most common in neonates and adolescents

There is a familial pattern

Testicular torsion
- In infants (up to 3 years old), the newly descended testis and its investing tunica
vaginalis are mobile within the scrotum → tunica vaginalis is not firmly fixed too the
dartos layer of the scrotum
o These may undergo extravaginal torsion
 Presents as hard, swollen testis (often non tender hemiscrotum)
 Those of acute onset should have urgent surgery
- Later in childhood (children and adolescents – typically after puberty), the testis
becomes suspended in a near vertical position, anchored by the spermatic cord and
by attachments to the posterior scrotal wall
o This attachment prevents rotation
o Abnormal fixation occurs when the tunica vaginalis attached more proximally
on the spermatic cord → creates long mesorchium around which the testis
can twist
 Torsion occurs in the adolescent period when the testis is growing
rapidly with puberty and increase in mass predisposes the testis to
spin on its axis
o Minor anatomical variations (often bilateral) can produce a narrow-based
pedicle with a horizontal (‘bell-clapper’ – 12% incidence) testicular lie that
allows the testis to twist about its axis within the tunica → intravaginal
torsion
 Pampiniform plexus veins become compressed causing venous
congestion
 After a few hours, venous infarction occurs unless the torsion is
corrected
- Presents with sudden onset of severe testicular pain, often with poorly localized
central abdominal pain (→ testis retains its embryological nerve supply) and
sometimes vomiting
o In early stages, affected testis is tender, slightly swollen and drawn up into
the neck of the scrotum, where the cord may be palpably thickened
 Episodes of intermittent testicular pain may precede the acute
presentation
 Testis may have a transverse orientation and an anteriorly located
epididymis
  Cremasteric reflex is often absent
 Superficial reflex in men that is elicited when the inner thigh is
stroked → cremaster muscle contracts and pull up the
ipsilateral testicle toward the inguinal canal
o Later stage: scrotal skin becomes red and edematous, making accurate
palpation difficult
 At this point the scrotum must be explored surgically

Torsion of the Epididymal Appendage (Hydatid of Morgagni)

- Most common cause of an acute scrotum
- Occurs most commonly between 7-10 years old
- Hydatid of Morgagni → small embryological remnant at the upper pole of the testis
o May undergo torsion and produce symptoms similar to testicular torsion
 Out of proportion to the small size of the infarcted tissue
o Infarction of the hydatid is of no consequence except that it must be
distinguished from testicular torsion
- Useful to loos carefully for a blue dot, under the scrotal skin, at the point of maximal
tenderness → confirms the diagnosis
o Sign is often lost as scrotal edema develops
- Self-limited and is best treated with NSAIDs and comfort measures such as warm
compresses
o Pain resolves as the appendage infarcts and necroses → may become a
calcified free body within the tunica vaginalis

Management of suspected testicular torsion

- Differentiating between acute epididymitis and torsion can be difficult
o If firm diagnosis can’t be reached → surgical exploration (mandatory)
o Investigation are of little value
- Urgent operation is usually imperative
o Delay leads to a risk of testicular necrosis after ~6 hours
 Determinants of salvage rates: time between onset of symptoms and
detorsion and the degree of cord twisting
o Scrotal incision is made, and this testis is examined and untwisted
 If the testis is black and fails to recover its color → necrotic and should
be removed
 If some color is restored, the testis is best left, although it may later
atrophy
 Ischemic damage can affect testicular morphology and fertility
o After untwisting, the testis is sutured to the midline septum and/or inner
layer of the scrotal wall (3 nonabsorbable sutures placed at different points)
o In children, it can be placed in a surgically created dartos pouch, under the
scrotal skin
 Both testis should be secured as predisposition to torsion is usually
bilateral
- If testicular torsion is suspected but a delay to the OR is unavoidable, manual
detorsion can be attempted
 o If successful, the testis will drop lowe in the scrotum and the patient will
respor sudden pain relief
o Manual detorsion should always be attepted first (book opening) then a
bilateral orchiopexy should be performed (mandatory)

TWIST score → risk of testicular torsion based on a symptom score

- Testis swelling = 2
- Hard testis = 2
- Absent cremasteric reflex = 1
- Nausea/vomiting = 1
- High-riding testis = 1
6-7 points → high positive and negative predictive values

US can be used to determine blood flow (but is not the most accurate) → will usually just
delay time

Differential Diagnosis:
- Torsion of appendage
- Epididymitis
o Rare in children
o Pain and swelling typically have a slow onset (over days)
- Idiopathic scrotal edema
o Between ages 5-9 years old
o Insidious onset that starts in perineum or inguinal region and spreads to the
hemiscrotum
- Henoch-Schönlein purpura
- Testicular trauma
Hernias and other groin problems
- Groin lumps and swelling account for ~10% of general surgery outpatient referrals
o Most common lumps in the groin are hernias (incl. inguinal and femoral)
o Inguinal hernias are more common in males due to the vulnerability of the
inguinal canal (due to descent of testis)
 In females’ inguinal hernias can occur due to a similar course of the
uterine round ligament
o Femoral hernias can below the inguinal ligament → particularly in women
- Enlarged lymph nodes caused by infection or malignancy can also lead to groin
lumps and swellings

Clinical examination
- Examine the patient both standing and lying
o First standing then lying
o Standing increases intraabdominal pressure and makes any hernia more
visible
 Can also be done using Valsalva methods
o Small inguinal hernias may reduce on lying down, and a scrotal varicocele will
empty
- Examine for the presence of a cough impulse and test the reducibility of the lump
o When patient coughs → intraabdominal pressure transmitted through
abdominal wall causes an expansible cough impulse in a hernia
- Demonstrate the relationship of the origin of lump to the inguinal ligament and the
pubic tubercle
- Consistency + reducibility:
o Inguinal hernias are usually soft and ‘squishy’
 Most reliable diagnostic signs are if the lump reduces when the
patient lies flat or can be reduced by gentle manipulation by patient
or clinician
 Longstanding hernias gradually become irreducible because of
adhesions within the sac → incarcerated
 In girls, a hard mass may be felt if the ovary protrudes into the sac
o Femoral hernias are nearly always irreducible and have no cough impulse as
the femoral canal is so narrow
- Silk glove sign: feeling the thickened peritoneum of the patent processus as the cord
is palpated
- Strangulation:
o Strangulated inguinal hernia can be readily diagnosed by finding an
irreducible hernia in the correct anatomical position
 Lump is tender and often red
o Strangulated femoral hernias are usually very small and unimpressive (usually
~ size of a grape)
o Sometimes present with abdominal pain or signs of obstruction but without
localized pain in the groin
Inguinal hernias
- Can occur at any age, with a higher prevalence in childhood, especially among
premature infants
o Other associated conditions: chronic lung disease, CF (would also have a
small or absent vas deferens)
o For men: hernias often appear before 5 y/o or after middle age
o Congenital predisposition, combined with work or sports activities, may
contribute to hernias in young men
- Hernias are repaired early to reduce the risk of strangulation
- Inguinal hernias are more common on the right side and can be bilateral in ~10% of
patients (usually females)

Direct and Indirect Inguinal Hernias

Disorder Anatomical/Developmental Clinical features
basis
Inguinal hernia – direct Simple bulging of abdominal Discomfort; lump usually
Leaves the abdomen contents resulting from disappears on lying down;
through a weakness or split inadequate support by weak risk of incarceration if large
in the transversalis fascia or ruptures posterior wall of but low risk of strangulation
inguinal canal (transversalis
fascia)
Inguinal hernia – indirect Passage of abdominal Potential for incarceration
Hernial sac lies within the contents, often incl. bowel, and strangulation; much
spermatic cord through inguinal canal more common in men
towards scrotum or labium
majus

- Indirect inguinal hernia:

o Sac leaves the abdomen via the deep (internal) inguinal ring to pass along the
inguinal canal, exiting through the superficial (external ring)
 Leaves the deep inguinal ring lateral to the inferior epigastric artery
 Lies within the cremaster muscle
o If the hernia can be completely reduced, finger pressure > deep ring will
prevent it reappearing on coughing
o Most frequent ≤ 50 years old
- Direct inguinal hernia:
o Emerges directly through the superficial ring, and cannot be controlled by
digital pressure over the deep ring
 Not attached to the spermatic cord
 Bulges medially to the inferior epigastric artery
o Most frequent ≥ 50 years old
- Inguinal hernia has its origin above the inguinal ligament, often descending over or
medial to the pubic tubercle

Anatomical considerations
- Anterior wall of inguinal canal → external oblique aponeurosis
 - Above the medial half of the inguinal ligament, the internal oblique and transversus
are deficient → D-shaped defect is filled with transversalis fascia
o Transversalis fascia is particularly strong in this region
o Posterior wall of inguinal canal → transversalis fascia
 Provides main restraint against herniation of abdominal contents
- Inferior borders of the internal oblique and transversus abdominis m. fuse to form
the conjoint musculature and tendon that extends form the lateral half of the
inguinal ligament to the pubic crest
- Spermatic cord passes through the deep ring (defect in the transversalis fascia)
- Inferior epigastric artery runs upwards from the external iliac artery immediately
medial to the deep ring
o Determines whether an inguinal hernia is direct or indirect

Mechanisms of Inguinal Hernia Formation

- Indirect hernia
o Peritoneal sac may represent a patent or reopened processes vaginalis
o May extend as far as the tunica vaginalis and surround the testis
o Neck of the sac is narrow as it’s confined by the borders of the deep ring
 More liable to strangulate
o Peak age is ~1 year
- Direct hernia
o Bulge forwards and rarely enter the scrotum
o Usually found in older patients with deficient muscles and weak transversalis
fascia
 Peak age ~70-80 years
o Neck of the sac is broad
o May occur suddenly after physical strain
 Transversalis fascia has split → appearance of a rupture
- Pantaloon hernia
o An indirect and a direct hernia occur together on the same side
- Hernia may consist of peritoneum and associated extraperitoneal fat, but if larger,
sac usually contains omentum or small bowel, or less commonly large bowel or
appendix
- Sliding hernia
o Retroperitoneal viscus ‘slides’ down the posterior wall and herniates directly
(occasionally indirectly) into the inguinal canal, dragging its overlying
peritoneum with it
o Visceral contents lie behind and outside the peritoneal sac
o Most commonly occurs in the left groin involving the descending and sigmoid
colon or in larger direct hernias, may involve the bladder
- Spigelian hernia
o Herniation through a fascial defect in the linea semilunaris at the lateral
border of the rectus abdominis
o Hernial sac comes to lie interstitially → between the layers of internal and
external oblique or transversus abdominis
 o Has some clinical characteristics of an inguinal hernia but the bulge lies
higher and may be difficult to palpate

Natural history of inguinal hernia

- Usually develop slowly; lifetime risk is high (>1 in 4 men, >1 in 30 women)
o Women with affected first degree relatives are at much higher risk of
developing inguinal hernia
- Risk factors:
o Inheritance: ↑ risk in 1st degree relatives, connective tissue disorders
o Age: ↑ risk of herniation with age
o Gender: much higher incidence in men
o Obesity: BMI inversely related to inguinal hernia risk
o Collagen metabolism: ↓ type 1:3 ration and ↑ systemic MMP-2
o Open prostatectomy
o Ventriculoperitoneal shunts for hydrocephalus are associated with an
increased incidence of inguinal hernias (esp. in neonates)
 Higher rates of bilaterality, incarceration, and recurrence are also
observed
- Association of any condition which persistently raises intraabdominal pressure
(constipation, straining at micturition, or chronic coughing) with hernia is weak
o in infants, a period of severe coughing or crying may precipitate an acute
indirect hernia, which may become irreducible
- Incarcerated hernia: chronically irreducible hernia that is not strangulated
o incidence of incarceration peaks in the first year of life
o can present with irreducible tender mass (possibly with severe pain and
vomiting)
 late signs: abdominal distension, bowel obstruction, and melena
 peritoneal signs suggest strangulated intestine (gas-filled loops may
be seen in scrotum in plain films)
o reduction: applying form and continuous pressure around the incarceration
 successful reduction is confirmed by a sudden ‘pop’ of contents back
into peritoneal cavity
 urgent surgery is necessary if reduction is unsuccessful or incomplete
o following reduction, 24-48 hours is given to allow resolution of edema prior
to open repair
 laparoscopic approach is preferred for incarcerated hernias
 postoperative complications are increased in incarcerated hernias
 males: testicular loss or injury due to impinged blood supply
 females: ovary and/or fallopian tube are more commonly
involved
- Strangulated hernia: surgical emergency
o Difficult to reduce or cause intermittent pain are at particular risk of
strangulation
o Strangulation occurs if hernial content become constricted by the neck of the
sac or by twisting
 Hernia first becomes irreducible then tender, then later red
  Symptoms and signs of bowel obstruction (vomiting, colicky
abdominal pain, distension, and absolute constipation) develop over
the next few hours, followed by peritonitis (if bowel perforates)
o Obstruction of venous return leads to swelling and later to arterial
obstruction
o If strangulation is not relieved → infarction
o Strangulation can follow incarceration but luckily is uncommon in young
children, unlike in adults

Differential diagnosis: retractile testis, lymphadenopathy, hydrocele, varicocele, and

prepubertal fat

Management of Inguinal Hernias

- Inguinal herniorrhaphy and herniotomy (open repair)
o Lichtenstein: mesh implant technique → uses a ‘tension-free’ technique
 Patch of nonabsorbable, open-weave, mesh to repair and reinforce
the defect rather than pulling together muscle and fascial tissue
together under tension
 Advantages:
 Technique is easily learned, and trainee surgeons can reliably
produce good results
 Postoperative pain is substantially less, allowing ↑ mobility
and early return to normal activities
 Recurrence rates are exceptionally low
 Relatively cheap and cost effective
- Herniotomy
o Patent processus vaginalis is merely ligated and excised
o Transverse inguinal crease incision is made → Scarpa fascia is opened to
access the external oblique aponeurosis
 Care is taken to identify and preserve the ilioinguinal nerve
o In boys, the anteromedial hernia sac is separated from the cord structures; in
girls, it is mobilized up to the internal inguinal ring
o Hernia sac is clamped, divided, and ligated proximally at the internal inguinal
ring
o In laparoscopy, contralateral inguinal ring can be evaluated for patent
processus vaginalis
- Complications of hernia repair
o Early complications: scrotal hematoma and wound infection
 Scrotal hematoma can compromise testis blood flow and may require
prompt evacuation
 Residual asymptomatic hydroceles are common and may require
aspiration if persistent after 6-12 months
o Late complications: recurrence, chronic groin pain (5% incidence in children),
and testicular atrophy (caused by inadvertent damage to testicular artery)
 Recurrence: inguinal hernias recur in 2-25% of cases over a lifetime
 Inappropriate technique
  Operator inexperience
 Technical failure
 Missing diagnosis of concomitant femoral hernia
 Inherently poor musculature or connective tissue, chronic
cough, urinary obstruction, constipation, or resumption of
heavy work too soon after repair
 Iatrogenic cryptorchidism is infrequent → reoperative orchidopexy
- Laparoscopic repair is now standard procedure in many centers
o Can be categorized as intracorporeal or extracorporeal/percutaneous
 Intracorporeal: placing purse-string or N-shapes sutures in the
periorificial peritoneum at the level of the internal inguinal ring
 The periorificial peritoneum around the inguinal ring is cut,
and a suture is used to repair the hernia defect
 Extracorporeal: placing a suture circumferentially around the internal
ring and tying the knot using percutaneous techniques
o Advantages:
 Simultaneous repair of inguinal and femoral hernias
 Less postoperative pain
 Quicker return to normal activities
o Disadvantages:
 Slightly higher risk of major complications and recurrences
o Particularly recommended for recurrent hernias and bilateral repair
- Comparison
o Laparoscopic inguinal hernia repair (LIHR)
 provides better visualization of vital cord structures and reduces the
risk of complications such as testicular atrophy and secondary
cryptorchidism
 allows for identification and treatment of contralateral patent
processus vaginalis
 present in up to half of the patients (esp. the younger ones)
 generally, has a shorter operative time
 wound infection, postoperative hydrocele, iatrogenic cryptorchidism,
and testicular atrophy are less common
o recurrence rates are similar (0-6%)
o
- Postoperative care: avoiding strenuous activities and gradually returning to normal
activity over 2-3 weeks

Femoral hernia
- Incidence is higher in women and increases with age
o ↑ intraabdominal pressure, and other factors related to pregnancy, may be
important since the incidence is higher in parous than nulliparous women
- Formed by a protrusion of peritoneum into the potential space of the femoral canal
o Sac may contain abdominal viscera (usually small bowel) or omentum
- ~40% present with strangulation
Clinical features
- Hernia is usually small, appearing as a lump immediately below the inguinal ligament
and just lateral to its medial attachment to the pubic tubercle
- Cough impulse can rarely be detected (femoral canal is narrow)
- Hernia is deeply fixed (immobile)
- Can easily be missed in an obese patient and CT of the abdomen may be required to
clarify the diagnosis
- Strangulated femoral hernia
o There are often no obvious localizing symptoms and signs in strangulated
femoral hernia
o Presenting features are those of a distal small bowel obstruction
o Richter hernia
 In ~30%, only a portion of the bowel circumference is trapped in the
hernial sac
 Although the bowel lumen remains patent and the patient
continues to pass flatus, peristalsis is sufficiently disrupted for
other signs of obstruction to occur → vomiting

Management
- Since their propensity for strangulation, all femoral hernias, even if asymptomatic,
should be repaired without delay
- Elective repair: isolating, emptying, and excising the peritoneal sac
o Femoral canal is then closed with nonabsorbable sutures or with a plug
placed between the pectineus fascia and inguinal ligament
- Canal can be exposed by several different methods
o Femoral/low approach
o Lotheissen/high approach (via posterior wall of the inguinal canal
o McEvedy/pararectus extraperitoneal approach → rarely used
Enlarged Inguinal Lymph Nodes
- Are clustered into three anatomical groups
o Upper group (blue; 5-6 nodes)
 Lateral nodes drain: lateral lower abdominal wall, upper lateral thigh,
gluteal region
 Medial nodes drain: umbilicus and medial lower abdominal wall, male
external genitalia, lower anal canal and perianal region, vagina below
hymen, uterus via round ligament
o Lower group (pink; 4-5 nodes): drain most of lower limb
- Drain the lower abdominal wall and lower back, perineum (incl. vulva and vagina),
anal canal, penis and scrotal skin, and the whole lower limb
o Testis are derived from retroperitoneal area → drain to the upper paraaortic
nodes within the abdomen rather than inguinal nodes
- Can be enlarged due to local drainage or due to generalized lymphadenopathy
(lymphoma, systemic infection)
o Multiple small firm (‘shotty’) nodes are commonly found and are accepted as
normal if <1cm in diameter
 Probably result from minor infections of the lower limb

Clinical features
- Present with pain or a lump in the groin (often discovered incidentally)
- Usually mobile but become fixed to the surrounding tissues (when infiltrated by
tumor)
o In general, nodes smaller than 1 cm are unlikely to be malignant
- US can confirm enlarged lymph nodes and guide needle biopsy
- Exam should include palpating lymph nodes of the neck and axillae and palpating the
liver and the spleen
o Skin of drainage field should be examined closely
o Rectal exam is mandatory to exclude anal carcinoma

Saphena Varix
- Dilatation of the long saphenous vein in the groin, just proximal to its junction with
the femoral vein
- Caused by vascular incompetence at this point
- There are usually substantial varicose veins elsewhere in the long saphenous system
- Can reach the size of a golf ball or even larger
- PE: swelling is usually soft and diffuse
o Diagnostic feature: empties with minimal pressure and refills on release (‘the
sign of emptying’)
o Cough impulse is invariably present
- Treatment: high saphenous ligation

Femoral Artery Aneurysm

- Uncommon as a cause of lumps in the groin
- Diagnosis is made on clinical examination
o Lump lies below the midpoint of the inguinal ligament
 o Has a characteristic expansile pulsation

Ventral Hernias
Umbilical Hernia
- Common disorder in children
- Fascial defect is present at birth but may resolve without the need for an operation

Anatomy
- After birth, closure of umbilical ring is the result of complex interactions with the
lateral body wall folding in a medial direction, fusion of the rectus abdominis
muscles into the linea alba, and umbilical orifice contraction that is aided by elastic
fibers from the obliterated umbilical arteries
- Failure of this process → umbilical hernia
o Hernia sac is peritoneum and is usually very adherent to the dermis of the
umbilical skin
o The extent of skin protrusion is not always indicative of the size of the defect

Incidence
- Umbilical hernias are present in ~15-25% of newborns
o Premature and low birth weight infants have a higher incidence
- Infants with other conditions (Beckwith-Wiedemann syndrome; Hurler syndrome;
various trisomy’s; and congenital hypothyroidism) have higher incidence

Treatment
- Umbilical hernias close spontaneously
o It is very safe to observe the hernia until age 4-5 to allow closure to occur
 Even after this age many hernias (50%) will still close
o >90% spontaneously resolve before 1 year old
o The primary danger associated with waiting is the possibility of incarceration
and strangulation → quite rare
- Operative treatment (can usually be completed as an outpatient procedure)
o Transverse infraumbilical incision is made
o Hernia sac is identified and dissected free from the dermis underlying the
umbilical cicatrix
 EITHER excision of the sac to the fascial edges
 OR more limited excision of the sac or inversion of the sac through the
fascial opening
o Sutures are placed and tied → closure of fascial defect
o Skin is sutured
Epigastric Hernias
- Midline herniations through defects in the linea alba, anywhere between xiphoid
process and umbilicus
o Typical contents are peritoneal fat
- Common, with an incidence up to 5%
o 4 times more common in males
- Are often tiny (defect <0.5 cm)
- Most are asymptomatic and the presence of a lump and sometimes episodic sharp
pain on exertion are the usual presenting complaints
o Half are symptomatic at presentation
- Treatment: surgical repair (closing defect + reinforcement with mesh)
o These do not spontaneously close
o Recurrence is not common

Spigelian Hernia
- Quite rare in children; can be difficult to detect and diagnose
o Occur more frequently in girls and occur equally on both sides of the
abdomen
- Actual defect occurs at the intersection of the linea semicircularis, linea semilunaris,
and the lateral border of the rectus abdominis muscle
o Usually involves absence or attenuation of the transversus abdominis and
internal oblique muscles
- Hernia defect ranges in size from 1-3 cm
- Pain in the area with a feeling of fullness or an actual mass are the most common
symptoms
- Occasionally associated with skeletal abnormalities and also may be associated with
ipsilateral cryptorchidism
- Treatment: surgical repair
o Transverse incision over the defect with excision of the hernia sac and closure
of the defect
o Commonly found below the external oblique muscle
o May require mesh if large

Lumbar hernia
- Typically present by 2 years old as a visible bulge in the area bordered by the 12 th rib,
sacrospinalis muscle, and internal oblique muscle
Abdominal Wall Defects
Exomphalos and gastroschisis
- Developmental abnormalities in the region of the umbilicus
- Diagnosed on antenatal US (around 20 weeks’ gestation) or present at birth as
neonatal emergencies and they require urgent surgery
- Prevalence of both is relatively similar

First aid at birth

- Baby with anterior abdominal wall defect is at great risk of heat and water loss from
evaporation because of the moist exposed viscera
o Baby should be placed in a humidicrib with the entire torso wrapped with
clear plastic
o Wet gauze is not recommended because it cools to quickly and can cause
further heat loss
- Excess fluid resuscitation is detrimental and can result in edema, delayed closure,
and an increased risk of abdominal compartment syndrome
- Insert NG tube to decompress the stomach and herniating bowel and do not feed
the baby
o Minimizing gut volume facilitates operative reduction of herniated bowel
- Positioning the neonate on the right side helps prevent mesentery kinking and bowel
ischemia
- Evaluation of any other anomalies (renal, hypoglycemia, cardiac)

Spontaneous vaginal delivery is safe for both

Exomphalos (omphalocele)
- Congenital hernia into the base of the umbilical cord
- Caused by incomplete folding of the embryonic disc and failure of the umbilical ring
to form correctly
o Caused by the failure of the viscera to return to the abdominal cavity
o Incidence is higher in prenatal screening that at birth, indicating hidden
mortality due to spontaneous loss of the fetus or termination
- As opposed to gastroschisis, incidence has remained stable
- Diagnosis is made at the normal 18 week US evaluation

Clinical features
- Hernia is covered by fused amniotic membrane and peritoneum
o Sac is shiny and translucent but lacks a blood supply and begins to dry out
and deteriorate after birth
 Within 12 hours it becomes yellow and opaque
o Very occasionally, the membrane ruptures before birth and the eviscerated
bowel becomes matted and indurated with dense adhesions → bowel
appears shorter than normal
- Inflammation is believed to be caused by chemical irritation from meconium and
urine in the amniotic fluid
 - Size of defect and volume of the sac are variable
o Exomphalos major: defect >5cm in diameter and contains gut, liver and/or
spleen
o Exomphalos minor: defect <5cm in diameter and contains only gut within the
sac
- Relatively high risk of coexisting and significant abnormalities in a fetus with
exomphalos (35%)
o Esp. cardiac and renal malformations
o Beckwith-Wiedemann syndrome: severe hypoglycemia, organomegaly,
excess bodyweight, exomphalos minor, macroglossia
- Can be classified based on their location in the abdomen (hypogastric, central,
epigastric) and size (hernias of the card, small, medium, large, giant)
o Increasing size of the omphalocele is associated with a worse outcome

Investigations
- Chest x-ray and ECG are required to identify any cardiac lesions and intercurrent
pulmonary conditions (ex. Atelectasis or meconium inhalation)
- Kidneys may be examined by US
- Risk assessment:
o Can be based on the presence or absence of associated anomalies

Treatments
- Aim is to reduce the contents of the exomphalos and repair the defect of the
abdominal wall
- Method of treatment depends on:
o General condition of the infant
o Presence of other anomalies
o Whether the sac is intact or ruptured
o The size of the umbilical ring
o Whether part of the liver has herniated into the sac
- Immediate reduction of the bowel and closure of the defect → best course when
defect is <5cm
o Neonate is fit for an operation and closure may be obtained
o Excision of sac and closure of fascia and skin over the abdominal contents
 Care must be taken not to injure the hepatic veins and bladder
- Excision of the sac and construction of a cylindrical tube may be used for larger
defects
o Sheet of silastic or Teflon is sewn to the edge of the defect
o Alternatively, a postoperative dressing may be attached to the skin around
and over the defect, and use to serially reduce the volume of the exomphalos
over 7-10 days
 Dressing then removed and the defect is definitively closed
- If anesthesia is contraindicated or defect is very large (>8cm) and contains herniated
liver → non-operative management
 o Sac is painted with an astringent solution or covered with a silver-based
dressing to encourage formation of a tough, dry eschar which separates
when new skin has covered the area beneath (Scarification)
 May take 8-12 weeks or longer
o Subsequent wound contraction reduces the hernia progressively over 4-8
months and makes the definitive repair easier
- Postoperative care:
o After neonatal repair, patients may require mechanical ventilation for several
days
o Feeding can begin when bowel activity resumes
o Postoperative antibiotics are given for 24-48 hours
o Repair of a ventral hernia may be delated for 1 year or more to allow
stabilization and abdominal domain increase
- Survival rate for isolated omphalocele is >90%

Complications
- Early: increased intraabdominal pressure, acute hepatic congestion, renal failure,
bowel infarction, and wound complications
- Pulmonary hypoplasia and hypertension are associated with omphaloceles
- GERD is more common

Gastroschisis
- Increased incidence in mothers younger than 21 years of age
o Significant increase in incidence worldwide in past 2 decades
o Preterm delivery is more frequent in infants with gastroschisis
- May result from rupture of a physiological hernia in the cord between 6- and 10-
weeks’ gestation
o Failure of mesoderm formation in the anterior abdominal wall or failure of
migration of the lateral folds
- Fetus is usually normal genetically but has had an ‘accident’ affecting the umbilical
cord
o IUGR is often observed

Clinical features
- Abnormally ↑ maternal serum α-fetoprotein leads to performing the US
- Defect in abdominal wall is typically small (1-3 cm in diameter)
o Is nearly always to the right of a normally closed umbilicus
- Evisceration may involve most of the small and large bowel, which become densely
matted and adherent with amniotic peritonitis and fibrin from vomiting, defecation,
and micturition in utero
o Particularly during last semester
- Differs from a ruptures exomphalos in that there is:
o Greater risk of hypothermia
o Smaller abdominal wall defect and no covering sac
o Lower incidence of serious coexisting malformations
o Greater incidence (10%) of a small bowel atresia
 - Closing gastroschisis: the decrease in defect size prior to delivery, which can result in
diminished blood supply and the development of intestinal atresia or congenital
short bowel syndrome
o Prenatal US cannot reliably differentiate this condition, but intraabdominal
bowel distension may occur → indicating need for early delivery in some
cases
o Usually results in short gut syndrome

Prenatal Management and Delivery

- Factors considered important incl.: (Associated with inflammatory thickening of the
visceral bowel walls, resulting in the appearance of ‘matted’ intestinal loops)
o Intra-abdominal bowel dilation
o Bowel wall thickening
o Gastric dilation
o IUGR
o Polyhydramnios
o Liver herniation
o Bladder herniation
o Changes in bowel dilation over gestation
- ↑ levels of cytokines in the amniotic fluid and the effects of fetal urine are thought
to cause the abnormal collagen deposition
o ↓ interstitial cells of Cajal in bowel suggest the role of the proinflammatory
state in utero
- Vaginal delivery and C-section are both considered safe
- Thorough exam of the neonate is important to detect any associated anomalies
(bowel atresia is most common)
- Risk stratification is based on the presence or absence of abdominal complications
(atresia, ischemia, perforation, or NEC)
o Can be classified as complex or simple
 Complex: higher mortality rates, require multiple operative
interventions, having prolonged hospitalization, and ↑ risk of sepsis
and intestinal failure

Treatment
- Goals:
o Reduction of eviscerated organs
o Closure of the defect
o Nutritional support
o Prevention or early treatment of complications
- First aid measures are established, and the bowel is carefully inspected for viability
and evidence of atresia bands crossing the bowel loops should be lysed

o If all is good → primary closure
 Can be done in the OR or at the cot side, with or without general
anesthesia
  Intra-abdominal pressure measurements guide the surgeon during
reduction with pressures above certain threshold indicating the need
for a silo or patch closure
o If not → delayed closure with prosthetic silo (staged reduction)
 Silo is positioned under the fascial opening and gradually shortened as
the bowel is reduced daily
 Bowel viability should be continually assessed
 Definitive closure in staged closure is similar to primary closure
- Abdominal compartment syndrome: dangerous complication of reduction
o Usually due to overzealous attempts to return the viscera into an abdominal
cavity that is too small
o Attempts are made to minimize the risk through:
 NG suction to minimize bowel contents and gas
 Anorectal washouts and stimulation to evoke decompression of the
colon
 Enlargement of the defect and intraperitoneal ‘milking’ of the bowel
to evacuate as much meconium as possible through the anus
 Bladder decompression with urethral catheter
o Treatment: prompt laparotomy and silo placement
- Associated intestinal atresia (~10%; most commonly jejunal or ileal)
o Complicated management and is associated with worse outcomes
o Management depends on the condition of the intestine
 Surgeons typically avoid performing a bowel anastomosis in the
presence of extensive inflammatory peel due to concerns about
suture integrity
o If atresia is detected at birth or during final closure, an ostomy can be created
to allow for earlier feeding while waiting for intestines to normalize
o There is no consensus for optimal treatment
- Postoperative care:
o Following primary closure → monitoring the effects of ↑ intraabdominal
pressure
 Ventilation perturbation
 Renal function changes
 GI ischemia
o Associated with abnormal intestinal motility and nutrient absorption, which
gradually improves over time
 Enteral feeding is typically delayed for weeks while waiting for bowel
function to return to normal
 NG decompression and parenteral nutrition are requiring during this
waiting period
o Postoperative NEC can occur, and it may lead to short bowel syndrome and
associated complication

Long term outcomes

- Complex gastroschisis is associated with poorer long-term outcomes
o Delayed attainment of full enteral feedings
 o Longer TPN use
o Extended hospitalization
o Increased risk of intestinal failure
o Liver disease
o Need for intestinal transplant
- Most gastroschisis patients have an intestinal rotational anomaly but it is typically
not repaired at the time of closure
- Cryptorchidism is associated
Disorders of the Male Genitalia
Inflammation of epididymis and testes

Epididymitis
- Bacterial epididymitis is the most common inflammatory disorder of scrotal contents
- Usually secondary to urethral infection that ascends via the vas deferens
o E. coli (50-65-year old’s)
o Chlamydia or Gonorrhea (15-30-year age group)
- Testis is rarely infected, although the inflammation may cause testicular tenderness
- Pain usually begins acutely
- PE: affected side of scrotum and its contents are swollen, edematous and tender,
and the scrotal skin can be red and warm
o It may be difficult to palpate epididymis and testicle separately once infection
is established
o Urinary symptoms are usually present (always in younger patients)
- Treatment:
o Initial bed rest and pain relief
o 2-4 weeks of appropriate broad-spectrum antibiotics
 Guidelines recommend a 14-day course of oral doxycycline and a
single IM injection of ceftriaxone for patients at risk for chlamydia and
gonorrhea
 Oral levofloxacin, ciprofloxacin, or ofloxacin are recommended for
gram-negative organisms (E. coli)

Tuberculous epididymitis
- TB may involve the epididymis via the bloodstream from a pulmonary or other focus
- TB UTI cab spread to the epididymis, with swelling as the presenting complaint
- PE: whole length of the epididymis is thickened, nontender, and ‘cold’, with a
beaded cord (i.e., involvement of the vas in the spermatic cord)
o A TB epididymis can be readily distinguished from the testis on palpation
- If untreated, the testis may also become involved
- Diagnosis
o Analysis of serial early morning urine specimens for mycobacteria or
histological examination of percutaneous needle biopsies
 Patients will have sterile pyurias and a ↑ ESR

Orchitis
- Primary bacterial orchitis is rare and may result from pyogenic infection in the
genital tract elsewhere
- Tertiary gummatous syphilis may involve the testis → diffuse nontender enlargement
- Viral orchitis is most often caused by mumps
o In post pubertal males, bilateral mumps orchitis produces infertility in 50%
o Manifests 4-6 days after the onset of parotitis, with unilateral or bilateral
enlarged, tender testes and an inflammatory hydrocele
 o Treatment is directed at symptomatic relief

Hydrocele
- Excessive collected of fluid within the tunica vaginalis (between parietal and visceral
layers)
o Tunica vaginalis contains a little serous fluid, which produced and reabsorbed
at an equivalent rate
Primary hydrocele
- In infants and children, a hydrocele is usually an expression of a PPV (→
communicating hydrocele)
o Hydroceles in boys below the age of 1 year usually resolve spontaneously
o Surgical repair is recommended if the hydrocele fails to resolve by age 2 years
- In some, the scrotal swelling disappears overnight → communicating hydrocele
o Fluctuates in size, and is usually related to ambulation
- Scrotal hydroceles without associated patency of the processus vaginalis are also
encountered in newborns
- Primary hydroceles may develop in adulthood, particularly in the elderly, by the slow
accumulation of serious fluid (→ impaired reabsorption → non-communicating)
o Can reach a huge size
o Swelling is soft and nontender and the testis cannot usually be palpated
o Reasonable chance of spontaneous resolution (75%)
- Diagnosis: presence of fluid is confirmed by transillumination
o No history of reducibility and no associated symptoms → nontender
o Doppler US help to distinguish hydroceles from varicocele and testicular
torsion (these conditions may also be accompanied by a hydrocele)
- Management:
o In majority of infants, surgical treatment is not indicated within the first year
because of the tendency for spontaneous resolution
 Little risk is taken as progression to hernia is rare and does not result
in incarceration
 If there is no spontaneous resolution after 1 year → surgery
 Early surgery is indicated if there is suspicion of a concomitant
inguinal hernia or underlying testicular pathology
o Operation: ligation of the PPV or scrotal via inguinal incision and the distal
stump is left open

Secondary hydrocele
- May develop in response to a testicular tumor of inflammation
- Hydrocele is small and the testis can easily be palpated to reveal the primary
abnormality
- Scrotal approach is used in the treatment of secondary non-communicating
hydroceles
o Symptomatic: hydrocele operating
 Everting the sac and oversewing the edges (Jaboulay procedure) or
plicating the sac (Lord method)
 If the sac is thick, it is best excised
 o Aspiration can be used for those that can’t undergo surgery
 If a testicular tumor is a possibility, a hydrocele must not be aspirated
as malignant cells can be disseminated via the scrotal skin to its
lymphatic field

Hydrocele of the cord (Encysted hydrocele of the cord)

- Rare
- Hydrocele develops in a remnant of the processus vaginalis somewhere along the
course of the spermatic cord

Fournier Gangrene → urological emergency

- A form of necrotizing fasciitis of genitalia and perineum and usually causes systemic
sepsis
- Does not involve the testis
- The underlying causes include genitourinary trauma (skin injury, paraphimosis,
urethral disruption from urethral instrumentation or catheter), surgery
(circumcision), perirectal abscess and urethral stricture
- Predisposing factors:
o DM
o Corticosteroid use
o Chronic alcohol excess
- Principle infecting organism is an anaerobe but there is often synergistic aerobic
infection
- Treatment: resuscitation, broad-spectrum antibiotics, and surgical excision of all
necrotic tissue
o Likely to require repeat procedures
o The extent of the debridement usually required later reconstruction by a
plastic surgery team

Epididymal cyst and spermatocele

- Multiple cysts can develop in the upper pole of the epididymis and present as
painless scrotal swelling
o Slightly younger age group than hydroceles
o The testis can be palpated separately from the cysts, which transilluminate
- Spermatocele: single cyst containing spermatozoa
o Usually occur in the head of the epididymis
o Clinically similar to epididymal cysts but may or may not transilluminate
o Occasionally, they occur in the spermatic cord and surgical excision may
cause obstruction to passage of sperm → if bilateral, then infertility

Varicocele
- Dilatation and tortuosity of the pampiniform venous plexus of the spermatic cord
- Much more common on the left (90%)
o Results from the different venous drainage of the two sides
  On the left, the testicular vein drains into the higher-pressure renal
vein, whereas the right testicular vein drains directly into the vena
cava
- Common (15% of young adult males)
- Usually, asymptomatic but is often discovered during examination for infertility
o Varicocele increases scrotal temperature which may inhibit sperm numbers
and function and cause possible loss of testicular volume
- When lying flat, the distended veins collapse and become impalpable → best
diagnosed when patient is standing
o Small varicocele (grade 1) is only felt with a Valsalva maneuver
o Moderate sized varicocele (grade 2) can be felt as thickened veins in the
spermatic cord
o Large varicocele (grade 3) feels like ‘a bag of worms’
- Rarely, a left-sided varicocele may be caused by an invading renal cell carcinoma
obstructing the left renal vein
o A new onset right-sided varicocele can be caused by renal cell carcinoma
obstructing the vena cava or compression from other retroperitoneal masses
 Such varicoceles do not collapse when the patient lies flat
- Treatment:
o In adults, surgical treatment of varicocele is indicated for relief of pain or
treatment of low sperm count
o In children or adolescents, treatment may be advised if there is evidence of
delayed testicular growth, and to improve spermatogenesis
o Treatment of choice: percutaneous embolization (microsurgical
varicocelectomy)

Testicular tumors
- Relatively uncommon, making up ~1.5% of male cancers and 5% of all urological
cancers
o Most common cancer in men in their 3rd and 4th decades
- Curative treatment is now available, even when metastatic
- Rest in notebook

Absent Scrotal Testis (Cryptorchidism)

- Occurs in 3-4% of male infants at birth, falling to ~1% by 12 months
- Can be classified as:
o Retractile: intermittent active cremasteric reflex, which draws the testis out
of the scrotum
 Testis can be gently ‘milked’ back into the scrotum
 Predisposes to ‘testicular ascent’ → testis previously in the scrotum
retracting into the groin – seen in boys aged 7-9 years
o Incomplete descent: testis lies along the normal line of descent;
intraabdominal, inguinal, or prescrotal
o Ectopic: abnormal line of testicular descent outside the external ring
 Testis may be palpable in the perineum, femoral region, or base of
penis
 o Absent: anorchia is rare but can be caused by antenatal intraabdominal
torsion
o Atrophic: secondary to trauma or iatrogenic
- Corrected by orchidopexy at a young age
o To best preserve spermatogenesis, the testis should be surgically placed in
the scrotum between 6 months and 1 year
- Main concerns with maldescended testes are the risks of malignancy, subfertility,
and torsion or trauma in an abnormal position

Foreskin (Prepuce) Problems in Adults

Phimosis
- Physiological phimosis is present at birth and during childhood until adhesions
between the inner foreskin and glans penis release and the foreskin becomes
retractile
o <1% will persist into adulthood
 Incidence is 9-20% in 5-13-year-olds and 1% in 16-18-year-olds
o Progressive separation of the inner prepuce from the glans is associated with
build-up of epithelial debris (smegma) and aided by penile erections
o Most do not need treatment, unless there are complications, such as
recurrent balanitis, UTI or BXO
- Adult males present with a foreskin that will not fully retract, causing pain or
erection and intercourse
o Usually caused by fibrosis of the foreskin
 May be caused by chronic or recurrent low-grade Candida infection or
BXO
o May be accompanied by stenosis of the urethral meatus, also caused by
recurrent inflammation and fibrosis
- Topical steroids can be tried, but definitive treatment usually involves circumcision
- Balanoposthitis (Balanitis)
o Overt inflammation of the glans penis and foreskin (with discharge of pus)
o Occurs most commonly in children
 Occurs in 6% of uncircumcised boys
o Inflammation alone is most often caused by Candida and fecal bacteria
- BXO (Balanitis xerotica obliterans - lichen sclerosus et atrophicus)
o Fibrotic condition of the foreskin → ~25% of children with phimosis have this
 Non-painful chronic inflammatory disease
o Produces thickened, stenosed, often depigmented foreskin, which is often
adherent to the glans
 Can involve urethral meatus and may cause stenosis (sometimes
requiring meatotomy)
o Circumcision is usually curative
o Histopathological diagnosis
Physiological Pathological
No sign of scarring Scarring
Upon retraction the inner prepuce is seen Narrow ring of the prepuce is fibrous, often
 bulging outward from the narrow ring of white and thickened
the prepuce → ‘pouting’
Inner layer of the prepuce is not seen
coming out

Paraphimosis → urological emergency

- If a phimotic foreskin is forcibly retracted, the tight meatal band may lodge in the
coronal sulcus making reduction impossible
- Progressive edema of the glans and the foreskin the exacerbates the difficulty
o Impaired perfusion may lead to necrosis of the prepuce and ultimately of the
glans
- May occur at any age, but is particularly common in elderly men
- In most cases, the foreskin can be reduced by firm manual compression of the glans
and foreskin
o Local anesthetic jelly is applied first for lubrication and pain relief
o Local anesthetic penile subcutaneous ring block is sometimes needed
- Sometimes, a dorsal slit under local or general anesthesia is needed to effect
reduction
- If reduced manually, a circumcision or preputioplasty is offered at a later date, when
the edema and inflammation have resolved, to avoid recurrence

Management
- Hygiene
o Foreskin should not be retracted for cleaning until this can be done easily
o Care should be taken to reduce the foreskin back down over the glans to
prevent paraphimosis
- Conservative treatment: topical corticosteroids and manual stretching over period of
4-8 weeks

Peyronie Disease
- Most commonly in men aged 40-60
- Some cases are thought to result from penile trauma during sexual activity and
others are associated with Dupuytren contracture of the palmar fascia
- Slow progressive asymmetrical fibrotic plaques develop in the fascia surrounding the
corpora cavernosa
o Corpus spongiosum, incl. the glans, is spared
o Plaques may become calcified
- Condition causes thee penis to bend towards thee affected side on erection, making
intercourse difficult and painful
- There may be spontaneous partial resolution with time → surgery is usually deferred
for 12 months after initial presentation
- Severe persistent cases require surgery
o Nesbit operation: creating pleats in the corpus on the contralateral side →
unavoidable penis shortening
o Lue procedure: excision of the plaques, which are replaced by a patch of
tissue
  Reserved for more significant curvature and preserves penile length
but has a higher risk of impotence
o Either procedure may restore symmetrical erection

Hypospadias
- Risk factors: genetic, placental and/or environmental
o Low birth weight
- Over the last 25 years, a significant increase in the incidence of hypospadias have
been found
- Classification
o Based on the anatomical location of the proximally displaced urethral orifice
 Distal-anterior hypospadias → located on the glans or distal shaft of
the penis and the most common type of hypospadias
 Intermediate-middle → penile
 Proximal posterior → penoscrotal, scrotal, perineal
o Anatomical location of the meatus may not always be enough to explain the
severity
 Mild hypospadias: glandular or penile isolated hypospadias without
associated chordee, micropenis, or scrotal anomaly
 Severe hypospadias: penoscrotal, perineal hypospadias with
associated chordee and scrotal abnormalities

Diagnostic evaluation
- Position, shape, and width of the orifice
- Presence of atretic urethra and division of corpus spongiosum
- Appearance of the preputial hood and scrotum
- Size of the penis
- Curvature of the penis on erection
- Associated anomalies
o Cryptorchidism (10%)
o PPV/inguinal hernia (9-15%)
o Severe hypospadias with unilaterally or bilaterally impalpable testis, or with
ambiguous genitalia, requires a complete genetic and endocrine work-up
immediately after birth

Management
-
Non-acute abdominal and urological
problems in children
Vesicoureteric reflux (VUR)
- Any anatomical or functional urinary tract abnormality predisposes to infections
(esp. in children)
o In children, most common is vesicoureteric reflux → retrograde flow of urine
from bladder to kidneys
 Exposes the upper tracts to the greater range of pressure variation of
the lower tract and to ascending infections
- There is a faulty mechanism at the junction of ureter and bladder (vesicoureteric
junction)
- Neonatal VUR is caused by anatomical abnormalities, with both sexes affected
equally
o Later, the condition appears predominantly in girls where voiding
disturbances play a large role
o Vicious circle may develop, with reflux leading to infection, then bladder
instability and further dysfunctional voiding

Pathophysiology
- Normally, distal ureters pass into the bladder so when pressure increases in the
bladder, the ureter is flattened → ‘flap-valve anti-reflux mechanism’
- Primary VUR is most common and usually results from a minor (often familial)
abnormality of ureteric insertion or from ectopic or duplex ureters
- Secondary VUR may be caused by bladder outlet obstruction, neuropathic bladder,
or surgical procedures to the lower end of the ureter
- Ascending infection begins with bacteria reaching the bladder via urethra →
infecting urine refluxes into upper tracts but cannot be cleared effectively →
infection of upper tract

Clinical presentation + Investigation

- During antenatal screening, VUR can be detected as urinary tract dilation
- Common presentation: one or more UTIs at any age
o Girls are more prone than boys in the first year
o Babies do not exhibit typical symptoms of UTI
o In symptomatic UTIs, the prevalence of VUR is as high as 50% in neonates,
and 30% in those aged 2-18
- To demonstrate reflux, sequential investigations are US, micturating cystography,
and isotope scans using DMSA and MAG3
o Micturating cystography should only be used in selected cases but it is the
gold standard
o Severe dilating VUR requires isotope studies
Management
- Grades 1 and 2 → there is an 85% chance of
resolution of reflux as the child grows
o In meantime, risk of UTI should be
minimized by encouraging high fluid
intake, avoiding constipation, and
maintaining perineal hygiene
o Child is maintained on continuous
antibacterial chemotherapy and
followed-up regularly
- Surgical correction becomes indicated when
there are recurrent infections, deterioration
of upper tract function or non-compliance
with medical management
o Otherwise, it’s reserved for severe dilated VUR

Congenital diaphragmatic hernia

-