Groin & Scrotum
Conditions of the scrotum can also develop in newborn and infant males. Our paediatricians can diagnose undescended testes or retractile testes and suggest the appropriate surgery.
Sometimes, newborn males can develop hydroceles and adolescent males can develop varicoceles, and both can be corrected by our surgeons.
What are paediatric hernias?
For children, a hernia may occur during the first years of life. When infants and children develop hernias in their groin, they are called inguinal hernias.
Inguinal hernia in children can occur for any child at any age. However, they are more common in premature babies and males.
Children are born with the potential hernia. When a section of bowel finds its way into the hernia sac, a groin bulge may be seen. This may be visible intermittently. Usually the lump is painless and spontaneously disappears as the contents of the hernia return into the tummy cavity.
If a hernia bulge is seen once, but then is not seen for a while, it does not mean the hernia has been cured. The hernia lump will show itself again at some point, and surgical repair by a paediatric surgeon is required.
When to treat an inguinal hernia?
Inguinal hernias do not get better on their own. They always require surgical repair. In newborn babies and young infants, hernias are referred promptly to the paediatric surgeons and electively repaired within a few days.
Uncorrected inguinal hernias in this age group have a high risk of incarceration, or, the hernia getting stuck. This is when bowel content in the hernia gets swollen and cannot return into the tummy cavity. The hernia lump usually becomes very red and tender.
The blood supply of the stuck loop of bowel may be interrupted. This can result in loss of blood flow to that segment of the bowel. Also, in male babies, the tightly stuck hernia can compress the vessels supplying the testes and interrupt blood flow.
A ‘stuck’ or ‘incarcerated’ hernia is an emergency. You are advised to immediately take your child to the children’s hospital emergency department.
In older children with inguinal hernias, the risk of incarceration is much lower. In these cases, we will discuss with you a suitable time to electively repair the hernia.
Umbilical hernias are common in infancy. This is when a hernia occurs through a gap in the tummy muscle, where the base of the umbilical cord used to be.
An umbilical hernia for an infant, baby, or toddler can be quite large. There will often be a bluish tinge to the skin. However, they are unlikely to cause pain or symptoms, and rarely get stuck or incarcerated like inguinal hernias.
Umbilical hernias have a high chance of closing and disappearing spontaneously as the child grows.
When to treat an umbilical hernia?
If the umbilical hernia is still present by the time the child is 18 months old, then it is unlikely to spontaneously close. Correcting the umbilical hernia for your toddler with surgical repair is usually recommended after this age.
If an umbilical hernia is present, we are always happy to review your child. We will then follow up and re-examine once they are 18 months old. We can advise you further if and when repair is required.
Epigastric hernias are often visible as small pea-sized lumps under the skin of the child’s tummy. They are seen along the line above the belly button.
The epigastric hernia lump is usually a small amount of fatty tissue. This tissue herniates through a small defect in the muscle of the tummy wall.
Occasionally, the hernia can be painful or tender for the child.
When to treat an epigastric hernia?
Treatment and recovery for hernias
Hernias for infants and children of all ages are repaired under general anaesthetic. The operation is usually a day procedure. The specialist paediatric surgeon will electively repair the hernia using dissolving sutures. Foreign material mesh is rarely required.
Newborn babies and premature babies having hernia repair may require routine overnight observation and monitoring in hospital after the general anaesthetic.
Babies and toddlers recover within a few days after hernia repair. Simple paracetamol and ibuprofen are usually sufficient for pain relief.
Children tend to recover quickly after umbilical hernia repair. A week off school and two weeks off sports and swimming are recommended after surgery for school age children.
Testes problems in children
Undescended testes are common in newborn male infants. At birth, the testes of a term baby should be in the scrotum.
Sometimes the scrotum on the affected side is empty, and the testis is felt somewhere in the groin outside of the scrotum. In these cases, the testis or testes are called “undescended”.
Sometimes, the scrotum is empty, and the testis on that side is unable to be felt. This condition is termed the ‘impalpable’ testis.
Most children with undescended testes have the problem only on one side, with the other being normal. Some children can have undescended testes on both sides.
If, at three months of age, the testis is still not in the scrotum, then it will not come down spontaneously. It is very important to get a specialist paediatric surgery and urology review at this stage.
If, upon examination, the testis is determined to be undescended or impalpable, then corrective surgery is needed to bring the testis down. This procedure is known as “orchidopexy”, and is ideally planned for when the baby is six months of age.
Treatment and Recovery
Orchidopexy surgery is performed by the specialist paediatric surgeon and urologist under a short general anaesthetic. It is usually a day procedure. Depending on your child’s case, the surgery may involve one or two stages.
Most undescended testes that can be felt in the groin can be repaired by a single stage orchidopexy. This will be performed by the specialist paediatric surgeon at around six months of age. After the operation, the testis will be within the scrotum and no further treatment is usually required.
Sometimes the testis is absent from the scrotum or groin, and cannot be felt at all. In these cases, surgery is planned to investigate and manage the problem. This will occur at around six months of age onwards. During surgery, a small laparoscope or camera is introduced into the tummy. This is to check if the absent testis is still inside of the tummy. If it is, then the first stage of two is undertaken to start bringing the testis down.
In the first stage, vessels tethering the testis are divided by keyhole surgery. This is preparation for bringing the testis down all the way to the scrotum in the next stage. The second stage is performed six months after the first stage.
Orchidopexy for undescended testes is very important. Data shows that it is ideal to bring the undescended testis down at around six months of age, or very soon thereafter. This offers the best chance of minimising the risk of future malignancy and fertility problems in the undescended testis.
Data shows that if surgery is delayed after 18 months of age, there is an incremental increase in fertility problems and malignancy risk within the undescended testis. So even if diagnosis of undescended testis is inadvertently delayed, the sooner paediatric urology review is arranged, the earlier surgery can be offered to minimise these future risks.
Boys born with normally descended testes can still appear to have an empty scrotum, intermittently, once they are a few months old.
Retractile testes are normally descended testes that are intermittently pulled out of the scrotum. This is caused by an overactive groin muscle that wraps around the cord suspending the testis. This muscle is called the cremaster muscle.
It is very important that a specialist paediatric surgeon and urologist examines the child. They will assess whether the testes are retractile or truly undescended.
If the testes are retractile, they can be brought down to the base of the scrotum upon examination. Undescended testes cannot.
Retractile testes have a high chance of ceasing to be retractile as the child grows. Most boys with retractile testes will settle without any surgery.
However, there is a risk above 10% that retractile testes can permanently ascend out of the scrotum and tighten as the child grows. It is therefore highly recommended that the child with retractile testes undergoes an annual check by the specialist paediatric surgeon and urologist.
If the testis is found to have ascended, it is tight in the groin and cannot be brought down to the base of the scrotum. It will then require surgical correction by orchidopexy, to place it within the scrotum, to allow for optimal future function.
Sometimes boys will have normally descended testes at birth. However, when they are older, they find that one or both of their testes has ascended into the groin and will not come down.
Treatment and Recovery
Specialist paediatric surgery and urology review is recommended, and the child can undergo orchidopexy for the ascended testis.
Simple paracetamol and ibuprofen are usually sufficient for pain relief after orchidopexy. Children usually recover quickly. A week off school and two weeks off sports and swimming are recommended after surgery.
A hydrocele is a collection of straw coloured fluid around the testis. Sometimes, the hydrocele can extend into the groin. Occasionally, the hydrocele can be just in the groin with no fluid around the testis.
Hydroceles are very common in newborn males. Hydroceles usually do not cause pain and are harmless to the testis and to the child.
Hydroceles in infant males have a very high chance of spontaneously disappearing. They often correct themselves by the time the child is 18 months of age. The specialist paediatric surgeon and urologist can arrange periodic surveillance reviews to monitor the hydrocele as the baby grows.
If a hydrocele is still present after 18 months of age, it is unlikely to correct itself. After this age, surgical correction is usually recommended.
It is recommended that the paediatric surgeon and urologist assesses the hydrocele. If repair is required, the hydrocele repair surgery is performed under a short general anaesthetic as a day procedure. The procedure is performed through a small groin incision with dissolving sutures and foreign mesh material is usually not required.
Sometimes large hydroceles can occur in teenage boys. These also require surgical repair. In teenage boys, sometimes a groin incision as well as a scrotal incision may be required to correct the hydrocele. Even in this age group, hydrocele repair is a day procedure under a short general anaesthetic, and dissolving sutures are used.
Simple paracetamol and ibuprofen are usually sufficient for pain relief after hydrocele repair. Children usually recover quickly after hydrocele repair. A week off school and two weeks off sports and swimming are recommended after surgery. Adolescents with large hydroceles often have persistent swelling for a few months after the surgery. This swelling slowly settles without any intervention.
A varicocele is an enlargement of the veins within the scrotum. Also known as testicular varicocele, this condition is common in adolescent boys. It usually occurs in the left side of the scrotum.
Varicoceles in adolescent males may be associated with restriction of growth in the associated left testis.
Review by the specialist paediatric urologists is recommended. Often no treatment in childhood for the varicocele is required, and we shall arrange appropriate surveillance. Treatment to correct the varicocele is offered if:
- The varicocele is causing symptoms like pain or discomfort
- The child is disturbed by the appearance of the varicocele
- The left testis is significantly smaller in size than the right
We will discuss options with you for correcting the varicocele. The recommended varicocele surgery may be open or keyhole surgery. Other treatments include injecting the affected veins with special agents that will cause them to ‘sclerose’ or shrivel up. This is called “embolisation of the varicocele” or “sclerosing the varicocele”.
We strive to deliver the highest level of paediatric surgical service to families. All children, whether they are newborn, toddlers, young children or teenagers, deserve excellent support and care. As surgeons we believe that it is essential to address paediatric urology and surgical problems in accordance with world’s best practice.
If children require surgery, our role encompasses building a reassuring environment to prepare your family for the surgery, and of course to provide expert surgical care and follow-up. At WA Paediatric Surgery and Urology, both our surgeons and our team will be here to assist you with kindness and support.
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Contact our paediatric surgeons and urologists
Dr Andrew Barker
Dr Naeem Samnakay
85 Monash Avenue, Nedlands, WA 6009