Fifth Stage Pediatric Surgery Dr. Moayed – Lecture 4

B. Inguinal hernias, Hydroceles, Undescended & Ectopic Testis
A hernia is defined as a protrusion of a portion of an organ or tissue through an
abnormal opening. For groin (inguinal or femoral) hernias, this protrusion is into a hernial
sac. Whether or not the mere presence of a hernial sac (or processus vaginalis) constitutes
a hernia is debated. Inguinal hernias in children are almost exclusively indirect type. Those
rare instances of direct inguinal hernia are caused by previous surgery and floor
disruption. An indirect inguinal hernia protrudes through the internal inguinal ring, within
the cremaster fascia, extending down the spermatic cord for varying distances. The direct
hernia protrudes through the posterior wall of the inguinal canal, i.e., medial to deep
inferior epigastric vessels, destroying or stretching the transversalis fascia. The
embryology of indirect inguinal hernia is as follows: the duct descending to the testicle is
a small offshoot of the great peritoneal sac in the lower abdomen. During the third month
of gestation, the processus vaginalis extends down toward the scrotum and follows the
chorda gubernaculum that extends from the testicle or the retroperitoneum to the
scrotum. During the seventh month, the testicle descends into the scrotum, where the
processus vaginalis forms a covering for the testicle and the serous sac in which it resides.
At about the time of birth, the portion of the processus vaginalis between the testicle and
the abdominal cavity obliterates, leaving a peritoneal cavity separate from the tunica
vaginalis that surrounds the testicle.
Approximately 1-3% of children have a hernia. For infants born prematurely, the
incidence varies from 3-5%. The typical patient with an inguinal hernia has an intermittent
lump or bulge in the groin, scrotum, or labia noted at times of increased intra -abdominal
pressure. A communicating hydrocele is always associated with a hernia. This hydrocele
fluctuates in size and is usually larger in ambulatory patients at the end of the day. If a
loop of bowel becomes entrapped (incarcerated) in a hernia, the patient develops pain
followed by signs of intestinal obstruction. If not reduced, compromised blood supply
(strangulation) leads to perforation and peritonitis. Most incarcerated hernias in children
can be reduced.
The incidence of inguinal hernia (IH) in premature babies (9-11%) is higher than full-
term (3-5%), with a dramatic risk of incarceration (30%). Associated to these episodes of
incarceration are chances of: gonadal infarction (the undescended testes complicated by
a hernia are more vulnerable to vascular compromise and atrophy), bowel obstruction
and strangulation. Symptomatic hernia can complicate the clinical course of babies at
NICU ill with hyaline membrane, sepsis, NEC and other conditions needing ventilatory
support. Repair should be undertaken before hospital discharge to avoid complications.
Prematures have: poorly developed respiratory control center, collapsible rib cage,
deficient fatigue-resistant muscular fibers in the diaphragm that predispose then to
potential life-threatening post-op respiratory complications such as: need of assisted
ventilation (most common), apnea and bradycardia, emesis, cyanosis and re-intubation
(due to laryngospasm). Independent risk factors associated to this complications are (1)
history of RDS/bronchopulmonary dysplasia, (2) history of patent ductus arteriosus, (3)
low absolute weight (< 1.5 Kg), and (4) anemia (Hgb < 10 gm- is associated to a higher
incidence of post-op apnea). Postconceptual age (sum of intra- and extrauterine life) has
been cited as the factor having greatest impact on post-op complications. These

observations makes imperative that preemies (with post conceptual age of less than 45
weeks) be carefully monitored in -hospital for at least 24 hours after surgical repair of their
hernias. Outpatient repair is s afer for those premature above the 60 wk. of postconceptual
age. The very low birth weight infant with symptomatic hernia can benefit from epidural
At times, the indirect inguinal hernia will extend into the scrotum and can be
reduced by exter nal, gentle pressure. Occasionally, the hernia will present as a bulge in
the soft tissue overlying the internal ring. It is sometimes difficult to demonstrate and the
physician must rely on the patient's history of an intermittent bulge in the groin seen with
crying, coughing or straining.
Elective herniorrhaphy at a near convenient time is treatment of choice. Since risk
of incarceration is high in children, repair should be undertaken shortly after diagnosis.
Simple high ligation of the sac is all that is required. Pediatric patients are allowed to
return to full activity immediately after hernia repair. Patients presenting with
incarceration should have an attempt at reduction (possible in greater than 98% with
experience), and then admission for repair during that hospitalization. Bilateral
exploration is done routinely by most experienced pediatric surgeons. Recently the use of
groin laparoscopy through the hernial sac permits visualization of the contralateral side.
Approximately 1% of females with in guinal hernias will have the testicular
feminization syndrome. Testicular feminization syndrome (TFS) is a genetic form of male
pseudohermaphroditism (patient who is genetically 46 XY but has deficient
masculinization of external genitalia) caused by compl ete or partial resistance of end
organs to the peripheral effects of androgens. This androgenic insensitivity is caused by
a mutation of the gene for androgenic receptor inherited as an X -linked recessive trait. In
the complete form the external genitalia appear to be female with a rudimentary vagina,
absent uterus and ovaries. The infant may present with inguinal hernias that at surgery
may contain testes. Axillary/pubic hair is sparse and primary amenorrhea is present. The
incomplete form may represent un dervirilized infertile men. Evaluation should include:
karyotype, hormonal assays, pelvic ultrasound, urethrovaginogram, gonadal biopsy and
labial skin bx for androgen receptor assay. These patients will never menstruate or bear
children. Malignant degener ation (germ cell tumors) of the gonads is increased (22 -33%).
Early gonadectomy is advised to: decrease the possible development of malignancy,
avoid the latter psychological trauma to the older child, and eliminate risk of losing the pt
during follow -up. Vaginal reconstruction is planned when the patient wishes to be sexually
active. These children develop into very normal appearing females that are sterile since
no female organs are present.
Inguinal hernias are the most common surgical pathology seen in infants and
children. A lump in the inguinal canal area of a newborn or infant female is most probably
an ovarian incarcerated inguinal hernia. On very rare occasion the lump is a testis in a
child with testicular feminization syndrome. Clinically the irr educible ovarian lump is
usually asymptomatic, movable and non -tender mass within the labia majora. Ultrasound
can determine the nature of the gonad present. The main problem with an ovarian hernia
in infants is the incidence of ovarian torsion associated before repair. Ovaries trapped
within inguinal hernias undergo torsion far more commonly than ovaries and tubes in the

normal pelvic position increasing the chances of infarction. Torsion can occur at any time
after diagnosis of the hernia. The incarcerate d ovarian pedicle is narrowed and lengthened
within the defect and the internal ring serves as a fixed point around which a twist can
occur. The risk of torsion and infarction creates the view that ovarian hernias should be
repaired at the earliest electiv e opportunity if they can be reduced manually. Children
with edema, tenderness or skin discoloration in the inguinal area should be repaired
immediately. Early recognition and management of this condition reduce the risk of
gonadal infarction. During repai r surgeons must be aware that in 20% of girls with inguinal
hernia, the fallopian tubes occasionally with the ovary or uterus comprise the wall of the
hernial sac (sliding component ).
Incarceration and strangulation are the most dreaded complications of inguinal
hernias in children. Incarceration refers to viscera (bowel, ovaries, and bladder) that
protrudes through the in guinal defect and cannot return back to its anatomical position
without manipulation or surgery. Bowel incarceration in infants with inguinal hernia is a
notable cause of intestinal obstruction in this age group. Strangulation is the ischemic
effect caused on the trapped viscera by the incarcerated defect. Incarceration occurs in
almost one -third of inguinal hernias. It is more common in children less than one year of
age and males. With prolonged incarceration there can also occur testicular infarction. In
infant girls the normal anatomy is altered when an ovary is trapped in a hernia sac, and
these changes make torsion more likely. This risk warrants treating the asymptomatic
irreducible ovary as any other incarcerated hernia with urgency. Incarceration in creases
the rate of complications, is seen in a younger population of children and increases
hospital stay. Children with incarcerated hernia should have a trial of manual reduction
followed by prompt repair within the next five to seven days to avoid re -incarceration.
A hydrocele is a collection of fluid in the space surrounding the testicle between the
layers of the tunica vaginalis. Hydroceles can be scrotal, of the cord, abdominal, or a
combination of the above. A hydrocele of the cord is the fluid -fill ed remnant of the
processus vaginalis separated from the tunica vaginalis. A communicating hydrocele is
one that communicates with the peritoneal cavity by way of a narrow opening into a
hernial sac. Hydroceles are common in infants. Some are associated wi th an inguinal
hernia. They are often bilateral, and like hernias, are more common on the right than the
left. Most hydroceles will resolve spontaneously by 1 -2 years of age. After this time,
elective repair can be performed at any time. Operation is done through the groin and
search made for an associated hernia. Aspiration of a hydrocele should never be
attempted. As a therapeutic measure it is ineffective, and as a diagnostic tool it is a
catastrophe if a loop of bowel is entrapped. A possible exception to this is the
postoperative recurrent hydrocele.
Abdomino -scrotal hydrocele (ASH), also known as "hydrocele en bissac", is a very
rare condition seen in infants consisting of a collection of fluid in the tunica vaginalis
extending through the inguinal can al into the abdominal cavity. Clinically, the child with
an inguino -scrotal hydrocele has an abdominal mass of variable size and firm consistency
characterized by increase in tension of the hydrocele when squeezing the abdominal mass
and vice versa. The ab dominal compartment can be retroperitoneal or properitoneal. An
increasing pressure within the hydrocele is transmitted above the deep inguinal ring

because of the inexpansible musculofascial covering of the inguinal canal. The diagnosis
of an abdomino -scr otal hydrocele is made with the help of ultrasound or MRI showing the
fluid filled cavities in both the abdominal (pelvic) and scrotal compartments in
communication. ASH should be differentiated from other cystic tumors of the abdominal
cavity such as hydr onephrosis, bladder diverticulum, mesenteric cysts and
lymphangiomas. ASH has been found to cause obstructive uropathy, reduced blood supply
to the testis or hemorrhage. Total excision of the abdominoscrotal hydrocele through an
inguinal approach is the pr oposed treatment of choice.
The undescended testis is a term we use to describe all instances in which the testis
cannot be manually manipulated into the scrotum. The testes form from the medial
portion of the urogenital ridge extending from the diaphragm into the pelvis. In arrested
descent, they may be found from the kidneys to the internal inguinal ring. Rapid descent
through the internal inguinal ring commences at approximately week 28, the left testis
preceding the right. Adequate amounts of male hormo nes are necessary for descent. The
highest levels of male hormones in the maternal circulation have been demonstrated at
week 28. Thus, it appears that failure of descent may be related to inadequate male
hormone levels or to failure of the endorgan to res pond.
The undescended testes may be found from the hilum of the kidney to the external
inguinal ring. A patent processus vaginalis or true hernial sac will be present 90% of the
time. The incidence is about 0.28% of the population, approximately 50% occurs on the
right, 25% on the left, and 25% occurring bilaterally.
The diagnosis of undescended testes is usually made by the parents or first
examining physician. The important point is the absolute necessity of distinguishing
between retractile testes and th e true undescended testes. Testes that can be drawn to
the scrotum, even if they retract again, are retractile testes and not undescended, the
squatting position may aid in helping descend the testes for exam. Retractile testis needs
no further surgical ma nagement.
Since Leydig cell degeneration can occur after age two, present recommendations
are for orchiopexy before age 2. Although testicular malignancy is rare, undescended
testes have a 40 -50 times higher incidence of developing seminomas. This can occu r in
the contralateral normally descended testis as well as the undescended testis. Surgical
repair does not reduce the incidence of malignancy, but does allow for examination and
earlier detection. Another reason for surgical repair is the higher incidenc e of trauma and
torsion in the undescended testis. Bilateral undescended testes may be initially treated
with a four -week course of human chorionic gonadotrophin. Approximately 15 -30% of
patients will have descent with this therapy. Surgical repair is most commonly performed
by a Dartos pouch technique. Laparoscopy helps in non -palpable undescended testis by
identifying those testes that did not developed, suffered an ischemic intrauterine event,
and in performing first stage Steven -Fowler technique.
Whenever a child is born with an empty scrotum, the physical examination should
include a diligent palpable search for the undescended testis in the inguinal, femoral,
perineal or medial thigh areas. Testes palpable in areas away from the normal descent
from the retroperitoneum to the scrotum are termed ectopic testis. An ectopic testis is

caused by misallocation of the ipsilateral genito -femoral nerve controlled stimulation
causing the gubernaculum to migrate to the wrong site because the chemota ctic signal is
arising from this wrong place. Testes palpable in the inguinal canal or found intra -
abdominally are termed undescended.
Compared with undescended testes, ectopic testes are extremely rare found most
commonly in the perineal ipsilateral area. Other sites include the femoral canal,
suprapubic region (at base of the penis), medial thigh, preperitoneal, umbilical,
contralateral scrotum or associated with gastroschisis. The perineal testis is particularly
subject to trauma.
Management is orchiopex y as soon as the diagnosis is established. The most
effective route of approach for repair is inguinal allowing replacement of the testis into
the corresponding hemiscrotum without difficulty. Other surgeons use a low scrotal
approach due to the low incide nce of concomitant hernia. Because of the histopathologic
features involved, prognosis is better than that associated with cryptorchidism.
C. Umbilical Hernias & Granulomas
Between the sixth and tenth gestational week, the developing gastrointestinal tract
is partially extruded into the umbilical cord with return into the abdomen by the tenth
week. By the time of birth, the umbilical ring has become entirely closed by the developing
abdominal wall except for the space occupied by the cord, which contains th e umbilical
vein, paired umbilical arteries, and the fibrous remnants of the urachus and
omphalomesenteric duct (yolk sac). After ligation of the cord, the vessels thrombosed and
the cord dries and sloughs off, leaving a granulating surface that heals by c icatrization
and is covered by epithelium. This is followed by scar contraction and retraction of the
umbilicus. It is believed that most umbilical hernias occur through the cephalad portion of
the umbilical ring, where the contracted scar around the oblit erated umbilical vein is less
dense than in the caudal portion of the scar. Umbilical hernias are very common,
especially in prematures, blacks, and certain syndromes, such as Down's. The incidence
decrease with age since many will close spontaneously. The diagnosis is made by physical
exam; there is a fascial defect at the umbilicus. Complications such as strangulation or
incarceration are extremely rare in children.
Umbilical strapping should not be done since it does not promote closure and may
lead to s kin erosion. Elective repair is usually delayed until after five years of age since
closure may occur spontaneously or the defect may get smaller, allowing easier repair.
Operative repair includes excision of the sac and horizontal one -layer closure throug h a
small infraumbilical incision.
Persistent umbilical swelling and discharge during the neonatal period is of serious
concern to both parents and physicians. Among umbilical swelling, the umbilical
granuloma is one of the most commonly seen condition in the pediatric practice. The
normal granuloma, a common inflammatory reaction to the resolving umbilical stump of
a newborn should disappear by the 2nd to 3rd week of life after proper hygiene. Persistent
beyond this time will need some type of therapy. Umb ilical granuloma is managed with
75% Silver nitrate stick application. Silver nitrate is not innocuous and when apply liberally
can cause a minor burn of the periumbilical skin area of the baby. Caution must be

observed while applying Silver nitrate; caref ul drying the umbilical exudate to prevent
periumbilical spillage, and discussion with parent that burns may occur but apparently
are not serious. Whenever Silver nitrate therapy fails and discharge persists, or contains
urine or fecal material, the physic ian should suspect that the child has either a patent
urachus or omphalomesenteric duct remnant as both conditions resemble the common
umbilical granuloma seen in general practice. Ultrasound studies of the periumbilical area
looking for a cyst, masses or fixed bowel loops can help determine the presence of such
congenital remnants. Management of the persistent umbilical granuloma is surgical with
double ligature, cauterization of the base or formal umbilical exploration.
D. Omphalocele and Gastroschisis
The three most common abdominal wall defects in newborns are umbilical hernia,
gastroschisis and omphalocele. Omphalocele is a milder form of primary abdominoschisis
since during the embryonic folding process the outgrowth at the umbilical ring is
insuffici ent (shortage in apoptotic cell death). Bowel and/or viscera remains in the
umbilical cord causing a large abdominal wall defect. Defect may have liver, spleen,
stomach, and bowel in the sac while the abdominal cavity remains underdeveloped in
size. The sa c is composed of chorium, Wharton's jelly and peritoneum. The defect is
centrally localized and measures 4 -10 cm in diameter. A small defect of less than 2 cm
with bowel inside is referred as a hernia of the umbilical cord. There is a high incidence
(30 -60 %)of associated anomalies in patients with omphalocele. Epigastric localized
omphalocele are associated with sternal and intracardiac defects (i.e., Pentalogy of
Cantrell), and hypogastric omphalocele have a high association with genito -urinary
defects (i. e., Cloacal Exstrophy). All have malrotation. Cardiac, neurogenic, genitourinary,
skeletal and chromosomal changes and syndromes are the cornerstones of mortality.
Antenatal diagnosis may affect management by stimulating search for associated
anomalies and changing the site, mode or timing of delivery. Cesarean section is
warranted in large omphaloceles to avoid liver damage and dystocia. After initial
stabilization management requires consideration of the size of defect, prematurity and
associated anomalie s. Primary closure with correction of the malrotation should be
attempted whenever possible. If this is not possible, then a plastic mesh/silastic chimney
is fashioned around the defect to cover the intestinal contents and the contents slowly
reduced over 5-14 days. Antibiotics and nutritional support are mandatory. Manage
control centers around sepsis, respiratory status, liver and bowel dysfunction from
increased intraabdominal pressure.
The exact embryology of gastroschisis is unclear. The defect is alw ays to the right
of the midline with a normally attached umbilical cord. Theories include failure of the right
lateral somatopleure to form properly, intrauterine rupture and intrauterine vascular
accident leading to ischemia of the right developing rectus . Associated anomalies are
rare, with an 11% incidence of atresia. Treatment is identical to omphalocele except more
urgent to avoid problems with the exposed bowel (dehydration and hypothermia). More
than 90% babies survived. Prenatal diagnosis has brough t a controversy toward optimal
mode of delivery (Cesarean vs vaginal). The appearance of the bowel is edematous,
matted and foreshortened due to exposure to amniotic fluid, and the constrictive vascular
effects of a small defect.

A giant omphalocele is defined as a defect larger than 10 cm in length that harbors
the liver. Prenatally diagnosed giant omphaloceles will need cesarean section as route of
birth to avoid fetal liver rupture. Management of giant omphalocele has a high morbidity
and mortality due to the defect size, visceroabdomi nal disproportion, and the associated
congenital and genetic malformations. The large size of the defect and small abdominal
cavity creates a situation where primary closure is almost impossible unless some sort of
stage reduction is tailored. Pulmonary hy poplasia, genetic defects and cardiac
malformation are the source of early mortality in these babies. The pendulum of
management of giant omphalocele has moved toward a more conservative initial
management using topical coverage creams to create granulatio n tissue and skin on top
of the membrane followed by repair of the ventral hernia much later in life when the
medical condition of the child permits. Silver sulfadiazine (Silvadene) provides a moist
wound healing environment that promotes epithelization an d simultaneously minimizes
the risk of invasive infection including antifungal coverage. Silver toxicity, though rare can
include seizures, peripheral neuropathy, ocular pathology, nephrotic syndrome, raised
liver enzymes, leukopenia and algiria. For small er size defects the use of silo, tissue
expanders, biologic mesh, vacuum -assisted closure or component separation technique
closure is indicated. Giant omphalocele is associated with deficits in developmental
achievements in most of the affected infants ra nging from mild to profound delays.
E. Epigastric Hernias
Congenital epigastric defects occur anywhere in the linea alba from the navel to the
xiphoid process. They represent almost 5% of all hernias defect that presents in children.
Most epigastric hernia s occur in the midline, are small (15 -25 mm), asymptomatic and
reducible. Multiple fascial defects can also be present in 20% of all cases. The defect might
arise congenitally from an abnormally wide orifice of a blood vessel during development
of the line a alba. The bump is the result of a piece of preperitoneal fat stuck through the
fascial defect. Tenderness is an unusual symptom while growth of the defect occurs with
time. Most surgeons recommend repair of the defect at the time of presentation. Repair
is an outpatient procedure done under general anesthesia with low morbidity and risk of
recurrence. Voluminous epigastric hernia (5 -10 cm) with a sac that contains epiploic
appendages or viscera (ileum loops, stomach) has also been rarely reported in infan ts.
F. Recurrent Inguinal Hernias
Inguinal hernias continue to be the most common congenital pathology in children
needing surgical repair early in life. Approximately 1 -3% of children have an inguinal
hernia. The incidence is higher in premature babies (3 -5%). Almost all inguinal hernias in
children are the indirect type (99%). The few direct hernias in children are the result of
previous surgery or inguinal floor disruption.
Management of inguinal hernias in infants and children is straightforward:
outpat ient surgery after diagnosis for most cases. The procedure consists of high ligation
of the hernial sac.
Incidence of developing a recurrent inguinal hernia is around 0.8%. Most
recurrences occur two years after the initial surgery. Several factors play a role in
increasing hernia recurrence. These are: 1) Missed sac or inadequate ligation of the

indirect sac. 2) Children operated for incarcerated inguinal hernias since tissue is more
friable and edematous at the time of surgery. 3) Infection of the wound a fter hernia repair
predisposing to tissue breakdown and a higher recurrence rate. 4) Connective tissue
disorders (Hurler, Ehlers -Danlos, etc.). 5) Growth failure and poor nutrition. 6) Prematurity
has been identified as a comorbid factor in hernia recurren ce. 7) Children hernia repair
done by non -pediatric surgeons is also a risk factor for recurrence. 8) Conditions causing
increase intra -abdominal pressure (VP shunts, posterior urethral valves, bladder
exstrophy repair, weight lifting and respiratory condi tions) are also related to higher rate
of recurrence in children.
Repair of the recurrent hernia is done through the inguinal scar or using
laparoscopy. The sac is mobilized and ligated. Laparoscopic repair of recurrent inguinal
hernia has the advantage of passing through a virgin field reducing damage to vas or
vessels and allowing inspection of the area with direct purse string repair of the defect.
G. Acute Scrotum & Epididymitis
The term acute scrotum refers to signs and symptoms associated with local
inflammation of the scrotum that appears suddenly and usually is not associated with
trauma. Is a common urological emergency. Such signs and symptoms include scrotal
pain, swelling, redness and heat. The most common causes of acute scrotum in children
cons titute testicular torsion, appendix testis torsion, epididymitis, orchitis and pyocele.
Testicular torsion, a surgical emergency, occurs in 15% of all cases and is the most
important condition to diagnose and manage early in order to avoid testicular loss, fertility
problems and medico -legal issues. Testicular loss commences past the twelve hours of
initiation of symptoms. Beyond twenty -four hours of symptoms testicular loss in the norm.
This is the main reason why in the absence of ancillary studies surgeo ns immediately
explore the acute scrotum. The two most commonly used preoperative studies are
testicular scan and color Doppler ultrasound. Testicular scans reliable show whether the
testes have vascular flow or not, but are difficult to be obtained in th e middle of the night.
Doppler ultrasounds are operator dependant and when done by experienced physician
can help reduce the number of emergency operations and hospitalization days. Clinical
judgment by the surgeon is probably the most important factor in assessing testicular
salvage. In the face of doubt the next step in management is immediate surgical scrotal
exploration. Idiopathic scrotal edema is a very uncommon cause of acute scrotal swelling,
but considered the commonest cause of the 'acute scrotum' in prepubertal boys.
Idiopathic scrotal swelling is characterized by edema and erythema of the scrotal wall, is
usually bilateral and can sometimes involve the shaft of the penis. The swelling and
erythema can extend into the abdominal wall and perineum. Children affected with acute
scrotal swelling are four to six years in age with symptoms present for less than 24 hours
at the time of initial medical evaluation. The cause of the swelling is usually not identified
but can be associated to reaction to an a llergen, bug bite, contact dermatitis or
angioneurotic edema. Leukocytosis is absent, urinalysis is usually normal and urine
culture is sterile. Peripheral eosinophilia is present in some patients. A connection with
trauma, periurethral disease, or strepto coccal disease appears unlikely. The differential
diagnosis includes torsion of the testis or one of the testicular appendages, hydrocele,
varicocele, trauma, tumor, idiopathic scrotal edema, and Henoch -Sch?nlein purpura. Color

Duplex ultrasound of the scr otum will show increase testicular blood flow and thickening
of skin and muscle of the scrotum. Exploration is required when a normal testis cannot
absolutely be identified. Swelling usually resolves within two to five days. Management
consists of bed rest , reassurance, and oral histamine.
Acute inflammation of the epididymis is an infectious process which usually occurs
during adolescent years, very rarely during prepubertal ages. The infectious process is
caused by a distal urethral obstruction, ectopic u reter entering the seminal vesicles or
epididymis, or after instrumentation. Bacterial or viral organisms are involved in the
infectious process. Epididymitis seems to be more common than acute testicular torsion.
Early clinical manifestations of epididymi tis include scrotal edema, pain, erythema,
tenderness with an associated reactive hydrocele. The epididymis turns elongated and
exquisitely tender to palpation. The differential diagnosis includes testicular torsion,
torsion of the testicular appendage or idiopathic scrotal edema. The urinalysis will
demonstrate pyuria with bacteriuria. Leukocytosis is also identified. Color Doppler
ultrasound or testicular scans can determine rapidly if we are dealing with torsion due to
reduced or absent testicular blood flow in need of urgent surgery. In the event of doubt
or absence of imaging studies the diagnosis of an acute scrotum requires scrotal
exploration. Management of epididymitis includes intravenous antibiotics, pain
medication, scrotal support and bed rest. Further renal ultrasound and excretory
urography are needed after the episode subsides to determine a congenital urologic

(Small Addition from E-Book, HDD):

Meckel’s Diverticulum
Meckel's diverticulum denotes those anatomic structures resulting from the
umbilical and intra -abdominal persistence of the embryonic vitelline duct (yolk stalk).
Meckel's diverticulum is clinically significant, either when discovered incidentally at
celiotomy or recognize as the cause of symptoms, which are intestinal bleeding,
abdominal pain, or intestinal obstruction. Children with symptomatic Meckel's present
with hemorrhage (40%), intestinal obstruction (30%), diverticulitis (20%), and umbilical
discharge or disease (6%). Diagnosis is related to presentation. Intermittent rectal
bleeding may be diagnosed on occasion by 99mTc sodium pertechtenate. Barium studies
are unreliable. Persistent bleeding requires laparotomy even if the Meckel's scan is
negative. Diverticulitis or perforation presents with finding similar to appendicitis.
Obstruction secondary to i ntussusception is diagnosed by clinical findings and barium
enema. Incidental Meckel's diverticulum is generally handled by simple wedge excision in
children. Bleeding Meckel's is managed by resection of the bowel and end -to -end
anastomosis. Diverticulitis is handled by either method. Asymptomatic Meckel’s
diverticula identified incidentally should be removed if upon palpation there is
questionable ectopic (gastric or pancreatic) mucosa.
Thank you,,,

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