NW Newborn Clinical Guideline - Inguinal, Scrotal, and Genital Problems in Neonates

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

Examination after birth frequently reveals abnormalities in the inguinal, scrotal, or genital regions.
Some of these abnormalities require urgent attention; others require non-urgent referral, or parental reassurance.

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)