This guide from pediatric urologist Yi Li, MD, presents diagnostic steps and treatment options for conditions including undescended testes, hydroceles, hernias, and the range of problems that can cause acute groin pain in young patients. Li offers tips on physical palpation, whether to order an ultrasound, when to consider surgery, and how to answer the questions posed by worried parents.
So I'm very excited to give this talk because this is some of my favorite cases to manage and see in, in clinic and to operate on. And so, uh for this, I'm gonna kind of focus on cryptorchidism, un descended testes. And then we'll talk a little bit about hydroceles, hernias and acute scrotum. And then very briefly mention microlithiasis because I've seen a few referrals and questions about that as well. So jumping right in with undescended testes. So this is the most common male genital birth defect. I think it's actually the most common surgery performed by pediatric urologists uh nationwide. And there's incidents of about 1% at three months of age. And we pretty much understand now that spontaneous descent is unlikely after 3 to 6 months of age. And the etiology of this is pretty poorly understood. I think it's important to understand the definitions and what we're diagnosing. So, you know, a cryptorchid or unscented test, this is a test that's never been in the scrotum. You're gonna have an ectopic test, this which is a test. This, that is, you know, somewhere else and not along the normal course of descent. A retractile or gliding testis is uh a normal variation where the, there's an active chromo reflex and there's room in the tunica for the test is to slide up into the inguinal canal and down in the scrotum, an ascended test. This is a test. This that's was previously descended and then became undescended as the child is growing and then acquired descended test. This is a previously descended test is that then became unsc ended after inguinal surgery or something else that happened to the patient. And when we think about un descended test is the other important thing is to sort of classify the location or the position of their rest. So we pretty much think of them as palpable or nonpalpable. So the palpable ones are in the inguinal canal or in the high scrotum and the nonpalpable ones are either intraabdominal or they could be managing and just doesn't exist. And then also important to differentiate unilateral or bilateral. So how do we do the diagnosis? I think this is the key part and this is the part that I do in clinic mostly. And that's with the physical exam is, is sort of the crux of this. So we get patients in the frog like position, check the contralateral test. This if, if you're, we're talking about one side to make sure that the testicles they are normal. And then for the undescended test is you kind of start at the uh Iliac crest and then sweep towards the scrotum. So that's where the inguinal canal is. And as you sweep inferiorly, you should be able to either feel a test, this or not. And the A U A guidelines is that the PC P should palpate for test is quality and position at each recommended wild Child visit with the um grade b of evidence. So I like this picture a lot because this is actually how I do it uh with soap because I think soap is really helpful. So, you know, starting from that Iliac crest and then sliding your hand, your fingers along that groin crease. If the test, this doesn't get pushed into the scrotum, which you can sort of or into the high scrotum, which you can catch with your other hand. Sometimes you just feel a little pop and that's good enough for me to say, ok, that testicle is palpable and in the groin versus not. And so, uh you know, the difference here is an undescended slash ascended slash ectopic test. This is one that cannot be brought into the scrotum or it can be brought in the scrotum. But as soon as you let it go, it pops back up. And this is a key differential because this is one that requires surgery to fix versus a retractile testis which you know, might be up in the canal. But if you swing it down with this exam and bring in the scrotum and you feel the testicle and then you let go and it kind of stays there. That one does not require surgery and that just requires an annual exam. And usually when puberty happens, the testes grows and then stay in the longer uh goes up. Those testes are at risk for a cent. Um So boys with gliding testes or retractile testes, I do counsel them that they may have, you know, they should check closely and if in the future it becomes, you know, difficult to find again, you know, surgery can still be on the table. Even if at the time I see them, they're retractile and not um completely descended. You know, one key point we like to emphasize is that the American Neurological Association guidelines recommends not doing any imaging. So studies have found that ultrasound CT scan and MRI is not helpful. Um because if you have a gliding test is if you get an ultrasound and it happens to be in the canal, it'll just be in the canal. And that doesn't really tell you much about whether or not the patient needs surgery. So it's really the physical exam. That's sort of key here in terms of making uh a clinical decision making on management that being said, you know, imaging can be useful in certain cases, uh special cases. Well, I won't jump into that right now. So we haven't understand to test this, you know, what do parents want to know? What are the things that they're gonna be concerned about. Um And it's basically, I think three things, one is what's the malignancy risk? And are there fertility issues? And is there a hormone function? Right. So those are the main function of the testes? And um there's a worry about testis cancer, especially if you do some googling. So there is an increased risk of testicular cancer and undescended testes. And we know that age does uh of inter intervention does affect risk. So this was a study done here at U CS F that looked and found that uh after age nine or 10, that's when the risk kind of increases about six fold uh for testicular cancer and undeed testes. And so therefore, there is impetus to try to get it fixed sooner than later. And interestingly, even if you have a unilateral undescended testes, the increased risk of cancer is in both testes. Um And we're not entirely sure why that is in terms of fertility potential. There's definitely a decrease in paternity rates in patients with bilateral un descended testes in unilateral cases. Uh there is decreased sperm count numbers on semen analysis, but overall paternity. So, you know, percentage of patients who are able to get pregnant when they're trying is preserved, that being said age of intervention again, influences the degree of risk. And then finally, there's a question of testosterone production and the clinical significance of this, I think is unclear, you know, in studies with looking at uh boys during many puberty and puberty, there were elevated LH to T levels um and ratios. But in adults, there have been some conflicting studies where some studies have shown preserved T levels. Some studies have shown lower T levels but unclear clinical significance. So at least from this perspective, I think we can comfortably tell parents that usually, you know, testosterones unaffected. Uh uh at least in terms of the function, the function that we need. And then other reasons that I counsel patients, besides, you know, those three main things, for reasons to fix un descended testes, there is an increased risk of trauma and injury. So if you imagine a testicle, the scrotum, you run into a table edge and it kind of swings out of the way. But if it's in the canal and you run into a table edge, you have an increased risk of testicular injury and rupture. There's also increased risk of torsion of these testes because they're not fixing the scrotum, uh you know, in the normal fashion. And the other problem with this is sometimes hard to identify. So you, we will see patients with undescended test these with the testicular torsion that present late to us because you know, they're having abdominal pain and there's, you know, groin pain and not, and we're not really sure what's going on. It's not as obvious as a tors scrotal testes. And also because it, you know, looks funny and we want kids to have two testicles in their scrotum. So when they're shown off to their friends, you know, nobody's confused about where the testicle is. So surgery timing, I kind of alluded to this earlier, uh earlier is better. Um The A AP recommends before one year of age and the A U A recommends between 6 to 18 months. Um, you know, the general thought for timing is you, you wanna do genital surgery before age two in general, if possible, because then we're kind of avoiding the patient being really aware of the genitals. We're not uh getting mixed up in sort of potty training ages. Um And so get that out of the way and recovery is just, I think a little bit easier when all the incisions are covered under the diaper and kind of out of the way. Um You know, we think that uh from a urology perspective, we think that pediatric anesthesia is about as safe as it's gonna get at six months. So we're comfortable between 6 to 18 months of age. There was a randomized controlled trial that, you know, fix these testicles at nine months versus three years. And the nine month group did have more compensatory testicular growth, you know. So what that clinically means, we're not sure, but probably means that the earlier you fix this, this the better and again, older patients, you know, the older you get and also the higher up the testes are the more abnormal they are. So when we looked at the histology of these testes, um we saw a decreased lading in germ cells with each month of testicular and decent and then severe germ cell depletion uh in patients with intraabdominal testes, uh briefly talking about surgical management. So it's outpatient surgery. If we have a palpable testis, then we do an inguinal and a scrotal incision. And so this is kind of the decision tree here. Um If it's a nonpalpable testis, we'll do laparoscopy. This is a picture of, you know, a testis sitting here at the internal ring which is open. So there's a hernia connection down of the scrotum here and then this testicle is kind of swinging out here. Um When you have an intraabdominal testis, uh some or non p sorry, I should say when you have a nonpalpable testis, sometimes you get in there and you don't even see, you still don't see a testicle. And that could be because you, you know, were misled in your exam and it's actually in the inguinal canal. So you can explore um or you have a testicular nubin or basically an absent test. This is also possible risk for surgery. So I tell pa patients and families, you know, when we get in there, there are a couple of different outcomes that could happen. One is we could get in there and it could look really abnormal. And so then we would consider doing a biopsy or if it looked really abnormal. And I was worried we would talk about maybe doing an orchiectomy if it's a nubin and looks non viable, then I think it's reasonable to take it out since you're already there. Even though we don't think that there's really a cancer risk to a testicular nubin uh for the intraabdominal testes. Sometimes that needs to be staged. So you need to do more than one surgery that's called a Fowler Stevens. Uh ori and the first stage, you basically transect the testicular artery, which is usually the limiting factor in bringing it down. Then you give it six months for the collateral blood supply to grow in and then you come back and you bring it down into the scrotum. Uh tell families sometimes they may be absent. I mentioned before we could go in there, there could be no test this. And then in 1% of cases, you could do a perfectly great Orex, you bring it all the way down, but the testicle could still atrophy over time. Uh probably either from a unrecognized injury to the artery or it just didn't like being moved. Um And I tell families, you know, in, in any of these cases where we either there's not a testicle on that side or lose a testicle. If the other side is good, then we don't need to worry. You know, the kid will go through puberty, no problem can grow a beard. Uh If that they're destined for that, I can't grow a beard, but potentially the kid could grow a beard and um have Children, you know, with one testicle. So a couple of clinical pearls from an article I like, you know, a neonatal physical exam is important to plan for manage for cryptorchidism. Uh The prevalence decreases during four year of life, first year of life and it's more pronounced in premature infants. So we typically can wait. I usually wait till six months. Uh before deciding I'm moving forward with surgery repair, um and bilateral and this nonpalpable test system, then we, we need to work up and make sure we don't miss a diagnosis of uh disorder of sex differentiation. So, conge congenital adrenal hyperplasia can present that way where you have a really masculinize phallus and scrotum but no testes. Um So that does need a work up and then testicular ascent is a real thing. So just because we, you see a patient later in life that has an undescended testes, that doesn't mean that that was missed early in life. It could have been that they had descended testes and then became a ascended and again, should be corrected sooner than later. And then, uh again, ultrasound uh has little plays a little role, has modest poor evidence in diagnosis and management. So I'm gonna just talk about a couple of quick cases. So a four week old checkup, there's a left test is in the in England canal. What's the next step? And the answer to that is reassure re examine a follow up because it could still potentially descend. So, refer to urology if it's still not able to be brought down in the scrotum at 4 to 6 months, 13 year old, recent immigrant with absent right test is not palpable in the canal. Next steps. And this is actually to check with family and surgical history. I had this patient who uh the kid had no idea why he didn't have a testicle and couldn't remember if he had one or not. Then we finally got a hold of family um back home and it turns out he had had an orchiectomy for torsion years ago and he just didn't remember. Uh So we didn't, ended up not having to go look for that testicle because we got that surgical history. But if uh if they didn't have that history, then we would, would want to consider laparoscopy to be able to identify intraabdominal testes. Uh So that's uh you know, we, we manage it and don't leave a higher cancer risk organ in the, in the belly. All right. And I guess we're gonna do questions at the end. So I'm gonna move straight on to hydros and hernias. So, uh very brief etiology and epidemiology, you know, uh indirect, these are in Children, they're indirect hernia. So they go through the inguinal canal through a patent processes, vaginalis. Um This occurs in about 3% of term newborns and even higher 9% of premature newborns. And they can be associated with other things that you know, cause elevated intra abdominal pressure or issues with um connective tissue. So, cystic fibrosis, patients with VP shunt, you are Down syndrome and patients who are undergoing peritoneal dialysis. So I like this picture from Boston Children. I use this a lot in clinic. Um But basically, here's our normal uh abdomen, abdominal lining and the testicle in the scrotum. And then here is sort of the processes vaginalis where the scrotum descends into the uh or the test is descend into the scrotum and you're gonna have a noncommunicating hydrocele where there's fluid around the testicle, but it's not communicating with the proton or communicating hydrocele where there is some fluid that's able to go back and forth. So the communicating ones typically can be compressed and on history. They'll tell you that it changes in size throughout the day. Um The non communicating ones typically don't change in size and those can be a little bit more tense, you know, if it's a really filled sac um and can be uncomfortable. Uh the light bulb test or the trans imation test, I think is a good one where you put the light on it and you can see that it looks like a light bulb. So this is just fluid around testicle rather than you know, uh a hernia and uh bowel contents. So, intervention hydro seals can spontaneously resolve within the first year of life. Um, the resolution rates decrease once the child's up and moving around. And so the, the intraabdominal pressure I think gets elevated is the theory. And so they don't close. And so, you know, surgical corrections indicated around two years of age is when we offer surgery for this theoretically. Um in noncommunicating hydro seals, if it's small and it doesn't bother anybody. You don't really need to fix that. I tend to lean more towards closing the communicating ones just because I think there's risk that they could increase in size over time. Um at the risk of for those turning into hernias is relatively low, but just makes me feel better to close the hernia sac. Um because we know that there's a communication. So a hernia similarly, Boston children's picture uh and different from a hydro because now we have a large opening and then you have bowel contents that are either going into the scrotum or just into the canal. Um So diagnosed by intermittent painless bulge in the groin, it should be in or scrotum. Um and they can be a exacerbated by elevated uh peritoneal pressures, vals salve activities and it's usually painless. Um You can't have patients, can't have nausea, discomfort with incarceration. So, incarceration is if the hernia comes out and then is unable to be reduced versus strangulation where it's actually incarcerated, but also now have cut off the blood supply and that's where you develop a severe pain, vomiting and becomes an emergency. So, an exam you want to palpate for a bulge at the inguinal ring, uh You can have the patient valsalva to try to reproduce it. Uh It, you may not always reproduce the hernia exam. Um You can think about getting an ultrasound, but if they don't have an active herniation, sometimes they don't see it. Sometimes they, they, they will read a hydro scales of hernia. Uh And I've had reads of possible hernia and then we go in there, we actually don't see anything at all. So ultrasound, I think is a useful tool to an adjunct, but I don't use that as the primary diagnosis. It's more the physical exam and the history. Um And I should say that uh even if you don't reproduce the hernia exam, if the history is consistent, then it's still indicated to fix it. So hernias do require surgical repair uh anywhere from 12 to 33% based on studies will incarcerate within the first year of observation. So back in the day when we would just watch these, um a lot of these kids would then develop incarceration or strangulation if they're not repaired quickly. Um If you're able to reduce and it moves freely in your exam, then typically I try to get him on the schedule within a couple of weeks. Uh or at least within a month, uh, if you're unable to reduce it or if there's evidence of strangulation, then that's an emergency. And so that goes to the, er, um, and then we try to, uh, emergently repair that and get that reduced and fix it again. Strangulation. So we have bowel stuck in the hernia. Uh, the intestines are blocked causing vomit, nausea, vomiting, you can lose uh, blood flow to the testes or due to compression on the rheumatic cord. And then there's gonna be uh, erythema and duration, uh, fever. And so this needs to be admitted. Typically, we try to reduce it prior to surgery. So, you know, even under under anesthesia, sometimes we can get them relaxed enough and muscle relaxants to be able to reduce it. Because if you try to operate on this, while the ball is stuck in there, it's much higher risk of complications including bowel injuries and injuries to the court. So, some clinical pearls for hydroxyl hernias, uh, doesn't matter what age, even if they're newborns, uh, you know, infants, uh with their clinical signs, there's needs to have it fixed, uh, for hydro seals, there's a high tendency for spontaneous resolution and can watch those and again, incarceration trying to reduce the hernia before surgery and then, uh, contralateral groin exploration. This is actually an interesting point because traditionally, years ago, people would always fix the other side when they were in there for surgery. And we found that that's indicated that even if they, you know, people would look in with a laparoscope at the other side and see an opening, uh you know, at the internal ring and decide to go fix that. But we found that even if that opening exists, uh usually there, it doesn't develop into a clinically significant hernia. So there's no reason to fix the other side. A couple of quick cases, two month old with unilateral Squirtle swelling change inside throughout the day, no groin bulge. Um So this is probably uh hydrocele. So observation because he's only two month old and then same patient, but now there's an occasional groin bulge. And for that patient, if we're worried about hernia, then we're gonna repair it surgically. Ok. Uh Briefly the acute scrotum, which is could be in its own um you know, full day seminar. Uh I'm just gonna talk about testicular torsion and ependyma in kids primarily. But these are sort of the other possible differential diagnoses for acute testicular pain, scrotal pain, uh briefly testicular torsion. I really like this twist score. So that's testicular swelling, a hard testicle if it's high riding, absent chromo reflex or nausea, vomiting. And those are basically what you're looking for an exam. Uh and the way you score this, I think it's the first two, if it's present, it gets two points and if it's absent, it gets zero and the other three you get one point and if you have less than two points, then you don't need to worry about torsion and don't need to get an ultrasound. If you have 5 to 7 points, then you don't need to get an ultrasound because you're sure that it's a torsion. And if you're anywhere in between, then an ultrasound can be helpful in helping make that diagnosis. So, uh you know, urgent surgical exploration is key to managing testicular torsion. So salva are highest within eight hours onset. Um I tell patients, you know, if it's 24 hour, if it's less than 24 hours, I say, hey, we have a pretty good chance of saving if it's been more than 24 hours, they say, hey, we probably don't have a great chance of saving it. Um Then again, ultrasound can be helpful in making the diagnosis. Manual detorsion can be attempted if there's gonna be delays to surgery. So if you guys are in a place where getting to uh a pediatric operating room is gonna take some time, uh The tradition is traditional way to do it is to open the book. About 66%. 2 3rd of torsion is sort of medial torsion and then one third is the other way. So opening the book only works for about two thirds of cases. Um But it's worth an attempt because you could, you know, potentially save a testicle if it's gonna delay. Uh if surgery is gonna be delayed very quickly neonatal testicular torsion is a hard IND hemiscrotum at birth or during infancy. Um This is a, it's, it's an extra vaginal torsion where the entire auna twists versus, you know, the adolescent torsion, which is a torsion within the tunica. Um, if it's prenatal happens during fetal development there, it's gonna be non tender and beyond salvage. But if it's within the first month of life, then it's gonna be painful and potentially could be saved for the prenatal torsion. There's some controversy on whether or not we need to operate on these. Um, you know, with a very low salvage rate and the anesthesia risk for newborns and we're not even sure that it confers risk to the opposite side because it's not really a bell clapper issue. Um So, you know, medical legally, most surgeons I think will still operate on these prenatal torsion. Um But there's some controversy there. Ependymitis is 20% of acute SERM cases in adolescence is actually omits. Unlike testicular torsion, there's gradual onset and usually not associated with nausea, nausea, vomiting. I mean, early on sometimes the exam will just be a painful pius versus or later presentations could be pius and testes are painful and an ultrasound, we'll see hyperemia uh to the pius and sometimes the testis typically, uh in Children, it's not bacterial. If there's urethral discharge or the patient is sexually active, then can swab and treat for STD S. But in general, our practice is to not, uh especially for um, younger Children who are not sexually active. We obtain a urine culture but we will not treat with antibiotics unless the culture comes back positive. So we'll just manage that with ibuprofen and scrotal support and it's usually, you know, virally mediated and, and self-limiting again. A couple quick cases, 15 year old with sudden onset testicular pain and swelling, manual reduction in the er, prior to ultrasound with immediate improvement of pain and an ultrasound with good flow. What's the next step? So this patient still needs an urgent referral for oropi to prevent torsion events. So, they've basically shown that they have the quote unquote bell clapper deformity and are at risk for torsion and so should have surgery to prevent future torsion events. Five year old un descended left testicle, sudden onset abdominal pain, groin pain with nausea, vomiting. So this is a patient I mentioned earlier need to consider torsion an inguinal testis uh which even though the five year old is not within our bimodal age range with an cent of testis, they're at risk for torsion. And then uh last thing, testicular microlithiasis. Um I I just thought this was an interesting topic to mention briefly because, you know, the management of this has been unclear. Uh In the past, there had been associations made in the adult literature with microlithiasis and testicular cancer. And so for a while, uh testicular micro thesis, when found on ultrasound became something that we were excited about and followed this. The article from 2021 was kind of the final statement where they did a prognostic value uh assessment and systematic review and they looked at 600 some patients and only one patient ended up with uh testicular magni malignancy. And so, uh we do not think that micros is a risk factor for testicular tumor in Children. And even with other risk factors like un ascended testes that confers possible cancer risk in adults but not in kids. And so micro thesis is something that we can provide reassurance and then follow up with the annual testicular exams with PC P and you know, self testicular exams. Ok. So that's all I have. Uh these are my clinics. Um and uh that was fun. So thanks for inviting me and having me.
