Infant with Groin Swelling
Answer: D
This infant has a reducible inguinal hernia. Risk factors include prematurity (5% of full-term newborns versus up to 10% of premature newborns) and male gender (boys are at 3 times higher risk than girls). The right side is more common, due to the later descent of the right testicle, and later obliteration of the processus vaginalis.
The presentation of pediatric inguinal hernia can be divided into three presentations: no mass, reducible mass, or non-reducible mass. Most children with inguinal hernia have a history of an intermittent bulge, especially with straining; they may be asymptomatic on presentation. A child with a reducible mass may have non-specific signs and symptoms such as irritability or decreased appetite. An incarcerated mass will be discrete, tender, firm, and non-reducible; if there is suspicion for strangulation, reduction should not be attempted. A child who presents with no mass or a reducible mass may be safely discharged with follow-up and plans for an elective herniorrhaphy (D). Parents should be given strict return precautions.
Incarcerated or strangulated hernias require urgent surgery (A). An uncommon but confounding diagnosis is the Amyand hernia, which is an appendix that becomes inflamed/infected when it is included in the herniated loop of bowel (approximately 1% of inguinal hernias).
A hydrocoele (B) is a collection of peritoneal fluid that is caused by a patent processus vaginalis (itself a risk factor for hernia). Hydrocoeles typically involve only the scrotum, transilluminate, and are non-tender.
Testicular torsion (C) causes pain, vomiting, and irritability; there is typically a swollen and tender mass in the scrotum (although a testicle may undergo torsion at anytime, even in the process of descending from the abdomen). A retractile testis may be due to an exaggerated cremasteric reflex.
Given this child’s benign presentation, no testing is needed in the ED; outpatient follow-up and elective (non-urgent) surgery may be considered versus observation. Surgical approaches include high ligation and excision of the processus vaginalis, placation of the floor of the inguinal canal, complete reconstruction of the canal with the conjoint tendon, and laparoscopic herniorrhaphy.
This infant has a reducible inguinal hernia. Risk factors include prematurity (5% of full-term newborns versus up to 10% of premature newborns) and male gender (boys are at 3 times higher risk than girls). The right side is more common, due to the later descent of the right testicle, and later obliteration of the processus vaginalis.
The presentation of pediatric inguinal hernia can be divided into three presentations: no mass, reducible mass, or non-reducible mass. Most children with inguinal hernia have a history of an intermittent bulge, especially with straining; they may be asymptomatic on presentation. A child with a reducible mass may have non-specific signs and symptoms such as irritability or decreased appetite. An incarcerated mass will be discrete, tender, firm, and non-reducible; if there is suspicion for strangulation, reduction should not be attempted. A child who presents with no mass or a reducible mass may be safely discharged with follow-up and plans for an elective herniorrhaphy (D). Parents should be given strict return precautions.
Incarcerated or strangulated hernias require urgent surgery (A). An uncommon but confounding diagnosis is the Amyand hernia, which is an appendix that becomes inflamed/infected when it is included in the herniated loop of bowel (approximately 1% of inguinal hernias).
A hydrocoele (B) is a collection of peritoneal fluid that is caused by a patent processus vaginalis (itself a risk factor for hernia). Hydrocoeles typically involve only the scrotum, transilluminate, and are non-tender.
Testicular torsion (C) causes pain, vomiting, and irritability; there is typically a swollen and tender mass in the scrotum (although a testicle may undergo torsion at anytime, even in the process of descending from the abdomen). A retractile testis may be due to an exaggerated cremasteric reflex.
Given this child’s benign presentation, no testing is needed in the ED; outpatient follow-up and elective (non-urgent) surgery may be considered versus observation. Surgical approaches include high ligation and excision of the processus vaginalis, placation of the floor of the inguinal canal, complete reconstruction of the canal with the conjoint tendon, and laparoscopic herniorrhaphy.