Week 37: Swelling in the Groin

testicular and epididymal lumps

- determine the relation of the two organs - if testes has lump or is enlarged= TUMOUR UNTIL PROVED OTHERWISE - infective lesions in epididymis --> painful thickening and are diffuse - epididymal cysts --> located on upper pole; they transilluminate

saphena varix

- dilation of long saphenous vein in the groin - caused by valvular incompetence - varicose veins - swelling is soft and diffuse - EMPTY AND REFILLS ON RELEASE - COUGH IMPULSE AND FLUID THRILL - treatment is high saphenous ligation

varicocoele

- dilation of pam-uniform plexus - 90% are on the left due to the testicular vein draining into high pressure renal vein - asmyptomatic but you can feel a BAG OF WORMS - when laying flat the distended veins collapse - it increases scrotal temperature and inhibits sperm function - in child --> treatment to preserve spermatogenesis; percutaneous embolization or surgical ligation - in adults --> pain relief and treatment for oligospermia

Meconium ileus

- distal ileum is obstructed by thick viscid meconium and mucus plug - 95% have CF - distal colon and rectum are very small - presents soon after birth with lower intestinal obstruction - gastografin enema - laparatomy - dilated ileum is resected and a primary anastomoses is performed - pancreatic enzymes are given - physiotherapy - pulmonary treatment

Epispadia/epispadie

- dorsal meatus - dorsal curvature - 1:120k if isolate - 1:50 combined with bladder exstrophy - associated with incontinence due to sphincter insufficiency

Nephroblastoma (Wilms tumor)

- early childhood - tumour arises from embryonal renal tissue - locally invasive and metastasis - often a large abdominal mass - typical signs of cancers - US/CT/Biopsy - neoadjudant chemo followed by radial nephrectomy

inguinal hernias: direct

- more common in elderly man with weak abdominal muscle - leaves abdomen via transversals fascia and goes directly through the external ring - MEDIAL to inferior epigastric vessels - cannot be controlled by pressure on the internal ring

testicular tumors

- most common cancer in men between 30 and 40 - risk factor is undescended testes - 90% are germ cell, the rest sex cord-stomal tumois - mainly seminomas seinoma - fast growing, aggressive tumour; lung secondaries; cervical lymph nodes - lactic dehydrogenase leydig cell - excessive hormone secretion causing precocious puberty in child; testicular feminization in an adults - painless, progressively enlarging lump - secondary hydrocele if testicular capsule is involved - orchidectomy via inguinal approach to explore and treat stage 1 - radical radio therapy for seminoma; chemo

Necrotising enterocolitis

- most common condition needing surgery - 0.7 - 3.0 per 1k live births - mortality between 20-40% - premies, SGA, seriously ill - reduced blood flow to intestine causing relative ischemia - bowel then becomes invaded by gas-producing bacteria causing transmural inflammation, necrosis and perforation - clinical diagnosis --> bile-stained vomit; passage of blood per rectum; abdominal distension - x-ray shows intramural gas - may lead to peritonitis - bell's staging - vigours resuscitaiton with IV fluids, nasogastric decompression and ABS - lapratomoy and resection if treatment fails

idiopathic scrotal edema/idiopatisch scrotum oedeem

- most often found in boys between 5 and 9 - slow onset erythema (Starts in perineum); it can itch but not usually painful - normal testicular perfusion - treated with comfort measures and antihistamines or topical CS

Peyronie's disease/ziekte van Peyronie

- unknown aetology --> trauma during sex; duputren's contracture of palmar fascia - young to middle aged adults - slowly progressive asymmetrical fibrotic plaques develop in fascia around corpora cavernoa - visible and calcified on x-ray - PENIS BENDS TOWARDS THE AFFECTED SIDE ON ERECTION - intercourse is difficult and painful - may be spontaneous partial resolution over time - Nesbit operation --> straitening bénis on contralateral side; results in shorter penis - or excise plaques and replace with tunica vaginalis

Abdominal wall defects

- usually diagnosed early due to US during pregnacny - children have high risk of heat and water losses --> placed in incubator and wrapping in foil

Paraphymosis/parafimosis

- when retracted foreskin gets stuck behind gland - leads to venous return congestion and the glans swells - painful and medical emergency - common in elderly whose foreskin isn't correctly pulled forward after retraction for catherisation or cleaning - in children due to experimentations - local anesthesia to shove it back - if that doesn't work, then general anesthesia - when edema is gone, circumcision should be done - preputioplasty

ventral hernias

can be epigastric, (para)umbilical and incisional

abdominal problems

chronic pain - common, idiopathic and gradually resolves - psycholoigcal factors chronic constipation - presents as overflow incontinence - high-fibre diet, increase fluid intake, laxatives (osmotic and stimulant) - if severe => look for CF, hypothyroidism and Hirschsprungs upper GI bleeding -may be due to swallowed maternal blood - gastritis in older infants - bleeding disorders and coagulopathy are uncommon

pantaloon hernia

direct and indirect inguinal hernia together SADDLE BAG

midgut malrotation

exists

neonatal hydronephrosis

following 2 diseases = swelling of kidney due to urine build-up - if large then do diagnostic to see if surgery is needed

disorders of the penis

here

abdominal emergencies in the NEWBORN

some are repeat of theme 9 so i won't describe them

maldescended testes: treatment

start treatment at age 6 mo because chance of infertility is low - at latest the treatment should be finished by 18 mo - hormonal treatment with GnRH as nasal spray in BILATERAL causes - surgery!!! between 6 and 12 mo --> orchidopexy for palpable testes - for non-palpable --> check under anesthesia if not palpable - if this is the case, then DIAGNOSTIC LAPRAOSCOPY to look for spermatic vessels --> if they are then standard orchipexy or removal of atrophic one - if there is abdominal testes --> one step Fowler-Stephens or a two step orchidopexy (higher success rate; 6 mo apart - for peeping testis (close to internal ring) --> defended laparoscopically

psoas abscess

- descending infection from colon perforation

intestinal obstruction

- 1 in 1500 live births - complete obstruction --> maternal polyhydramnios - child vomits, is constipated and has abdominal distention - poor feeding and failure to pass meconium (80% of babies pass in 24 hour) - bilious mvomiting is serious - high obstruction --> lack of distal intestinal gas - low obstruction --> dilated loops of bowel - GI contrast for malrotation - malrotation with volvulus - hirschsprungs - meconium ileus - GI atresia and stenosis (small bowel atresia result from intrauterine mesenteric vascular accidents or failure of canalization rather than true abnormalities)

testicular torsion

- 1 in 4000 men before the age of 25 - usually occurs perinatally in 75% of cases (can lead to testicular atrophy or absence) or during puberty - pubertal cases are intravaginal (inside tunica vaginalis); perinatal cases extravaginal - risk factors --> bell-clapper deformity or loose epididymal attachment - sudden on set of pain in testes/lower leg/abdomen + vomiting - wide gait - PE --> tender and swollen testicle, sometimes in horizontal position and ABSENT cresmasteric reflex - NO PREHN'S SIGN --> relief of symptoms with elevation of scrotum - US --> absent arterial flow - it remain CLINICAL DIAGNOSIS - if perinatal --> infarcted, hard, dark nontender scrotal mass - if postnatal --> inflamed acute scrotum - ALWAYS DO SURGICAL EXPLORATION IF IN DOUBT - manual detorsion without anesthesia - outwards first as it works in 2/3 of cases; if pain increases then the otherway - bilateral orchidopxy within 24 hours --> controversial in neonatal torsion - prognosis depends on degree of torsion - 360º leads to severe atrophy in few hours - incomplete may not atrophy even after 12 hours - <6 hours = 90-100% testicular survival - 12 to 24 hours = 20-50% survival - 24 hours = 0-10% survival - if too late --> take it out to prevent formation of antibodies against sperm - suberftility is found in 40% of patient with unilateral torsion - the androgens are slightly higher but still in normal range

Hypospadia/hypospadie

- 1:125-300 boys - incidence is increased significantly - risk factors --> genetic, placental and environmental - urethral orifice is proximally displaced on ventral side (= lower side) - there's a ventral curvature (chordee, the more proximal the meatus, the worse) - and hooded appearance of foreskin as ventral par is absent - distal-anterior on glans or distal shaft - intermediate-middle on penis - proximal-posterior on scrotum, penoscrotal, perineal - mild = glandular or penile without chordee, micropenis or abnormal scortum - severe = scrotal or denial with chordee or scrotal abnormalities - diagnosis at birth - important to note length and curvature of penis on erection - corpus spongious may be divided - associated co-morbidities --> cryptorchidism, PPV --> look for other disorders of sexual development!!!!

renal, vesicle and urethral abnormalities

- 90% are detected at antenatal scan

other disorders of acute scrotum

- Henoch Schonlein --> pain, erythema and swelling; joints, skin, GI system are usually affected as well - Trauma --> medical history is clue; swelling, tenderness, contusions or haemtaomsa; US should look for rupture of tunica albuginea (causes haemtocevle, should be repaired)

chronic groin pain/chronische lies pijn

- May be caused by inflamed lymph nodes - or by strained muscle attachments - may also be referred from hip joints

priapism

- abnormally prolonged erection, lasting 4+ hour - painful and can occur without sexual stimulation - doesn't resolve after ejaculation - only affects corpora cavernosa - glans is flaccid HIGH FLOW ARTERIAL - artery ruptures; traum - uncommon and painless LOW FLOW VENOUS - obstructed venous outlet - can result in ischemia, fibrosis and impotence - vary painful - commonly a side effect of injected intracavernosal drugs to treat erectile dysfunction - icepacks and external compression - aspiration of blood - drugs that work on receptors (of vessels) - surgical shunt

paraumbilical hernias

- acquired - occur due to wall defect in linea alba; is above or below umbilicus - causes umbilicus to be pushed aside --> SMILE appearance - more common in females - small can resolve during first two years - if large then surgical repair -repair when present beyond 5 years

abdominal emergencies in older children

- acute abdomen --> appendicitis, testicular torsion

renal dysplasia

- agenesis --> bilateral is incompatible with life; males - hypoplastic - multicystic --> kidney is nonfunctional; most spontaneously regress - ectopia - horsehoe kidney --> turners

Neuroblastoma

- also early childhood and embryonal - highly malignant - arises from sympa NS tissue in adrenal gland or sympathetic chain - surgical resection, chemo and radio - poor prognosis

scrotal lumps or swelling

- determine if swelling arises in groin, scrotum or spermatic cord by palpating the cord at scrotal neck *hernia = cord is broader *cyst/varicocele of cord is easily recognised *lumps = cord is normal diameter

vesicoureteral reflux (VUR)

- anatomical abnormality --> ureteric insertion/ectopic or duplex ureters/congenital megaureters - secondary --> bladder outlet obstruction, neuropathic bladder - abnormal storage or emptying of urine - ascending infecions - lower tract infections aggravate reflux - leads to vicious cycle of infection, bladder instability, reflex and dysfunctional voiding - leads to renal scarring and reflux neuropathy --> kidney damage --> renal insufficiency and hypertension - dilation on US - UTI's - in older children --> incontinence, dysuria, mimics appendicits - micturating cystography and isotope scan - minimise risk of UTI - continuous AB chemotherapy - regular follow-up - surgical correction/reimplanting ureter/injection of reflux at the junction - lifelong monitoring for hypertension (and function if bilateral)

congenital penile curvature/aangeboren penis kromming

- asymmetry of cavernous bodies --> when one stops growing during embryogenesis - can also be due to tethering - most ventral curvatures = hypospadias or cavernous body dysplasia; more common - dorsal curvatures = epispadias - curvature of >30º is clinically significant - >60º interferes with sex - history of abnormal shape during erection; documentation with dick picks - if skin abnormalities --> degloving or plication - corporal rotation, use of dermal or tunica vaginalis grafts - if due to fibrosis, the fibrosis needs to be excised - loss of 2.5 cm of penis length

GI atresias and stenosis: esophageal

- atresia with TOF - VACTERL association - polyhydramnios and no gastric bubble - excessive frothy saliva around mouth - feeding must be postponed - diagnosis with nasogastric tube

epididymitis

- bacterial infection spreads from the bladder and urethra to epididymis via vas deferens - can also be caused by viruses (treatment is supportive - UTI or urethritis in 50-65 age group and the very young (mycoplasma) - in 15-30 year age group --> CHLAMYDIA and GONORRHOEA - exclude torsion in boys under 15 with no urinary symptoms - acute pain - tender and swollen epididymis sometimes with fever - scrotal skin is red and warm - PE --> elevation of testes may relief pain (PREHN'S SIGN); testes are in normal position - more gradual onset - urine culture --> pyuria or bacteriuria - US --> inflammation and HYPEREMIA on affected site - self-limiting so no ABS are given, unless its and STD - bed rest - if there is an abscess or necrosis testis, do surgery - after infection a kidney-bladder US and micturating-cysts-urethrogram should be done

GI atresias and stenosis: duodenal

- bile stained vomit - poor feeding, FTT - double bubble x-ray - duodeno-duodenostomy --> slow recovery

Pelviureteric Junction dysfunction

- birth till 4th decades - congenital condition that manifests as hydronephrosis and intermittent obstruction of PUJ - usually functional abnormality --> aperistaltic segment of ureter that lack muscle - leads to reflex or urine into kidney when ureter contract - this increases pressure and cause deterioration of kidney -stasis may predispose to infection and stone formation - diagnosed antenatally - regular postnatal follow up with US - surgery if --> loss of renal function >10%; increase in diameter of renal pelvis >35 mm - also if there are obstructive symptoms, stone formation, recurrent infection + obstructed isotope excretion curve - pyeloplasty - nephrectomy with very bad function

some background on hernias

- can de the result of unclosed PV which usually closes after tests descend (calcitonin gene-related peptide is related in response to testosterone) - spermatic cross is surrounded by 3 layer of abdominal muscle --> internal spermatic facias (transversals abdominis ), cremaster muscle (IO), external spermatic fascia (EO aponeurosis) - PV = canal of Nuck in females and leads to labia major

congenital diaphragmatic hernia

- caused by failure of the pleuroperitoneal canal to close - 1 in 3500 live births - posterolateral --> most are on the left - diagnosis is made at antenatal screening - abdominal viscera lie in the chest which places the mediastinum and prevents full growth of the lungs - classic signs --> cyanosis, mediastinal shift and empty abdomen - chest x-ray with an orogastric tube is conformation - cardiac malformations are associated - orogastric decompression - assited venitlation and low airway pressure - ECMO treatment - then surgery when baby is stable - overall mortality is 50-70%

Acute scrotum

- characterized by severe scrotal pain (except in neonates) with/without swelling and erythema - medical emergency due to possibility of testicular ischaemia D.D - appendix testis torsion - testicular torsion!! - epididymitis!! - (mumps) orchitis - idiopathic scrotal edema --> dermatitis or insect bite - hydrocele - incarcerated hernia - varicocele - scrotal hematoma - fat necrosis due to cold damage - Henoch-Schonlein purpura and other systemic diseases - trauma/sexual abuse - tumour

inguinal hernias: indirect

- congenital - more common in children - bowel enters the internal ring and then through the inguinal call to exit at the external ring - herniates into the PPV - lies LATERAL to inferior epigastric vessels - can pass to stratum - at first asymptomatic except for an inguinal swelling when straining - pressing over internal ring prevent it from reappearing at coughing - reducable - more prone to strangulation - history and PE for diagnosis

examophalos/omphalocele

- congenital hernia at the base of umbilical cord due to incomplete embryonic dis folding - covered by amniotic membrane and fuse with peritoneum - can also have a ruptured sac and present like gastroschisis - hernia out of umbilicus - defect is bigger than in gastroschsis - major if >5 cm - minor if <5 cm - often CONCOMITTANT CONGENITAL ABNORMALITIES - Beckwith-Wiedemaan syndrome --> may lead to hypoglycemia; babies are macrocosmic and have organomegaly - minor is associated with more chromosomal defects - give glucose directly - if condition is good --> instantly fix the defect (if minor) - the amniotic sac can be used as natural silo --> healing takes 4-8 months and still requires definitive repair after this time

posterior urethral valves

- congenital mucosal folds in the posterior urethra that impede urinary flow - can be detected on antenatal US --> olgihydramnios, small thick-walled bladder; bilateral hydronephrosis - if not, then obstruction becomes apparent after life - if olgihydramnios is severe there is pulmonary hypoplasia - if born --> urethral cauterization; correct electrolyte abnormalities - US and micturating cystography confirms the diagnosis - definitie treatment is ablating the valves - renal replacement therapy or transplantation is needed in 50% - bladder augementation

epididymal cyst and spermatocele

- cysts transilluminate - multiple cysts in upper pole - painless scrotal swelling - young age group - spermatocele --> may present as third testis

Maldescended testes/cryptorchisme

- failure of testicular descent - most of the testes will descend spontaneously during first months of life (at 3-6 months) - bilateral condition in 30% - 80% are palpable --> can be either inguinal, ectopic or rectractile - most commonly found in externall ring - retractile testis have overreactive cremasteric reflex; can be milked back in; MOST COMMOHNLY - non-palpable one --> inguinal or ectopic - 50% are intra-abdominal; 20% are absent due to genesis or in-utero torsion; 30% are atrophic - atrophic = secondary to trauma, iatrogenic or androgen deprivation; may be trapped due to hernia surgery or trauma - absent = antenatal torsion, orchidectomy - ectopic terstes are most commonly found in superficial inguinal pouch!! - can also be contralateral, suprapubic, perineal - if history shows prior inguinal surgery, secondary undescended testes due to entrapment is likely - ask for family history of cryptorchidism; genetic disorders; hormonal exposure - PE --> palpataion in sitting child - when a testis isn't palpable check whether contralateral testis is hypertrophied --> if this is the case, likely that the other is absent (Still do surgery) - if no testis bilateral --> signs of disorders of sexual development or endocrine abnormalities

male sterilisations

- family wish is completed - vascetomy --> local anestesia, little cost - removal of vas deferens - operation is successful when sperm count is negative on two successive times (1 month apart, occurs after 20-25 ejaculations) - failure rate is 1 in every 500 due to spontaneous vas reconnection - complications --> postoperative scrotal haematom, wound infection, failure, sperm granuloma, chronic debilitating pain

inguinal hernias: treatment

- first try to reduce the hernia by pushing it back - if that doesn't work or there are signs of bowel obstrcution/ischemia --> surgery - for kids --> herniotomy where the PPV is ligated and excised; repair of abdominal defect isn't necessary - MacVay repair in direct hernias with older men --> sewing transversals aponeurotic arch and IO aponeurosis closer together - Lichtenstein method of herniorrhaphy --> mesh - bowel resection if there is incarceration - truss in case a surgery is impossible - avoid driving and heavy lifting in recovery period

Hydrocele

- fluid collection between parietal and visceral layers of tunica vaginalisis - can also present as a cyst-like structure --> CORD-HYDROCELE or HYDROCELE OF CANAL OF NUCK - in adult its due to impaired resorption, but can also be caused by tumor or inflammation - sometimes PPV --> abdominal viscera can herniate (indirect congenital inguinal hernia) - usually minimal opening in PV --> COMMUNICATING HYDROCELE; these disappear at night - NON-COMMUNICATING --> imbalance between secretion and resorption of fluid; or trauma - non-reducible, NON-TENDER, fluid filled scrotum - transilluminatiion!! - US or scrotal incision if in doubt - in first 12 mo --> watch and wait for spontaneous resolution - Surgery is only indicated with concomitant inguinal hernia or when it persists >24 mo - surgery ligates the PPV when there is a communication - a scrotal approach is done when there is no communication or cord hydrocele - a persisting hydrocele can lead to necrotising fascia = Fournier's gangrene

femoral hernia

- formed by protrusion of peritoneum into potential space of femoral canal; may contain momentum or small bowel - less common - more common in females - incidence increases with age - medial to the inguinal canal - 10-20% are bilateral - 40% present with strangulation - small lump below inguinal ligament - aren't reducible and have no cough impulse - strangulated --> grape like and unimpressive yet have serious consequences - surgery is preventative - consists of removing the sac and suturing the medial part of the inguinal ligament to the pectineal fascia --> narrows femoral canal

Enlarged inguinal lymph nodes

- generalised lymphadenopathy - systemic infection - drain abdominal wall, lower back, perineum, anal canal, scrotal skin, penis and whole lower limb (NOT TESTES --> para-aortic) - present with pain or lump but often discovered incidentally - usually mobile but become fixed when infiltrated by tumour - diagnosis is by exclusion - history of infection, symptoms of tumors - US or biopsy can be performed

hypospadie: treatment and complications

- hormonal treatment with DHT or b-CG --> penis is small or proximal hypospadias - indications for surgical correction --> abnormal urinary stream, severe curvature, cosmetic aspect - then at 6-18 mo surgery to form neo-urethra with foreskin and correcting curvature - mild cases --> one step tubularised insides plate urethroplasty - severe cases --> on-lay urethroplasty or a two stage procedure - DON'T DO CIRCUMCISION - long term follow up is needed for urethral strictures, voiding dysfunction and recurrent penil curvatures - penis size may be unsatisfactory

Anorectal abnormalities

- imperforate anus is either higher or low depending on whether the bowel terminates at the levator ani - usually a fistula is present as well - low malformation --> fistula opens to skin anterior to sphincter and meconium may pass - high malformation --> fistula to urethra in male vagina - examine perineum for fistuka - if one isn't found --> with 24 hours to examine perineum under anaesthesia - if one isn't found --> colostomy - in low lesions --> operations via perineum; anoplasty - high lesions require colostomy followed by reconstructing sphincter mechanisms

abdominal emergencies in infants and young children

- incarcaerated inguinal hernia - congenital hypertrophic pyloric stenosis --> males; hypolcholaremic alkalosis; aciduria due to dehydration; progressive and projectile; ravenous child - intussusception --> season increase in spring and auto due to virus; sausage-shaped mass; recurrent jelly still, drowsiness, venous infarction, vomiting; air enema - swallowed foreign body --> sharp is removed, magnet is removed, batteries are dangers; propulsive agents and laxatives can speed up; coin should be pooped out within a week

balano-posthitis

- infective inflammation of glans - children - candida or fall bacteria

orchitis

- inflammation of the testis - bacterial orchitis is rare - viral --> post-pubertal boys due to mumps - extremely sensitive testis with hydrocele - symptomatic treatment

failure to pass meconium

- meconium ileus - Hirschsprung's

GI atresias and stenosis: jejunoileal atresia

- mesenteric vascular accident - bile stained vomiting - visible peristalsis and abdominal distention - proximal bowel is hypertrophied - presenting signs depend on level *low = meconium ileum or hirschspurngs *high = duodenal atresia or malrotations - associated with CF

Phimosis/fimosis

- mostly physiological in children; incidence decreases with children - usually when continence is achieve, 95% of boys have retractile foreskins - with phimosis, there is a fibrotic ring at end of foreskin which prevents retraction --> stricture of preputial meatus PRIMARY - caused by fibrosis - candida - chronic foreskin irritation with spraying of urine - ballooning of foreskin - hygiëne is enough and give it time - high class steroid creme - only circumcise when there is recurrent infection - preputioplasty SECONDARY (25%) --> balanitis xerotica obliterans - happens around age of 8 - white fibrosis non-retractile foreskine and plaque - form of LS - circumcision!!

femoral aneurysm

- not as common - can occur as part of generalized aneurysmal disease - patients over 65 years, male - diagnosis is clinical - lies below the midpoint of the inguinal ligament - EXPANSILE PULSATION

epigastric hernias

- occur in the midline through a defect in the linea alba - tiny - occur in males - most are asymptomatic and time - episodic sharp pain on exertion - <1 cm --> direct suture repair - if larger, mesh repair

umbilical hernias

- occur through umbilical cicatrix - females, obesity and poor musclee tone - can be asymptomatic or very painful - small can resolve during first two years - if large then surgical repair -repair when present beyond 5 years

patent processus vaginalis

- only used for communicating hydrocele - wait and see --> most can resolve by the age of 2 - herniotomy

formation of rectum and anal canal

- primitive hindugt forms cloaca and a septum dived it into anterior compartment (urinary and genital tract) and posterior compartment (rectum and upper anal canal) - lower anal canal develops from ECTODERMAL invagination

Inguinal hernia/liesbreuk: epidemiology, risk factors

- protrusion of the peritoneum through a congenital or acquired opening of the abdominal wall - can consist of the intestines, greater momentum, bladder wall or ovatier - 5:1 for males - more common on the right side - for children --> between 6 mo and 5 years of age; PPV - risk factors --> increased abdominal pressure (ascites, dialysis, constipation), prematurity, cryptorchidism, CF, hip dislocations, connective tissue disorders, myelomeningocele, mucopaly saccharidoses

Penile carcinoma

- rare - poor hygiene, HPV - elderly - SQUAMOUS CELL which are well-differentiated - arise from inner surface of foreskin or the glans penis near coronal slucus - it invades locally and tens to penetrate distal urethra - well advanced before irregular lump, bleeding or discharge is noticed - may be hidden under foreskin - local surgical excision or glansectomy with reconstruction - advanced --> penectomy and block dissection of involved nodes - radiotherapy in stage 1 and for palliation

ectopia vesicae/bladder exstrophy/blaas extrophie

- rare and complex - bladder is exposed on abdominal wall -result of non-fusion of caudal abdominal wall - children often have epispadias and hip malrotations - sphincter are non-functional --> leaking of urine - surgical closure

Hirschsprung disease new

- rectal biopsy is diagnostic - rectal examination may cause explosive release of air and meconoium - severe form of enterocolitis may occur --> danger of disease decreases with age - surgery is delayed until child reaches 10kg - initial colostomy to allow baby to feed and grow - rectal washout - removal of ganglionic bowel and then a pull-through

circumscision

- reduces hiv tranmission and penile carcinoma - urethral meatus should be checked for stenosis

inguinal hernias: incarceration and complications

- risk factors are young age and prematurity - crying child with a NON-REDUCIBLE bump, swollen or cyantic testis; intermittent pain and vomiting (sign of bowel obstruction) - it should be reduced asap - if successful then sac resection 48+ hours later due to edema - acute surgery is required if it can't be reduced - strangulation --> bloody stools, vomiting, peritonitis and abdominal distention; DON'T TRY TO REDUCE; lump is tender and red - Testicular atrophy (esp after incarcerated) - Infection - postoperative haematoma or persisting hydrocele - chronic groin pain due to nerve trapping - cord or testis damage - Recurrence --> prematurity, incarcerated hernia, improper techniques, missed femoral hernia, poor musculature or return to heavy work is soon, diabetes or smoking which impair healing

appendix testis or epididymis torsion/torsie van de appendix testikel

- rudimentary tissues from Mullerian and Wolffian ducts - most frequent cause of acute scroumt - can be wrongly diagnosed as epididymitis or epididymo-orchitis - often chorus in boys between 7 and 10 years old - isolated tenderness of superior pole - BLUE DOT SIGN! --> not has this - more localized pain - exploration is not needed unless diagnosis si not certain - Self-limiting (becomes a calcified free body) - comfort measures --> limiting activity and applying warming bandages - NSAIDs - only do surgery with persistent pain

gastroschisis

- small defect near umbilicus (usually on the right) thought to be rupture of a physiological hernia in the cord at 6-10 weeks gestation - risk of bowel ischemia or atresia -bowel malrotation - either direct reduction into the defect and closure or a silo procedure (Reduction in 7-10 days followed by definitive repair)

lumps in the groin

- swelling and lumps account for 10% of surgical referrals - hernia is most common cause special points during examination - examine both lying down and standing up --> standing should reveal hernia - test cough impulse --> present with inguinal - example reducibility --> inguinal are partially reducible but this disappears over time; femoral are nerve - investigate origin, inguinal ligament and pubic bone --> inguinal are above ligament and lie more medial than femoral; other causes of lumps are below - take age into account --> indirect occur in younger patients

maldescended testes: complications

- testicular atrophy - torsion or trauma --> extravaginal - cosmetic appearance and psychological impact - lower fertility with unilateral - when bilateral stays untreated --> azoospermia (75%), oligospermia (100%) - when treated bilateral --> 75% are sub fertile; 42% infertile - malignancy --> self-examination

lower GI bleeding

NEONATES - anal fissure --> straining to pass large hard stool; pain at defecation; DRE is impossible; conservative treatment of constipation and pain - NEC - malrotation OLDER INFANTS - polyps --> always solitary in rectum or sigmoid colon; may be constipation, pain without fissure, prolapsing anus; resection - rectal prolapse --> common during first 2 years; can be gently manipulated back; stool softeners, hypertonic saline to induce fibrosis - perianal abscess --> common; due to infection of anal gland; drainage + opening of the entire tract - Meckels' diveritculum --> distal ileum near ileocaecal junction; usually asymptomatic; diverticulitis may mimic appendicitis; should be resected with 2 cm of normal ileum and then an anastomosis is formed

incisional hernias

are an iatrogenic hernia occurring in 2-10% of all abdominal operations secondary to breakdown of the fascial closure of prior surgery. - They are typically anterior and occur along the site of the incision or ostomy bag - Manifestation of this hernia occurs within the first year post surgery.

physiological differences between adults and children

neonate = until age of 28 days infant = up to 1 year child = between 1 and 18; young up to 2 year - basal metabolic rate is higher - blood volume is higher in relation to the body weight but is 250 ml - small fluid volume and fluid requirements are high as kidneys are less able to concentrate urine --> fluid deficiencies and electrolyte imbalances occur rapidly - low glycogen storage --> rapid hypoglycemia - decreased ability to regulate temperature --> large SA, poor vasomotor control and inability to shiver - immature liver --> physiological jaudnince - prothrombin production is reduced --> PROPHYLACTIC VITAMIN K - impaired immunological defenses

sliding hernia

visceral contents lie behind and outside the peritoneal sac - commonly with left groin involving the descending and sigmoid colon