4-Year-Old Boy with a Groin Mass (Case 48)

Chapter 67 4-Year-Old Boy with a Groin Mass (Case 48)



Barbara J. Pettit, MD



Differential Diagnosis




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Speaking Intelligently


My approach to a child with a groin mass is determined by the acuity and severity of the presentation. My general approach to a child referred to the office for a routine evaluation is to determine if the child needs an operation, further evaluation, or simple observation. My goal in evaluating a child with the acute onset of a mass is to determine if the child needs an emergency procedure to relieve a bowel obstruction caused by an incarcerated hernia or to restore blood flow to a testicle whose blood supply has been compromised by TT.



PATIENT CARE



Clinical Thinking



• The child’s age is an important factor in shaping a management plan. For example, my recommendations for tx of a hydrocele will be different in a 5-month-old versus a 5-year-old boy because of the different expectations for possible spontaneous resolution.

• Organs whose blood flow is compromised (bowel or an ovary strangulated in a hernia, or a torsed testis) have only a few hours before serious, possibly irreversible ischemic damage occurs. A dx must sometimes be made rapidly based on hx and physical findings alone, as there may not be time for diagnostic testing.

• Groin pathology may present as abdominal complaints and vice versa.


History



• Features of the general medical hx may help in determining the etiology of the mass. For example, inguinal hernias are more common in children with cystic fibrosis, connective tissue disorders, and children who have a ventriculoperitoneal shunt.

• The review of systems should focus on the presence of systemic symptoms such as fever and chills, abdominal symptoms such as pain, distention, nausea, emesis, and bowel changes, and genitourinary symptoms such as dysuria, frequency, and scrotal pain.

• A careful hx of the onset and course of a painless mass should be obtained. Particularly helpful are the following questions: How long has it been there? Does it come and go? If it does not come and go, is it staying stable in size or getting bigger or smaller?

• Similar questions should be asked about the acute, painful mass. In addition, ask about the onset, character, location, intensity, and radiation of the pain, as well as any drainage or hx of trauma.


Physical Examination



• The child’s general demeanor should be assessed. Characteristics include degree of comfort and a general assessment of the patient’s well-being.

• Signs of sexual development are particularly important in patients with painless scrotal masses.

• An abdominal examination is important, with particular emphasis on signs of bowel obstruction. These would include distention or tenderness.

• In boys, the genitalia are carefully examined beginning with the scrotum. The size and degree of rugal fold development are noted on both sides of the scrotum. Inflammatory scrotal changes are associated with TT, epididymo-orchitis, and incarceration of an inguinoscrotal hernia. Both testes are carefully palpated with attention to size and location. If the testes are not present in the scrotum, they may be palpable in the inguinal canals. The testes and surrounding structures are carefully palpated for the presence of masses. The spermatic cord on each side is palpated to determine if it feels normal or tender.

• In girls, the external genitalia should be examined for the presence of ambiguity (e.g., clitoral enlargement or other evidence of masculinization). The location and character of a groin mass should be noted.


Tests for Consideration












• U/A: Sometimes helpful in evaluating the presence of epididymo-orchitis.
 $38

• hCG stimulation test: May be done to differentiate bilateral undescended testes (UDTs) from completely absent testes if both testes are impalpable.
 $50



IMAGING CONSIDERATIONS












→ Color Doppler ultrasonography: Performed when torsion is suspected but should not unduly delay an operation.
 $300

→ Ultrasonography: Can be helpful in distinguishing a cystic from a solid groin mass.
 $250





















Clinical Entities Medical Knowledge
Inguinal Hernia
PΦ In the male fetus, the testis descends into the scrotum from the retroperitoneum, dragging with it a tube of peritoneum called the processus vaginalis (PV). The lumen of the PV begins to close before birth and is generally obliterated by 1 year. In girls, the round ligament also passes through the inguinal canal. In patients with hernias, the PV fails to obliterate. If the PV remains open, abdominal contents may herniate into it, creating an inguinal hernia. A hernia incarcerates when the abdominal contents will not reduce, and strangulates when the blood supply to the incarcerated contents is compromised.
TP The patient or family member will note a mass in the groin area. It usually enlarges when the patient cries or coughs, as both maneuvers increase intra-abdominal pressure. With incarceration, the mass no longer spontaneously reduces. If intestine has incarcerated, the patient will present with signs of abdominal obstruction, including distention and bilious vomiting. A patient with an incarcerated ovary may present with an irreducible mass but few other symptoms.
Dx The dx is made if the mass completely disappears when the child is relaxed or reduces with gentle pressure. Asymptomatic incarcerated ovaries may not reduce, will be just outside the external ring, and are movable and regular in consistency. Incarcerated inguinal hernias cannot be manually reduced, and the mass may be tender and inflamed. If the mass is not present, but the hx suggests a hernia, the older child can be asked to take a deep breath and bear down.
Tx Tx for irreducible incarcerated bowel or a strangulated, incarcerated ovary is emergency exploration. Hernias that are not incarcerated, or, in the case of the incarcerated ovary, are asymptomatic, should be electively repaired at the earliest opportunity. Repair may be done via a small groin incision or laparoscopically. See Sabiston 71, Becker 16.


Hydrocele















PΦ Pathophysiology is similar to hernias. In the noncommunicating type, the PV obliterates from above but fluid has accumulated in the distal PV. In the communicating variety, the PV has failed to obliterate but the opening is so small that only peritoneal fluid can pass through the patent PV.
TP Children with communicating hydroceles present with a hx of a scrotal mass that increases in size when they are upright and active during the day, and is small or absent in the morning after sleep. Noncommunicating scrotal hydroceles present as painless masses that gradually decrease in size.
Dx The differentiation of communicating versus noncommunicating hydrocele is based on hx as neither is usually manually reducible. A scrotal mass that is irreducible, nontender, smooth, movable in the scrotum, and transilluminates is consistent with a hydrocele. The testis may be difficult to palpate if a scrotal hydrocele is large but will appear as a small shadow when the mass is transilluminated. The cord structures are palpable above the mass where they exit from the external ring.
Tx Noncommunicating hydroceles in the first year of life can be observed as most will close spontaneously. Those that fail to resolve after 1 year are corrected surgically. Communicating hydroceles at any age are repaired electively through a small groin incision. See Sabiston 71, Becker 16.


Retractile and Undescended Testes









PΦ In UDTs, the normal testicular descent is halted at some point from the area of the retroperitoneum just below the kidney where the testes originate down through the inguinal canal into the scrotum. The testes may be palpable in the canal but cannot be brought down manually into the scrotum. Retractile testes are normally descended testes that simply have a vigorous cremasteric reflex and can be brought down manually into the scrotum.
TP
Children with both retractile and undescended testes may present with a small, nontender, regular, movable mass in the groin or at the top of the scrotum. The condition may be unilateral or bilateral.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on 4-Year-Old Boy with a Groin Mass (Case 48)

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