Umbilical hernia ,undescended testis

1. Case Scenario
Presented by
Abdulaziz Bagasi – medical intern
Supervised by Dr.Badr BinHimd
December 2016

2. Case
• A 6-month-old healthy girl presents with a bulge at
her umbilicus since birth.
• No accompanying symptoms and has been growing
and developing normally.
• Physical examination of the abdomen reveals a soft,
non-tender bulge at the umbilicus that is easily
reduced into the peritoneal cavity with gentle
pressure.
• Reduction allows palpation of the abdominal fascia,
revealing an 8 mm fascial defect.

3. What do you think ?

4. Pediatric Umbilical Hernia

5. What questions we should always
ask about ?

6.  Swelling Hx. :
- Where is it ?
- When did you notice it ?
- How did you notice it ?

7.  Swelling Hx. :
- Does it disappears ?
- Is there any change in it’s size,
shape and color ?
- Did she had had a previous similar
case?
- Does she has any other lumps?

8. What complications we are afraid of ?

9. COMPLICATIONS
- Incarceration.
- Strangulation.
- Perforation.

10. Strangulated hernias are differentiated from
incarcerated hernias by the following:
1. Pain out of proportion to examination
findings.
2. Fever or toxic appearance.

11. Physical Examination
• Identify The hernia.
• Look for a mass in the area of the fascial defect.
• Define the borders of the fascial defect.
• The size of the fascial defect
• Generally asymptomatic , it may cause mild
discomfort in some children.
• If presents with tenderness, incarceration and
strangulation should be suspected.

12. Pediatric Umbilical Hernia
• Definition
• Anatomy
• Risk factors.
• Clinical features
• Complications
• Management

13. Definition
Umbilical hernia :
Part of the intestine or fatty tissue bulges
through the muscle near umbilicus.

14. Anatomy
-The fascial opening (umbilical ring) exists to allow passage of the umbilical
vessels from the mother into the fetus.
-After birth, this fascial opening closes spontaneously with continued growth
of the rectus abdominis muscles toward one another.
-Closure of the umbilical ring is complete in almost all children by five years of
age.

16. Risk factors
• Incomplete closure of umbilical opening.
• Premature babies.
• Black infants.
• In patients with Ehlers-Danlos ,Beckwith-Wiedemann
syndrome ,Down syndrome, mucopolysaccharidoses ,
hypothyroidism ,or trisomy 18.
• Increased intraabdominal pressure from ascites or crying .

17. Clinical features
-Asymptomatic.
- Interfere with feeding if contain bowel wall .

18. Management
(Infant)
• Observation and reassurance as these defects
typically close by age 4 or 5 years.
• Rarely incarcerated.

19. What are the indications for referral?

20. indications for referral
1-More than 1.5 cm defect.
2- Bowel incarceration or strangulation.
3- if persistant more than 5 years of age.
4-Children with large, proboscoid (trunk-like).
5-Signs of infection.

21. Proboscoid hernia warranting early
repair

23. Case
• A 6-month-old male is brought in for a routine
checkup.
• Only one testicle is palpable.
• The genital examination is otherwise within
normal limits.
Which one of the following would be most
appropriate at this time?

24. -Introduction
-Normal Testicular Descent
-Terminology
-Risk factors
-Associated conditions
-Complications
-Management

25. Undescended testes (cryptorchidism)
-The most common genital disorder identified at birth.
-It is important to treat b/c increased risks of impairment of
fertility potential, testicular malignancy, torsion and/or
associated inguinal hernia.
-Between 2 and 5 percent of full-term and approximately 30
percent of premature male infants are born with an
undescended testis.

26. Normal Testicular Descent

27. Terminology
1)Cryptorchidism
a)True Undescended testes
b)Absent testis
2)Retractile testes
3)Ascending testes
4)Ectopic testes

28. 1)Cryptorchidism : a testis that is
not within the scrotum and does
not descend spontaneously into the
scrotum by four months of age
b)Absent testis – An
absent testis may be due
to agenesis or atrophy
a)True Undescended
testes have stopped short
along their normal path of
descent into the scrotum

29. 2)Retractile testes –are
normal testes that have been
pulled into a suprascrotal
position by the cremasteric
reflex.
3)Ascending testes –are
noted to be in a scrotal
position in early childhood and
then to "ascend" and become
undescended
4)Ectopic testes – Ectopic
testes descend normally
through the external ring
but then are diverted to an
aberrant position
-The testicle moved by hand from
the groin into the scrotum and
won't immediately retreat to the
groin.
-Spontaneously appear in the
scrotum and remain there for a
time , then disappear again for a
time .
Retractile testicle is different from
undescended testicle is that
undescended never entered the
scrotum.

30. Undescended testes
1- abdomen
2- inguinal canal
3-suprascrotal(prepubic) .
Ectopic testes
4-suprapubic (penile)
5-femoral region
6-perineal region
7- contralateral
hemiscrotum

31. Laparoscopic view of intraabdominal
testis

32. Bilateral suprascrotal undescended
testes

33. Right ectopic testis palpable in the
perineum.

34. Bilateral cryptorchidism

35. Risk factors
• Prematurity
• Small for gestational age at birth.
• Prenatal exposure to endocrine disruptors (eg,
diethylstilbestrol, pesticides).

36. Associated conditions
●Abdominal wall defects
●Neural tube defects
●Cerebral palsy
●Disorders of sexual development (eg, mixed gonadal
dysgenesis, ovotesticular disorders of sex
development, persistent Müllerian duct syndrome
●Genetic disorders causing diminished testosterone
secretion (eg, Kallmann syndrome, Klinefelter
syndrome, Prader-Willi syndrome)

37. What complications we are afraid of ?

38. Complications :
• Inguinal hernia : 90 percent of congenital undescended testes
have an associated patent processus vaginalis
• Testicular torsion:10 times more common in undescended testis.
• Testicular trauma
• Subfertility: increased incidence of lower sperm counts and lower
fertility rates
• Testicular cancer : incidence is approximately 5.4 per 100,000

39. Imp. Historical Points
• Whether or not the testes were in a scrotal location since
birth so Undescended (not retractile).
• Evidence of endocrine abnormalities during pregnancy (eg,
maternal androgen exposure, which may result in significant
virilization of a female fetus)
• Family history of unexplained neonatal deaths or genital
anomalies, or infertility (may indicate an associated genetic or
endocrinologic abnormality)

40. In physical examination
• The testicular examination in the infant and young
child requires two hands.
• One hand is placed near the anterior superior iliac
spine and the other on the scrotum
• The first hand is swept from the anterior iliac spine
along the inguinal canal to gently express any
retained testicular tissue into the scrotum

42. If patient come to you with undescended tesis

43. Palpable
DD.
True
undescend
ed testis
-In inguinal
canal .
- Since birth
Retractile
testis
spontaneously
appear in the
scrotum and remain
there for a time ,
then disappear again
.
Follow up
should be
examined
annually until
the outcome
of descent or
nondescent
becomes clear
Ectopic
testis
away from
undescended testes
(eg, suprapubic,
perineal)

44. Non-Palpable
DD.
True
undescended
testis
Absent testis
-agenesis
-intrauterine vascular
compromise.
Ectopic testis

45. 4 Case Scenarios
1) Bilateral Palpable
2) Bilateral non- Palpable
3)Unilateral non-Palpable
4)Unilateral Palpable

46. 1) Bilateral
Palpable
newborn
Refer at 6 month
for surgary
Older child (after
infancy)
Immediate
surgary

47. 2) Bilateral
non-
Palpable
newborn
Referral for
evaluation of
sexual
disorders
Older child
(after
infancy)
Hormonal
evaluation for
testicular
absence
surgical
exploration

48. 3)Unilateral
non-Palpable
newborn
With
hypospadia
Referral for
evaluation of
sexual
disorders
Normal
genitalia
Refer at 6 month
for surgary
Older child
(after
infancy)
Surgary

49. 4)Unilateral
Palpable
newborn
Refer at 6 month
for surgary
Older child (after
infancy)
Immediate
surgary

50. What are the indications for referral?

51. INDICATIONS FOR REFERRAL
• Congenital palpable or nonpalpable undescended
testes (unilateral or bilateral); referral between 6 and
12 months of age is recommended
• Ascending testis in boys beyond infancy
• Palpable tissue in the scrotum that is thought to be
an atrophic testis
• Difficulty differentiating between undescended,
retractile, or ectopic testis (at any age)

52. Case
A 6-month-old male is brought in for a routine
checkup. Only one testicle is palpable. The genital
examination is otherwise within normal limits.
Which one of the following would be most
appropriate at this time?
A) Observation only, until 18 months of age
B) Abdominal ultrasonography
C) Urologic referral for surgical exploration
D) HCG treatment for 3 months

53. Guideline statement
• Providers should refer infants with a history of cryptorchidism
(detected at birth) who do not have spontaneous testicular
descent by six months to an appropriate surgical specialist for
timely evaluation. (Grade B)
• Providers must immediately consult an appropriate specialist
for all phenotypic male newborns with bilateral, nonpalpable
testes for evaluation of a possible disorder of sex
development (DSD). (Grade A)

54. Guideline statement
• Providers should not perform ultrasound (US) or other
imaging modalities in the evaluation of boys with
cryptorchidism prior to referral as these studies rarely assist in
decision making. (Grade B)
• In boys with retractile testes, providers should assess the
position of the testes at least annually to monitor for
secondary ascent. (Grade B)

55. Guideline statement
• Surgical treatment as soon as possible after six months of age
for congenitally undescended testes and completed before
the child is two years old (ideally before one year) of age.
• In children with testicular ascent later in childhood, surgery
generally should be performed within six months of
identification.
• Treatment of undescended testes before puberty also may
reduce the risk of testicular cancer, and prevent testicular
torsion.