Inguinoscrotal swellings are common surgical problem. All surgeons should know how to diagnose and manage all these conditions.

1. INGUINOSCROTAL SWELLINGS
A PROBLEM ORIENTED APPROACH

2. INGUINOSCROTAL SWELLINGS
A PROBLEM ORIENTED APPROACH
Dr.B.SELVARAJ MS;Mch;FICS;
ASSOCIATE PROFESSOR IN PEDIATRIC SURGERY
PONDICHERRY INSTITUTE OF MEDICAL SCIENCES
PONDICHERRY- 605014; INDIA
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3. INGUINOSCROTAL SWELLINGS
A PROBLEM ORIENTED APPROACH
OBJECTIVES
Recognise various conditions
Clinch correct diagnosis
Appropriate investigations
Appropriate early treatment
Appropriate surgical referral
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4. INGUINOSCROTAL SWELLINGS
Hernia Hydrocele
Causes
Torsion Testis &
Testicular Appendages
Epididymo-orchitis
Testicular Tumor Inguinal Lymphadenitis
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5. INGUINAL HERNIA
Persistent patent Processus Vaginalis- always indirect
Male:Female ratio 9:1
Peak incidence in 1st year of life-common in premies
Rt side- 60%
Lt side-25%
Bilateral-15%
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6. INGUINAL HERNIA
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Inguinal swelling when baby cries
Silk glove sign+
Simple hernia reducible
Obstructed hernia Not reducible
Strangulated hernia Tense Tender
Bilious vomiting in obstructed strangulated hernia

7. INGUINAL HERNIA
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8. INGUINAL HERNIA- Complications
Incarceration – Premature Neonates1yr 50%
-- Mature Neonates 1yr 30%
-- Mature Neonates 1yr 15%
In huge hernia – Testicular atrophy in boys
-- Ovarian atrophy in girls
Strangulation -- Gangrenous bowel +
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9. INGUINAL HERNIA
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10. INGUINAL HERNIA- Operative
Management
Inguinal skin crease incision
Incise External oblique aponeurosis and
extend into superficial ring
Dissect off hernial sac from cord
structures
High ligation of sac Herniotomy
Close wound in layers
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11. INGUINAL HERNIA- Operative
Management
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12. INGUINAL HERNIA- Operative
Management
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13. INGUINAL HERNIA-Postop
complications
Injury to Vas deferens vessels
Testicular atrophy due to testicular artery injury
Recurrence due to failure of high ligation
Wound infection in obstructed strangulated hernia
Hydrocele when distal hernial sac around testis hasn’t been
left open
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15. HYDROCELE
Peritoneal fluid collection in processus vaginalis
Diurnal variation in size
Positive fluctuation Transillumination
Regression spontaneous closure of processus vaginalis
by 1 to 1.5 yrs
Get above the swelling+ve
Traction test +ve in Encysted Hydrocele
Huge Hydrocele Pressure atrophy of Testis
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16. HERNIAHYDROCELE-Types
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17. HYDROCELE
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18. HYDROCELE- Operation
High ligation of processus vaginalis-
Herniotomy
In Encysted Hydrocele in addition incise
and evacuate fluid; Don’t close incision
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20. TORSION TESTIS
Twisting of Testis StrangulationNecrosis
Common in Neonates at puberty
Affects Left side more
An Undescended Testis undergoes torsion frequently
Swollen hemiscrotum with edema erythema
Tender Testis
Cremasteric reflex- Absent
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21. TORSION TESTIS-TYPES
In Neonates In Adolescents Very rare
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Deformity

22. TORSION TESTIS
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23. TORSION TESTIS-Differential
Diagnosis
Epididymo
orchitis
Incarcerated
Hernia
Idiopathic
scrotal edema
Torsion of
Testicular
Appendages
Hydrocele
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24. TORSION TESTIS-Doppler
Study
Central testicular blood
flow Normal Testis
No Central testicular blood
flow but excessive peripheral
blood flow
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25. TORSION TESTIS-Management
Ipsilateral sideExploration,Detorsion and Fixation
orchiopexy
Contralateral side Exploration and Fixation
orchiopexy
In doubtful cases Nonavailability of Doppler scan
Better to explore rather than delay treatment
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26. Torsion of Testicular Appendages
Hydatid of testis epididymisRemnant of obliterated
Mullerian ducts
Sudden Swelling and redness of hemiscrotum
Tender Testis
‘Bluedot sign’ +ve
Cremastric reflex intact
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27. Testicular Appendages
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28. Torsion of Testicular Appendages
Bluedot sign
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29. Torsion of Testicular Appendages
Management
Explore Excise torsed appendages
In delayed cases 48 hrs
conservative treatment with
antibiotics
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31. EPIDIDYMOORCHITIS
Inflammation of epididymis Testis due to infection or trauma
Sudden onset of pain in a hemiscrotum
Commonly associated with UTI
Thickened Tender epididymis
Pain relief by elevation of hemiscrotum Prehn’s sign
Can be treated conservatively with antibiotics and
antiinflammatory drugs
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32. EPIDIDYMOORCHITIS
USG Scrotum
Thickened Epididymis
Reactive Hydrocele
Thick Scrotal wall
Doppler Scan
Excessive blood flow to Epididymis
Normal Testicular parenchymal blood flow
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34. TESTICULAR TUMORS
Account for 1% of all pediatric malignant tumors
Most are germinal in origin Malignant
Present before the age of 3 yrs
Endodermal sinus tumor Commonest malignant tumor
TeratomaCommonest benign tumor
Rhabdomyosarcoma Arise from paratesticular tissues
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35. TESTICULAR TUMORS
Present with painless hard testicular swelling
Scrotal skin is usually free
Estimation of Alfa-feto-protein Human chorionic
gonadotrophin- Tumor markers
Needle biopsy- contraindicated
High orchidectomy with retroperitoneal lymph node dissection
Pot op Radiotherapy or adjuvant chemotherapy
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36. TESTICULAR TUMORS
USG Testis
Anterior Hypoechoic
areaTesticular Tumor
Doppler Scan
Hypovascular intratesticular
tumor
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37. TESTICULAR TUMORS
High Orchidectomy
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39. INGUINAL LYMPHADENITIS
Look for any primary focus of infection or neoplasia
in drainage area – from umbilicus to toes
Most are due to reactive hyperplasia and responds
to antibiotics
Some may be due to Koch’s or Lymphoma
In persistent cases always do Excisional Biopsy
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