Case 9.4 – Common Surgical Conditions in Kids

Obtain a complete history and perform a physical examination to establish a diagnosis. The most likely diagnosis in this case is a strangulated inguinal hernia.

Immediate Management:

• Manual reduction: An immediate attempt should be made to reduce the hernia manually
• This is done by first disimpacting the hernia at the external inguinal ring, and then reducing it along the line of the inguinal canal
• Fortunately, most hernias that become stuck can be reduced manually

Subsequent Management:

• Once reduced, the hernia can then be repaired as an elective procedure within a few days
• This is best done in a specialist paediatric surgical centre

Inguinal Hernia

A widely patent proximal processus vaginalis allows bowel (and, in girls, the ovary as well) to enter the inguinal canal, producing a reducible lump in the groin called an indirect inguinal hernia.

Epidemiology:

• Occurs in about 2% of live male births but is less frequent in girls
• Greatest incidence is in the first year of life

Presentation:

• Intermittent swelling overlying the external inguinal ring that has been noticed by a parent
• May appear to cause discomfort at times
• Most likely to be obvious during episodes of crying or straining
• In infants may be seen during nappy changes

Management:

• Inguinal hernias should be repaired as soon as practicable

Strangulation:

• Common, particularly during the first 6 months of life
• Recognized when the groin swelling becomes irreducible
• Associated with irritability and crying (due to pain and abdominal cramps) and vomiting
• If left untreated, may damage the incarcerated bowel
• Occasionally, by compressing the testicular vessels may lead to testicular atrophy

Hydrocele

Presentation:

• Presents as a painless cystic swelling around the testis in the scrotum
• Contains peritoneal fluid that has tracked down a narrow but patent processus vaginalis
• Transilluminates brilliantly
• When the hydrocele is lax, the testis can be felt within it
• The upper limit can be demonstrated distal to the external inguinal ring, distinguishing it from an inguinal hernia
• No impulse on crying or straining

Natural History:

• Common in the first few months of life
• Do not cause discomfort
• Usually disappear spontaneously
• Surgery only indicated if the hydrocele persists beyond 2 years of age

Undescended Testes

Undescended testis (or cryptorchidism) is a term used to describe the testis that does not reside spontaneously in the scrotum.

Epidemiology:

• Occur in about 2% of boys
• More common in premature infants
• Spontaneous descent of the testis is unlikely beyond 3 months post-term

Importance:

• Will result in reduced fertility if left untreated
• Suspected that the higher temperature to which an undescended testis is subject impairs spermatogenesis

Diagnosis:

• Made by examining the inguinoscrotal region
• Normally, the testis should be found within the scrotal sac
• In cryptorchidism the scrotum looks empty
• The testis is 'milked' down the line of the inguinal canal towards the scrotum
• If the testis cannot be brought into the scrotum or will not remain there spontaneously it is considered undescended

Retractile Testis vs Undescended Testis:

• May be difficult to distinguish clinically
• In most normal boys the testis resides in the bottom of the scrotum
• The cremasteric reflex (prominent during mid-childhood) may cause it to move upwards
• Retractile testis: Can be brought down into the normal position and should stay there spontaneously, at least until the cremasteric reflex is stimulated
• Undescended testis: Will not stay in the scrotum spontaneously and usually cannot even be coerced beyond the neck of the scrotum
• Often smaller than a normal testis on the other side

Torsion of the Testes

There are a number of conditions that cause an acutely painful or enlarged scrotum of which torsion of a testicular appendage is the most common, and torsion of the testis itself the most important.

Clinical Presentation:

• The boy complains of severe pain in the scrotum

Torsion of Testicular Appendage (Early Stages):

• A blue-black 'pea-sized' swelling which is extremely tender to touch may be seen through the skin of the scrotum near the upper pole of the testis
• Palpation of the testis itself causes no discomfort
• Later, a reactive hydrocele develops, the tenderness becomes more generalized
• Clinical features may make it difficult to distinguish from torsion of the testis

Torsion of the Testis:

• Both the testis and the epididymis are exquisitely tender (unless necrosis has already occurred)
• The testis may be lying high within the scrotum
• In older boys the pain radiates to the ipsilateral iliac fossa
• May be associated with nausea and vomiting
• Produces symptoms similar to those of appendicitis
• Important: Always examine the scrotum in boys presenting with lower abdominal pain

Abnormalities of the Umbilicus

Abnormality	Comment
Exomphalos	Large defect at umbilicus containing bowel and liver covered by a sac Co-existing heart and kidney abnormalities common Requires surgical closure
Gastroschisis	A small defect immediately to the right of the umbilicus through which bowel (and sometimes the gonads) herniated Requires surgical repair
Umbilical hernia	Common, most resolve, but can reappear during pregnancy Asymptomatic Skin covered
Umbilical sepsis ('omphalitis')	Serious condition requiring treatment with intravenous antibiotics
Umbilical granuloma	Often pedunculated Common, treat with silver nitrate
Ectopic bowel mucosa	Treat with silver nitrate
Patent vitellointestinal duct	Sinus opening at umbilicus Communication with ileum Discharges faecal fluid and gas
Patent urachus	Communication with bladder and discharges urine

Smegma

• Smegma accumulates beneath the adherent foreskin
• Smegma is normal, and is released spontaneously as the foreskin separates from the glans penis
• When released, may be associated with some redness and irritation of the foreskin for a day or so: this, too, is a normal process
• Appears as asymmetrical accumulations of yellow-tinged material predominantly in the coronal groove beneath the foreskin
• May produce a noticeable swelling, which may be misdiagnosed as a dermoid cyst or tumour
• Often misinterpreted as being mid-shaft because a small child's coronal groove may be a long way from the tip of the foreskin

Balanitis

• Infection can develop beneath the foreskin
• If severe, pus may appear from the end of the foreskin
• Often associated with phimosis
• Infection may cause considerable redness and swelling of the penile shaft
• Requires treatment with either topical or oral antibiotics

Phimosis

• The opening at the tip of the foreskin has narrowed down to such a degree that the foreskin cannot be retracted
• The external urethral meatus is not visible
• Must be distinguished from the normal adherence of the foreskin to the glans
• In most boys, phimosis can be treated by application of steroid ointment (e.g. betamethasone valerate ointment) to the tight, shiny part of the foreskin
• This usually obviates the need for circumcision
• However, marked previous inflammation, infection, skin splitting and balanitis xerotica obliterans can lead to marked scarring - in many of these children the only reasonable treatment is circumcision
• Sometimes the severity of phimosis is such that there is ballooning of the foreskin on micturition
• On rare occasions it may even cause urinary retention with a distended bladder
• A degree of phimosis is common in infancy but tends to resolve spontaneously in the first few years of life, and is not considered abnormal in this age group

Paraphimosis

• Occurs when a mildly phimotic foreskin has been retracted over the glans and has become stuck behind the coronal groove
• Causes oedema of itself and the glans penis
• It is a painful and progressive process
• Treatment involves gentle manipulation of the foreskin forwards, which may require a general anaesthetic
• Circumcision is not performed at this time
• A few children may need circumcision subsequently if the phimosis does not respond to topical application of steroid ointment

Hypospadias

• The foreskin looks square and hangs off the penis
• The shaft of the penis is bent ventrally

The two main problems in hypospadias are:

• Location of the urethra: Can be found on the ventral side of the shaft of the penis, proximal to its correct position
• Chordee: Ventral angulation of the shaft and glans. Correction of chordee to straighten the penis is required to allow later successful sexual function

Important Notes:

• Circumcision is absolutely contraindicated in hypospadias because the skin of the prepuce is used during repair of the hypospadias
• Severe hypospadias may be indicative of an intersex abnormality
• When there is penoscrotal hypospadias and a bifid scrotum, the scrotum should be examined carefully for testes
• Some of these children may be females with congenital adrenal hyperplasia; the labioscrotal folds are labia rather than scrota, and the presumed urethral opening may in fact be the entrance to the vagina

The indications for circumcision remain controversial.

Arguments For Circumcision

• Circumcision lowers the risk of urinary tract infection in the first year of life (1 in 500 in circumcised vs 1 in 100 in uncircumcised)
• Although a rare condition (1/100,000), the risk of cancer of the penis is reduced 10 fold in circumcised males
• Studies are conflicting, but some report that circumcised males have a slightly lower risk of getting sexually transmitted infections. Only in Sub-Saharan Africa is the risk of HIV higher in uncircumcised males
• Circumcision eliminates risk of balanitis
• Circumcision eliminates the risk of phimosis
• Genital hygiene, which is particularly important in unsanitary conditions, may be easier after circumcision

Arguments Against Circumcision

• The overall complication rate varies from 0.2-10%
• Local infection and bleeding are the most common complications
• Infection is usually minor, but septicaemia and meningitis have been rarely described
• Damage to the meatus of the urethra leading to a meatal stricture
• Secondary phimosis and secondary chordee
• Problems with healing of the circumcision wound
• Almost all uncircumcised boys can be taught proper hygiene that can lower their chances of getting infections, cancer of the penis, and sexually transmitted diseases
• Loss of penis (1/1,000,000)

Midline Neck Swellings

Cause of Swelling	Comment
Thyroglossal cyst	Most common (80% of midline neck swellings) Moves with tongue protrusion and swallowing Attached to hyoid bone
Ectopic thyroid	Less common May be only thyroid tissue present May be difficult to distinguish from thyroglossal cyst Do thyroid isotope scan for diagnosis
Submental lymph node/abscess	Check inside mouth for primary infection Other cervical lymph nodes may be enlarged
Dermoid cyst	Small, mobile, non tender Yellow tinge through skin In subcutaneous layer
Goitre	Lower neck
Cystic hygroma	Hamartoma Usually evident from birth May be extensive

Torticollis, or wry neck, is a condition in which the head is tilted to one side and the chin is elevated and turned towards the other side.

Causation in Younger Children

• Postural torticollis: A benign condition that presents at birth and usually resolves in a few months and is due to intrauterine position
• Sternomastoid tumour:
  • Not present at birth
  • Presents in the third week of life with a hard lump in the neck, or that the head cannot be turned to one side
  • The head is flexed slightly to the side of the shortened sternomastoid muscle, and is turned to the contralateral side
  • May be a history of breech or forceps delivery
• Other conditions occurring at a younger age include:
  • Cervical hemivertebrae
  • Benign paroxysmal torticollis of infancy

Causation in Older Children

Causation in older children is generally due to acquired conditions or previously undetected congenital conditions. These include:

• Imbalance of ocular muscles due to strabismus
• Posterior fossa tumours
• Atlanto-occipital/axial subluxation following injury
• Sandifer's syndrome: Abnormal head tilt secondary to gastro-oesophageal reflux
• Lateral cervical lymphadenitis

Answers coming soon...