Inguinal, Scrotal and Genital Problems in Neonates
 

 

Reviewed by Carl Kuschel and Philip Morreau (Paediatric Surgery)
June
2006
Hydrocoele Inguinal Hernia Undescended Testes Testicular Torsion
Torsion of the Testicular Appendages Penile Torsion "Buried" Penis Hypospadias
  Microphallus Other Causes  
Problem Description Clinical findings Management

Hydrocoele

Persistence of the processus vaginalis results in peritoneal fluid in the scrotum around the testis or spermatic cord
  • Swelling in the scrotum
  • Can be unilateral or bilateral
  • Skin may have bluish discolouration if large
  • Can fluctuate in size (if communicating)
  • Has a distinct upper margin
  • Transilluminates
  • Non-tender
  • Rare in females
  • Careful examination to ensure that testis is present and that there is no inguinal hernia
  • Reassurance
  • Surgical review if still present at 18 months or diagnostic uncertainty at any age

Inguinal hernia

Swelling in inguinal region (can extend to scrotum in males, or to labia in females) secondary to persistence of a wide processus vaginalis, with herniation of bowel (or, in females, the ovary)

More common in premature infants

More common in infants with raised intra-abdominal pressure

  • Inguinal swelling (can extend to the scrotum in males or labia in females)
  • Difficult to define the upper margin of the swelling (unlike hydrocoeles)
  • Usually reducible
  • Will be firm and tender if incarcerated
  • May transilluminate
  • If reducible and infant in NICU – non-urgent surgical referral for surgical repair prior to discharge
  • If reducible and infant at home – discuss with surgical registrar (will usually be repaired within 1-2 weeks)
  • If incarcerated, urgent surgical referral

Undescended testes (cryptorchidism)

May affect 2% of males.

Testes should be in the scrotum by birth/term. In these infants a testis can be said to be undescended by 3 months

In preterm infants this can be confidently diagnosed by 6 months post delivery

  • The scrotum may be smooth and underdeveloped or may look normal
  • Assess penile size and any abnormalities (note: undescended testes and hypospadias indicates an intersex disorder till proven otherwise)
  • Examine infant for other abnormalities (association with other syndromes, e.g. Smith-Lemli-Opitz, Oto-Palato-Digital, Prune Belly Syndrome)
  • If possible intersex disorder, refer to the ambiguous genitalia guideline
  • For males with undescended testes, refer to paediatric surgical clinic
  • If remain undescended, orchidopexy usually performed within the first year. If associated with a hernia refer as per hernia guidelines

Testicular torsion

In neonates, typically perinatal in origin

Is also associated with undescended testes

  • Tender, red firm and enlarged testis
  • Will not transilluminate
  • Usually unilateral (but can be bilateral)
  • Differential includes testicular tumour
  • Urgent referral to paediatric surgery
  • Imaging (ultrasound with Doppler) may be useful but should not delay surgical referral

Torsion of the testicular appendages

May mimic testicular torsion.

Testicular appendages are only palpable when torsion has occurred

  • May see a blue dot (ecchymosis) on the scrotum
  • Urgent referral as per torsion with no ultrasound

Penile torsion

Counterclockwise (usually) rotation of the penile shaft, with meatus pointing obliquely
  • Median raphe of the penis spirals to the meatus
  • May be associated with hypospadias
  • Non-urgent referral to paediatric surgery

“Buried” penis

Penile shaft is hidden under the pre-penile skin
  • Penis is buried under the suprapubic fat pad
  • Ensure penile length is normal
  • Non-urgent referral to paediatric surgery

Hypospadias

See hypospadias guideline

Microphallus

See ambiguous genitalia guideline

Other causes of groin/ scrotal swelling

A range of other conditions may cause scrotal swelling including:
  • Ectopic or strangulated gonads
  • Varicocoele (not in neonates)
  • Intra-abdominal (e.g. adrenal) haemorrhage
  • Pneumoperitoneum
  • Calcifications following healed meconium peritonitis
  • Testicular tumour
  • Epididymitis (in association with UTI)