The Acute Groin in Pediatrics Brian F. Gilchrist, M.D. Thom E. Lobe, M.D.

Introduction The acute presentation of in~uinoscrotal pathology in pediatric patients demands urgent attention. The number of conditions which present in this fashion make the differential diagnosis equally difficult for the neophyte and for the veteran practitioner. Improper or delayed diagnosis may spell disaster ; however, a circumspect approach is easily developed if an appreciation of each of the groin maladies is understood both clinically and anatomically. A synoptic knowledge of the common groin anatomy and pathologies should be a part of the mental armamentarium of the physician called to evaluate and treat groin pathology. Table 1 and Figure 1 describe many of the factors involved in these conditions, which are discussed below.

Testicular torsion Testicular torsion is a surgical emergency. Infarction of a testicle may occur within a few hours if its blood supply is interrupted.’ Early recognition and prompt operation, then, are imperative if the From the University of Tennessee, Le Bonheur Children’s Medical Center, St. Jude Children’s Research Hospital, Memphis, Tennessee. Address correspondence to: Brian F. Gilchrist, M.D., New England Deaconess Hospital, Division of Transplant Surgery, 185 Pilgrim Road, Boston, MA 02215



testis is to survive. Torsion of the testis may be intravaginal or extravaginal.2 Intravaginal torsion occurs within the tunica vaginalis and results from an abnormally high investment of the tunica on the spermatic cord within the scrotum (often referred to as a &dquo;bell-clap-

per&dquo; deformity) .3 Extravaginal torsion results when the testis and the cord become twisted because of nonfixation of the testis, cord, or processus vaginalis. This entity is seen in newborns and in older patients with undescended testes. Torsion occludes the testicular vessels. Once venous obstruction has occurred, swelling may lead to arterial occlusion and testicular infarction. The duration of sympin the period before toms infarction occurs varies and depends on the magnitude of the torsion (360 degrees vs 720 degrees). Testicular loss may occur as early as two hours after the onset of symptoms, though a few testes appear to survive a torsion of longer than 12


Approximately 30% of children who present with testicular torsion have had previous brief episodes of testicular pain. Torsion of the testicle may occur at any age; however, pubertal boys are the most susceptible subgroup. One out of 160 males is affected with this probleM.4 Neonates who present with a red, swollen scrotum at birth and who are found ultimately to have testicular torsion generally lose the gonad. Neonatal torsion usually occurs as a

prenatal event;5 a neogenerally is salvaged

nate’s testicle

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if the torsion has occurred



Torsion of the testis is generally heralded by pain, which is almost always the first symptom. The pain may begin either suddenly or gradually, but with time it increases and is usually severe regardless of the subjective pain threshold of a given patient. Edema and swelling of the scrotum occur rapidly and sometimes will involve the opposite side. Indeed, this involvement often confounds the diagnosis because the scrotum may look infected or traumatized. The systemic effects of the torsion frequently include early nausea,~ and vomiting and fever may also occur. Intermittent torsion has been described.’ Clinically, the scrotum is swollen and red, and often there is a bluish hue to the affected side. The testis may lie transversely, suggesting torsion, and it is so exquisitely tender that accurate palpation is rarely possible. Torsion of an undescended testis occurs more frequently than it does for a descended testis, due to its lack of fixation.’ The presentation of torsion in an undescended testis is different: a tender mass is noted high in the groin in association with an empty scrotum. This may be easily confused with lymphadenitis or an inguinal hernia. Epididymo-orchitis is the entity most commonly confused with testicular torsion. There are several differentiating features. The age of the patient is usually the best clue. Epididymitis and orchitis are rarely seen

before puberty,

except in chil-

vage. The clinician stands at the feet of the supine patient and attempts to untwist the testicle gently by rotating the testicle outward from a medial to a lateral orientation. This maneuver may result in immediate symptomatic relief but should not lull the clinician into equivocation about surgery. Exploration is still mandatory.

Torsion of the Appendix Testis

Figure 1. An appreciation of the complexity and elegance of the inguinal canal is paramount in any discussion of pathology involving the groin. The major anatomic structures that may be involved with any given groin malady are shown here.

congenital anomalieS.8 urinary symptoms are more common in epididymitis. In this setting, rectal examination with prostatic massage is often helpful in distinguishing between an infectious etiology and torsion, dren with Fever and

because in the case ofinfarction, the prostatic massage often produces urine that has bacteria or pus. Many surgeons advocate radionuclide scanning for diagnosing testicular torsion. Technetium 99m scans will document absent testicular blood flow if there is torsion, but testicular infarction induces an inflammatory reaction of adjacent tissues and may confound interpretation of the study. Success is highly dependent on the immediate availability of a technician and the experience of the interpreter;’ even then, this study is thought to be unreliable by some.9 Others have used ultrasound to document the presence of testicular pulsations; however, this test is very unreliable.lo°11 Color Doppler ultrasound may be more accurate in the early diagnosis of testicular

torsion.l2 Laboratory tests or imagthe decision is based on the history operate and physical findings. Any patient with a tender mass must be presumed to have testicular torsion unless another diagnosis can be established promptly. Exploration is harmless in epididymo-orchitis but critical in torsion. Patients with testicular torsion should undergo scrotal exploration even when the symptoms have lasted more than 12 hours, because individual variations in arterial supply and the degree of torsion may allow for salvage. Some controversy exists regarding removal of an infarcted testicle, which might induce antibody formation and affect the contralateral side. It may be that a testis prone to torsion already shows impaired spermatogenesis.l3 More convincing studies on this controversial topic are needed. 14 Manual detorsion is an early option for the management of torsion. Some surgeons believe that manual detorsion can buy time, allowing for potential testicular sal-

ing notwithstanding, to

The appendix testis, or hydatid of Morgagni, is an anatomic vestige representing degenerated Mullerian remnants 15 (Figure 2). It is a pedunculated structure which arises from the superior portion of

the testis and lies within the tunica vaginalis. Its anatomy may lead to torsion; the appendix becomes twisted on its pedicle and infarcts. The symptoms are similar to those of torsion of the testicle proper. Some authors report, however, that torsion of the appendix testis is not as painful as torsion of the


Although torsion of the appendix testis is often missed preoperatively, the astute clinician should be able to make the proper diagnosis. It is generally a condition of boys and young adults; it rarely occurs in infancy. The disorder is punctuated by a sudden onset of sharp pain that is often severe and generally subsides with time. Swelling and tenderness occur and are usually restricted to the affected side of the scrotum. Diagnosis may be difficult because the swollen hydatid can seldom be felt at the upper pole of the testicle. Some authors mention the appearance of a localized spot of discoloration and suggest there tenderness rather than diffuse testicular tenderness. Torsion of the appendix testis must

(usually blue) may be point

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be considered in any differential diagnosis, along with testicular torsion and epididymitis. By taking a

very careful history, one may learn of similar episodes of swelling or mild-to-moderate pain which may have represented a slight twisting of this pedunculated structure. Gross feels this recurrence of symptoms is a noteworthy feature. 16 The urinalysis is normal. Two treatment options exist. When the diagnosis is certain, bed rest and analgesia are sufficient; however, one often explores the scrotum anticipating a torsed testicle, only to find an infarcted appendix testis.

Hydro cele form the Latin for &dquo;water cyst&dquo; 17 and usually refers to an accumulation of fluid in the scrotum next to the testis. In the fetus, the peritoneum has a downward projection, the processus vaginalis, which reaches into

Hydrocele comes


the scrotum. The inferior aspect of this sac precedes the descending testicle and later becomes pinched off to surround the testis as the tunica vaginalis (Figure 3). Accumulation of fluid within this space forms a &dquo;hydrocele of the tunica.&dquo; The upper part of the processus vaginalis lies alongside the spermatic cord (the round ligament, in the female) and is normally obliterated. However, it may persist and communicate with the peritoneal cavity. If it persists and is closed off from the peritoneum, it forms a hydrocele of the spermatic cord (or hydrocele of the canal ofNuck, in the female). Infant and childhood hydroceles are often labeled &dquo;communicating&dquo; when they are formed by the same mechanism as an indirect inguinal hernia (i.e., failed obliteration of the processus vaginalis). A narrowed processus may be too small for the intestine to enter, but fluid from the peritoneal cavity passes easily. The narrowed canal acts like a one-way valve: fluid passes &dquo;

Figure 2. The appendix testis is the most commonly involved vestige that can lead to torsion. Other, infrequently involved vestigial appendices are: a) organ of Girald, b) appendix of the epididymis, c) vas aberrans of Haller.

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into the scrotum with any increase in intra-abdominal pressure. The clinical presentation of an acute hydrocele is straightforward. There is usually a sudden appearance of swelling in the scrotum without pain or tenderness. The diagnosis is made by physical examination. The amount of fluid in the scrotum may cause the scrotum to be tense and appear blue, but it

is seldom tender. Two factors


important in judging whether a hydrocele is present. First, there may be diurnal variation in size, which is noted mostly in older children; the hydroceles are generally larger in the evening after the child has been upright all day. IS Second, compressing a hydrocele does not make it smaller; the communication is too narrow, and the one-way valve mechanism is present. Finally, transillumination of the hydrocele is not a reliable part of the physical examination. Transillumination cannot always distinguish a hydrocele from the dilated intestinal loops in a hernia.&dquo; A hydrocele of the tunica vaginalis seldom requires operation in the first year of life, as small accumulations of fluid in this space will often disappear without treatment. Younger infants should not be operated upon unless they are symptomatic and in discomfort. It is seldom necessary to treat a hydrocele of the canal of Nuck or of the spermatic cord in the first year of life. An important caveat to remember is that aspiration of a hydrocele should never be performed in an infant or child. Recurrence is common, and the dangers of infection are real. The injection of sclerosing fluids also may be harmful and without value. The repair is essentially the same procedure performed for repair of an inguinal hernia.

Inguinal Hernia Indirect

inguinal hernia is the of protrusion an abdominal viscus into a peritoneal sac, the processus vaginalis, which then transverses the inguinal canal2° (Figure 3). The contents of the sac are usually intestines but may be omentum or ovary(ies) and fallopian tube (s) in little girls. Repair of inguinal hernias is the most common operation performed on children, and boys with hernias outnumber girls by a ratio of approximately 5:1.21 The frequency of inguinal hernia may be higher in premature infants, patients with ventriculoperitoneal shunts or ascites, and those with Ehler-Danlos syndrome. 17 Approximately 50% of inguinal hernias are noted in the first year of life, and most of these in the first six months. A parent is usually the first to note an intermittent bulge in the groin, which appears when the child cries or strains but disappears when he is relaxed or sleeping. A hernia in a child is seldom

symptomatic except

when incar-

cerated, though many parents comment

that their infant is less

&dquo;fussy&dquo; after repair. The diagnosis is generally made by the history and may be confirmed by finding a reducible bulge in the groin or a thickened spermatic cord traversing the inguinal canal. It may be helpful to ask the parents to take a snapshot of the &dquo;bulge&dquo; when the history is in doubt and physical findings are not supportive. There are three noteworthy things to remember when evaluating hernias in children: 1) needle aspiration is contraindicated; 2) little else feels like






have a clear of the differential concept diagno-

examiner; 3)

one must

sis, which includes inguinal lym-

phadenopathy, undescended testes, and hydroceles. Hernias become an acute surgi-

Figure 3. The processus vaginalis is the key anatomic structure or hydrocele, as illustrated here.

in the

development of a

hernia cal ate.

problem when they incarcerBy definition, incarceration

when intra-abdominal or become stuck in pelvic the hernia sac beyond the internal inguinal ring. If the hernia is not promptly reduced, intestinal swelling and ultimately impairment of the blood supply, leading to strangulation, may occur. The characteristics of incarcerated hernia are severe, sudden onset pain and a hard, tender fixed mass in the groin. If the hernia has been present for some time, symptoms of intestinal obstruction with vomiting may be noted. Frequently there is no history of a hernia in these children. A caveat in evaluating a child with an incarcerated hernia is that a bidigital exam with one finger in the rectum and the other on the abdominal wall at the level of the internal inguinal ring is often the most sensitive part of the workup. This maneuver allows detection of the herniated structures as they traverse the internal inguinal ring, thus distinguishing a hernia from any other pathology of the groin. Reduction of an incarcerated occurs


hernia in an infant should always be attempted, because emergency operations in this setting carry a high risk of complications, especially wound infection and recurrence. Generally, most incarcerated hernias can be reduced if one is familiar with the techniques. Firm, steady pressure with the fingertips of both hands must be applied for several minutes to the mass at the level of the internal inguinal ring. Analgesics should be given for pain relief and sedation, though some feel they are contraindicated in infants under 6 months of age. Once the hernia is reduced, the child should be admitted to the hospital and examined serially to be certain there is no damage to the intestine or testis. The patient should be scheduled for operation within 24 to 48 hours. It is generally believed that this brief interval is sufficient to allow tissue edema to subside. Guidelines to follow include the dictum that all inguinal hernias should be repaired unless there are medical contraindications, regardless of the size or age of the child. There are several reasons for avoiding delay: inguinal hernias do

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not disappear spontaneously; the risk of incarceration is greater in smaller patients; and the operation is technically more difficult the longer the hernia has been present. A frequent misconception is that anesthesia presents a much higher risk in a young patient. This is not true if an experienced pediatric anesthesiologist is available to administer the anesthetic.22 The initial management of a hernia which is incarcerated without evidence of strangulation is nonoperative. Most pediatric surgeons use some form of analgesia and place the infant in the Trendelenburg position. The principle is to relax the abdominal wall muscles with analgesics, thus releasing the constriction of the internal inguinal ring. The child is observed for a period of about two hours. If spontaneous reduction has not occurred, the most common technique is to use gentle manual reduction. If this is unsuccessful, the patient is taken to the operat-

immediately. Approximately 80% to 95% of incarcerated ing


hernias will reduce without operation. Elective repair is performed within 48 hours to allow time for a decrease in tissue edema. The frequency of testicular compromise in this setting has been noted to range from 3% to 5%. One should always counsel the family that the blood supply to the testis may have been impaired by the incarceration. Although a cyanotic testicle is often found at operation, testicular atrophy is uncommon. Unless the testis is noted to be frankly necrotic at the time of the surgery, it should not be removed.


Purpura Although purpura



Henoch-Sch6nlein is sometimes con-

sidered in the differential diagnosis of acute groin swelling, it is rare.23 However, 2% to 38% of patients with this vasculitis are at risk for scrotal involvement, and reports describe HSP first presenting as scrotal swelling similar to testicular torsion. 24,25 Henoch-Sch6nlein purpura is a vasculitis of unknown etiology and is characterized by a nonthrombocytopenic purpura, which usually shows skin, joint, intestinal, and renal involvement.26 It occurs most commonly between 2 and 20 years of age, and its pathology demonstrates an acute


inflammatory reac-


the capillaries. Allen reported the first case of male genital involvement with this disease process in 1960.27 His paper described testicular and scrotal hemorrhage. Although the condition is generally a self-limited problem and is responsive to steroid therapy, many patients will undergo exploratory surgery because of the clinical similarity to testicular torsion. A negative exploration in this setting is not to be condemned. We believe that children with systemic manifestations of HSP, who have acute scrotal swelling, should be evaluated by a nuclear imaging scan and managed expectantly if these studies are normal. However, in children in whom the initial symptoms of the disease mimic torsion and in cases in which laboratory studies cannot rule out

torsion, prompt surgical exploration should be


Antenatal Perforations Antenatal perforation of a Meckel’s diverticulum presenting as an inflamed hydrocele has been reported, 21 indicating the plethora of antenatal problems which can present as acute groin lesions. For instance, meconium

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peritonitis due to an antenatal perforation may lead to fluid accumulation in a patent processus vaginalis.29 This may result in one side of the scrotum being swollen and red. Often, inguinal exploration will be undertaken for a diagnosis of strangulated hernia. These cases are notoriously difficult to diagnose, and inguinal exploration is almost always indicated. However, if there is any question that an antenatal abdominal catastrophe took place, a plain radiograph of the abdomen is indicated to document either free air or calcifications, which would suggest the need for


Idiopathic Scrotal Edema The cause of idiopathic scrotal edema is unknown. 30 It presents with a low-grade cellulitis involving one or both sides of the scrotum in prepubertal boys. The edema is rapid in its onset and commonly involves the groin and perineum. Occasionally the penis also is involved. There is very little pain, but local tenderness is present. When exploratory surgery is performed on these patients because of diagnostic uncertainty, the edema is noted to be confined to the subcutaneous tissues.31 The epididymis and the testis are microscopically normal, and testicular biopsy shows no abnormality. The peripheral white blood cell count in this condition is normal; however, occasionally there is associated eosinophilia, leading some authors to believe that idiopathic scrotal edema is an allergic phenomenon similar to angioneurotic edema. 32 During an evaluation of a swollen scrotum, idiopathic scrotal edema may resemble an intrascrotal torsion or epididymitis, but the lack of pain seen in idi-

opathic scrotal edema should make the distinction quite clear. Idiopathic scrotal edema subsides almost as rapidly as it appears and is generally gone within two days. No treatment is necessary, but occasionally some skin discoloration persists.33 The child and family should be coun-

seled regarding the persistence of this benign discoloration.

Varicocele A varicocele is a collection of varicose veins in the scrotum. Varicoceles are divided into two

primary and secondary. Secondary varicoceles occur on groups:

either side and are due to an extrinsic compression or intraluminal occlusion of a spermatic vein by a retroperitoneal tumor or

process. 34 primary varicoceles

The most


left-sided and




paMel I

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bilateral. 35

Many children have mild-to-moderate degrees of varicoceles. In some cases, the varicoceles resolve spontaneously. Clinicians and anatomists have shown that the veins principally affected in primary varicoceles are of the cremasteric system, which communicates with the pampiniform

plexus. -16 Most cases of childhood varicoceles require no treatment, but because of the gross appearance of a varicocele, parents need to be well-counseled. Clinically one sees a large scrotum, which often hangs lower than normal when the boy stands upright. Palpation of the scrotum is like feeling a &dquo;bag of worms.&dquo; The mass of veins disappears when the child lies down. Surgery is indicated if demonstrable testicular atrophy is present. Some centers treat varicoceles with retrograde embolization through the renal vein. However, the surgical approach

through has


inguinal approach

very low morbidity, and recurrence is uncommon. a

Epididymitis Acute bacterial epididymitis is in boys. If it is seen in the young child, it is usually as a complication of a urinary tract infection secondary to some local anatomic abnormality. 37 It may occur after urethral catherization, especially after endoscopic fulguration of the urethral valves, and epididymitis may occur with anorectal anomalies such as an imuncommon

perforate anus.38 The acute scrotal swelling which is produced by epididymitis may closely simulate testicular torsion. The presence of pyuria and bacilluria along with fever, leukocytosis, and other symptoms

referable to the urinary tract should clarify the diagnosis. If doubt remains whether the lesion is due to infection or to testicular torsion, scrotal exploration is fully justified. An important consideration to keep in mind is that when older boys develop epididymitis, there is often an absence of demonstrable bacterial infection. In such cases, it is felt that viruses or atypical bacteria may be the cause. In such a setting, an unusual organism such as Salmonella or Hemophilus may well be the etiologic agent. Direct hematogenous seeding may be the cause in these situations.19 Treatment with the appropriate antibiotics should be based on urine cultures and sensitivities. If epididymitis is seen in sexually active adolescents, they should be treated for gonorrhea or a chlamy-

dial infection. 11,41

Trauma Trauma to the groin may be the result of child abuse or trauma suffered in a motor vehicle accident. Trauma to the scrotum is the most frequent type of perineal trauma and most often results in a scrotal hematoma. However, testicular rupture may occur, and in these patients physical examination is

nearly impossible. Ultrasonography in this setting is very helpful. Testicular rupture should be repaired immediately, and reconstruction is technically easy to perform. A transverse laceration is usually found in the dense, fibrous tunica albuginea which surrounds the parenchyma of the testicle. Follow-up studies show that such testicles maintain adequate size after the repair and are functional. 12 Scrotal hematomas, while often painful, should be treated symptomatically with analgesics and scrotal support.

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a blue scrotum is after abdominal trauma because intraperitoneal blood has filled a hernia sac. The hernia in this case should be repaired electively after the injuries have healed.



Tumors Testicular tumors have a peak incidence in children 2 years old and a second period of increasing frequency during puberty.43 Also malignancy may be associated with an undescended testicle.44 Any child who presents with a scrotal mass must be considered as possi-

bly having a malignancy. Clinically, a testicular tumor is often painless, heavy, and firm. As we have discussed, scrotal transillumination does not help in distinguishing a hernia from a hydrocele, but it is very helpful in determining the presence of a testicular mass. Asymmetry between the two testicles should always raise suspicion of a tumor, and ultrasonography is very helpful in making an estimation of size difference. The differential diagnosis must include

epididymitis, torsion,



sion secondary to trauma. Meconium peritonitis may also cause a hard scrotal mass, but the radiographic evidence of calcification in the peritoneal cavity or scrotum will help make this diagnosis. Most testicular tumors seen in childhood are of germ-cell origin.45 Yolk-sac or endodermal sinus tumors account for about 60% of these testicular tumors in childhood.46 Seminomas in children are very rare but do appear more frequently in pubertal boys.&dquo; Exploration for a possible testicular tumor follows the classic principles of tumor surgery. Excision of the mass is performed through an inguinal incision, and a radical orchiectomy is performed

if malignant cells




dodermal-sinus or other malignant

germ-cell more

may require surgery, such as



retroperitoneal lymph-node pling.-iS Serum a-fetoprotein



centration is determined pre- and postoperatively and is followed serially. The diagnosis of malignancy must always be considered when evaluating a scrotal mass; computed tomography scanning and the use of magnetic resonance imaging can greatly aid in planning the need for and extent of surgery

Lymphadenitis Inguinal




nitis is also seen as a tender, sometimes inflamed mass in the groin. There is generally some evidence of a recent infection in the area of lymphatic drainage covered by the lymph nodes in this area. Examination of the lower extremities, with particular attention to the feet, is mandatory to help make this diagnosis. The nodes are often tender. Careful, unhurried examination will demonstrate a normal inguinal canal and spermatic cord. No treatment is necessary in this setting, unless the lymph nodes become suppurative. At that time, incision and drainage of the involved nodes should be performed and appropriate cultures sent to the bacteri-

ology laboratory. It is important to remember when evaluating inguinal lymphadenopathy that surgical results



treated with rifampin and ethambutol. This process should continue for two months; however, incisional biopsy of granulomas is often effective and time-con-

phadenopathy vary widely. Patients who have a positive PPD skin test may develop superficial skin granulomas, which heal spontaneously but which may persist for many months and produce great discomfort. These lesions


1980:824-828. 6.

Stillwell TJ, Kramer SA. Intermittent testicular torsion. Pediatrics.


Leappe LL. Torsion of the testis. In: Welch KJ, Randolph JG, Ravitch MM, et al, eds. Pediatric Surgery, vol 2. 4th ed. Chicago, IL: Year Book Publishers;


Riley TW, Mosbaugh PG, Coles JL, et al. Use of radioisotope scan in evaluation lesions. of intrascrotal J Urol.


Fischman AJ, Ahmad M, Chheda H, et al. Reliability of radionuclide scintigraphy for detection of testicular torsion: an animal study. Eur J Nucl Med.

Cat-scratch disease may also cause

tender, chronic, regional

lymphadenopathy of the groin. The natural history of cat-scratch disease is seen in a generally healthy child who has an enlarged lymph node which persists for several months, followed by gradual resolution. When the surgeon evaluates such a lymphadean inoculation site is nopathy, found in over 50% of the patients examined. Cats which have been studied have shown no evidence of illness, and in the laboratory, isolation of an infectious agent from cat saliva or cat claws has been universally unsuccessful. Treatment of lymphadenopathy from cat-scratch disease is expectant. The history and physical examination will give a diagnostic certainty in about 90% of cases. Suppuration of the nodes occurs in about 25% of patients and generally resolves spontaneously without



One must also keep in mind that lymph nodes in which tenderness and/or inflammation does not resolve over time or which feel rubbery or firm should be considered for biopsy. Such nodes may




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Evans JP, edema. Urology. 1977;9:549-551. Johnston JH. Abnormalities of the scro-


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The acute groin in pediatrics.

The Acute Groin in Pediatrics Brian F. Gilchrist, M.D. Thom E. Lobe, M.D. Introduction The acute presentation of in~uinoscrotal pathology in pediatri...
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