Inguinoscrotal masses

Recognising irreducible hernias and hernias at risk of incarceration will save a ball…Recognising undescended testes can save a ball…

See Part I at Saving Balls 101: The Acute Scrotum

Types of inguino-scrotal masses

• Hernia
• Hydrocele
• Undescended Testes
• Varicocoele

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Hernias and Hydrocoeles

 

Generally speaking, children get hernias due to incomplete obliteration of the processus vaginalis, allowing abdominal content to travel towards the groin or scrotum.

• If the content is just fluid coming through a narrow processus, it is a hydrocoele.
• If the content is solid (e.g. bowel, omentum, appendix, ovary) coming down a wide processus, it is a hernia.

Surgically speaking, we repair hernias and hydroceles in the same way – i.e. high ligation of the processus vaginalis.

Hydrocoeles are much less urgent a referral, as they will generally resolve over time. They can also appear when the child has a concurrent viral infection, and tend to resolve over weeks to months.

If they do persist longer than 2 years or keep enlarging and becoming very tense, we would consider repairing them.

Hernias are different.

The risk is not only of incarceration and strangulation of the hernia content (e.g. bowel), but also to the testis; pressure on the tiny testicular vessels can render the testis ischaemic.

 

The younger the child, the higher the risk of incarceration (over 30% in ex-premature babies).

This is why we repair hernias more urgently in neonates and infants than in school-aged children.

A neonate presenting with a reducible hernia should have their operation planned for the next elective list. They should not wait to be seen at the next available clinic appointment.

More balls may be saved this way.

The older the patient, the longer they can afford to wait for elective repair.

 

Irreducible inguinal hernias

Some attempt should be made to reduce such hernias, unless the overlying skin is already erythematous (suggesting an underlying ischemic organ).

Otherwise, keep the child comfortable (or baby wrapped up) until surgical help arrives.

If we are able to reduce the hernia, we tend to wait 12-24 hours before repairing it to allow oedema to settle (making our operation a little easier). In these cases, we need to ensure the hernia is fully reduced, as a partially reduced hernia can still exert pressure on the testicular vessels.

If we are unable to reduce the hernia, then an urgent operation is required.

 

Female inguinal hernias

Girls often get their ovaries trapped in their inguinal hernias.

These feel different from the usual bowel content. An ovary will feel firmer, and maybe somewhat mobile, like a bean. The bowel usually feels squishy. Ovaries can be very difficult to reduce, they are more robust than testes and do not become ischaemic as quickly.

 

Hydrocele of the cord

This often presents as a “third ball”; it is due to a cystic collection in the mid-portion of the processus vaginalis (see line drawing above).

They rarely cause problems and are repaired electively.

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Undescended Testes

The incidence of undescended testes is 4% at birth (higher in premature babies). This incidence falls to 1% at age 1. Most testes should be descended by age 3-6 months. It is uncommon for further descent after this age.

Undescended testes are usually found at the exit of or along the inguinal canal, but may sometimes be ectopic (e.g. base of penis, lateral thigh). Uncommonly, they are intra-abdominal – this location is more associated with abnormal testicular function.

 

Reasons for orchidopexy:

Preservation of fertility potential.

• The optimal temperature for spermatogenesis is slightly lower than body temperature, so testes located in the scrotum have better fertility potential.
• The recommended age for orchidopexy continues to change as our understanding of spermatogenesis evolves. The current recommendation is orchidopexy before age 1, as this is when the first stage of spermatogenesis begins.  (Much evidence is extrapolated from animal studies, and results of long-term studies have yet to confirm this.
• Timing of operation has to be weighed up: optimal testicular preservation vs general anaesthetic risk (which is higher if the baby is less than 6 months old).
• I would reassess the baby around age 6 months; and, if the testis is not descended by then, perform orchidopexy within the next 6 months.

 Malignancy risk

• Undescended testes (particularly bilateral) are at greater risk of testicular cancer (4.0 to 5.7 relative risk compared to general population, maybe up to RR 8), but not as high as previously thought. Taking into account the general risk is at most 1-10 per 10000 person years, testicular cancer will still be uncommon in undescended testes.
• After orchidopexy, the relative risk is 2-3. Lower risk if corrected before age 12.
• Seminomas more common in uncorrected undescended testes; non-seminomatous cancers in corrected testes.
• Take-home message: Boys should have lifelong surveillance via routine self-examination. This is the most sensitive way of picking up any testicular abnormalities. Orchidopexy makes it easier to examine and monitor the testes.

Retractile testes

Very common in younger pre-pubertal boys.

Can be mistaken for undescended testes.

Occurs because of the strong cremasteric muscles “retracting” the relatively small and light testes out of the scrotum.

Can be difficult to examine as the testes can retract further when exposed to cold hands!

 

Tips to differentiate retractile vs undescended testes:

1. Scrotum well-developed, loose & rugose. (cf undescended testes, where the scrotum is flat/hypoplastic, because the testis has never been inside. See above pictures)
2. Slow/gentle exposure. Do not reach for testes immediately – observe first. You may see the testis within the scrotum, moving up & down.

These just need to be observed.

The testes will become less retractile as the boy grows, and the testes become heavy enough to counter the strength of the cremasteric muscles.

 

Ascending testes

Where the testis was previously known to be intra-scrotal, and now “undescended”.

Can occur around the time of growth spurt (e.g. age 8-9) – as the boy’s torso “lengthens”, so should the spermatic cord. If it does not, there is a relative “shortening” of the cord, so that the testis no longer reaches the scrotum and seems to ‘ascend’.

Orchidopexy is also required, but the urgency is a little less than with primarily undescended testes, as the first stage of spermatogenesis is complete, and the next stage should not begin until puberty.

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Varicocoele

Thought of as “varicose veins” of the testicular veins.

More commonly in adolescent boys (and adults).

Classically feels like a “bag of worms”.

More commonly on the left, as testicular vein drains into higher-pressured left renal vein (cf right side drains into IVC).

Need to exclude any other causes of obstruction at this level (e.g. renal tumour, renal vein thrombosis).

 

Indications for treatment:

• Symptoms e.g. pain, throbbing, heaviness
• Testicular atrophy (ie testis on affected side becomes smaller compared to unaffected side)

 

Treatment options:

• Surgical ligation of testicular vessels – various options and approaches – all associated with various rates of recurrence
• Embolisation of testicular veins (interventional radiology) – lowest recurrence rate

 

References:

Lau ST, Lee YH, Caty MG. Current management of hernias and hydroceles. Seminars in Pediatric Surgery. Feb 2007; 16(1): 50-57.

Hutson JM, Clarke MCC. Current management of the undescended testicle. Seminars in Pediatric Surgery. Feb 2007; 16(1): 64-70.

(in fact, the whole Feb 2007 issue (vol 16, iss 1) of Seminars in Pediatric Surgery is on “Common Problems in Pediatric Surgery”, including appendicitis, pyloric stenosis, umbilical anomalies, and anorectal problems – worth a look if you can get your hands on it.)

Wood HM, Elder JS. Cryptorchidism and Testicular Cancer: Separating Fact From Fiction. The Journal of Urology. 2009;181(2):452-461.

John Radcliffe Hospital Cryptorchidism Study Group. Cryptorchidism: a prospective study of 7500 consecutive male births, 1984-8. Archives of Disease in Childhood. Jul 1992;67(7):892-899