Pediatric Primary Care (89 page)

a.  Human chorionic gonadotropin (hCG) stimulation test differentiates between anorchia and undescended testicles.

b.  hCG can stimulate testosterone production in functioning testes and can also result in testicular descent.

G.  Differential diagnosis.

1.  Retractile testes.

2.  Intersex conditions.

H.  Treatment.

1.  If at 6 months of age testes remain undescended, intervention is necessary.

a.  Type of treatment depends on testes' location, patient's age, association with other anomalies.

b.  Reasons for treatment: reduced fertility, risk of tumor formation, trauma, torsion, repair of commonly associated defects such as inguinal hernia, psychological factors related to body image.

2.  Placing testes into scrotum does not decrease risk of testicular cancer but does provide easy exam for early detection. Risk of testes cancer in cryptorchid male is 1 in 2000.

3.  Orchiopexy or open surgery fixes testicle in scrotum and repairs hernia if needed. Laparoscopy can be used to locate nonpalpable testes or blind-ending vessels. There is also laparoscopic approach to orchiopexy.

4.  Hormone administration is not as successful as surgical approach but good option in high-risk patients and/or patients who have testes found in high scrotum or at external inguinal ring.

I.  Follow up.

1.  After surgery, examine incisions at 2–4 weeks, 4–6 months postop.

2.  Hormonal therapy: Examine at 1 month, 6 months post-treatment (higher risk of reascension).

3.  Yearly exam important; patient should be taught self-exam at puberty. Can be performed by local medical provider or pediatric urologist.

a.  Asymmetry of testes needs further evaluation.

4.  Retractile testes should be evaluated annually for possible ascension.

J.  Complications.

1.  Testicular atrophy is rated most serious complication of orchiopexy.

K.  Education.

1.  All males need to be taught self-scrotal exam at puberty. Especially important with history of undescended testicle due to increased risk of cancer.

2.  Prior to puberty, annual exam should be done. Scrotal pain needs to be evaluated immediately to rule out risk of testicular torsion, trauma, epididymitis, torsed testicular appendage.

II. HYDROCELE

A.  Etiology.

1.  Occurs when processus vaginalis (channel that allows testicle to move from abdomen to scrotum during development) remains patent.

2.  Difference between hernia and hydrocele is size of patent processus vaginalis and its contents.

a.  Narrow channel only allows fluid from peritoneal cavity to pass, resulting in hydrocele.

b.  Inguinal hernia: much wider, can allow both fluid and intestinal contents to pass.

B.  Occurrence.

1.  About 80% of infants are born with patent processus vaginalis; by end of first month of life, decreases to about 60%.

2.  By 18–24 months of age, only 20–30% remain.

3.  Rare in females: 6 males to 1 female.

C.  Clinical manifestations.

1.  Females: rare, usually presents with soft bulge in labia or inguinal canal.

a.  Bulge can represent ovary or hernia.

b.  Intersex conditions (especially testicular feminization): evaluate in female.

2.  Males: parents complain of scrotal swelling in one or both sides. Can be continuous or intermittent; size can fluctu1ate.

a.  Parent may describe bluish hue to scrotum, often small in size in morning and growing larger during day as fluid accumulates.

b.  History is very important because may not be present at time of exam.

D.  Physical findings.

1.  Hydroceles typically transilluminate with penlight to scrotum.

2.  Palpate testicle; if testicle cannot be palpated, can be seen by transillumination. If testes not seen or palpated, need scrotal ultrasound to differentiate.

3.  Classified as communicating (patent processus vaginalis) or noncommunicating. Almost all congenital hydroceles are communicating. Noncommunicating hydroceles do not fluctuate in size.

4.  Condition rarely painful unless associated with hernia that becomes incarcerated.

E.  Diagnostic tests.

1.  If any concern regarding testes, ultrasound imaging is indicated.

F.  Differential diagnosis.

1.  Inguinal hernia.

2.  Epididymitis.

3.  Retractile testes.

4.  Ectopic testes.

5.  Absent testes.

G.  Treatment.

1.  Generally safe to watch hydroceles until 18–24 months. After that age spontaneous resolution is uncommon.

2.  Earlier surgical intervention is indicated if hydrocele is large or associated with hernia secondary to increased risk of incarceration. Any abnormality of testes requires evaluation by scrotal ultrasound and could lead to earlier surgical intervention.

H.  Follow up.

1.  Child younger than 18 months of age should be examined every 6 months. If no change, no intervention indicated until 18–24 months.

2.  If hydrocelectomy is performed, see patient 4 weeks postop to evaluate incision and scrotum. If exam is normal, can return to routine annual exam with healthcare provider.

I.  Complications.

1.  Complications from hydroceles are rare.

2.  Risk of incarcerated hernia in patients with wide patent processus vaginalis.

3.  Postoperative complications are rare; include recurrent hydrocele, testicular atrophy, lysis of vas deferens.

J.  Education.

1.  Although hydroceles and hernias are not really associated with increased risk of testicular cancer, discuss importance of self-scrotal exam.

2.  Teach parents importance of regular exam during observation period.

3.  If any scrotal pain, child needs to be seen immediately.

III. EPIDIDYMITIS

A.  Etiology.

1.  Epididymitis refers to edema, irritation of epididymis or lining of testicle.

2.  Can occur from infectious/inflammatory cause.

3.  Can be difficult to distinguish epididymitis from testicular torsion because both can be quite painful.

4.  Can be sexually acquired; Neisseria gonorrhoeae and Chlamydia are common pathogens.

5.  Can be related to genitourinary abnormalities or urethra manipulation.

6.  Rarely associated with heavy lifting or straining that result in efflux of urine into vas deferens. If urine is infectious, then bacterial epididymitis can occur; if not, chemical inflammation develops.

B.  Occurrence.

1.  Rare in children before puberty unless child has genitourinary abnormality.

2.  More commonly occurs in sexually active adolescents.

C.  Clinical manifestations.

1.  Most likely to occur in postpubertal male and very young males.

2.  Those with imperforate anus, exstrophy, neurogenic bladder, any conditions requiring intermittent catheterization are more prone to this type of infection.

D.  Physical findings.

1.  Include sexual history in postpubertal male.

2.  Urethral discharge may be present.

3.  Often slow onset of pain that continues to become more severe.

4.  May have dysuria and see blood or discharge in urine.

5.  Physical exam yields swollen and inflamed scrotum.

6.  May complain of tenderness along epididymis.

7.  If testicle is tender and swollen, may also have orchitis.

8.  Up to 33% may be febrile.