Testicular hernia (scrotal hernia) - causes, symptoms and treatment

What is a scrotal hernia

The content of the article

The contents of the abdominal cavity are supported by muscles, ligaments, tendons - fibrous connective tissue. There is a constant pressure inside the cavity, which increases when the abdominal muscles work, for example when coughing, laughing, defecating or urinating.

Too much pressure can cause the abdominal wall to weaken and become damaged, causing a hernia. It is worth knowing that there are places in the abdominal wall that are characterized by reduced strength, and this is where hernias are most often located:

• in the groin - 70% of cases;
• in the scrotum area - 12%;
• at the navel - 11%.

A scrotal hernia is a form of indirect inguinal hernia. The diagnosis is made when an inguinal hernia passes through the inguinal canal and descends into the scrotum. A bulge appears in the scrotum, which in medical terminology is called a hernial sac. Typically, part of the small intestine (on the right side) or part of the large intestine (on the left side) falls into the hernia.

Strangulated hernia

What is false cryptorchidism?

A false form of cryptorchidism or an increased cremasteric reflex is a normal condition in which the cremasteric muscle pulls the testicle into the inguinal canal. The formation of false cryptorchidism is observed in children under stress and freezing. Most often, an increased cremasteric reflex is observed at the age of 6-7 years, when the false form of the disease is most often detected. In this case, the gonad can be manually lowered to the bottom of the scrotum and it remains there for some time; in a warm bath, the testicle descends into the scrotum on its own, which indicates a false disease. The false form of cryptorchidism does not require treatment.

Scrotal hernia: causes

A scrotal hernia in a child is caused by pathological development of the fetus. In the womb, the testicles descend into the scrotum through the inguinal canal, which soon closes. If it does not close, a scrotal hernia forms. Scrotal hernia most often occurs in premature babies because they have weak muscles, and as a result, tears can form in thinner areas of the abdominal wall.

Scrotal hernia can also occur in adults. More often, the pathology occurs in men who are overweight and have problems with urination (for example, due to an enlarged prostate). Men with chronic constipation and pulmonary embolism also tend to develop a scrotal hernia.

Inguinal hernia in a child

In general, an inguinal hernia in children is a pathological appearance (or bulging, protrusion) of the abdominal organs between the abdominal muscles. Such organs can be the small intestine (its loop, the most common case) and other intestinal fragments, the bladder, the ovary in girls and a number of others. In 30-50% of cases, an inguinal hernia in a child is detected in the first year of life by a pediatrician or neonatologist, and is a fairly common pathology in infants and young children (diagnosed in 5% of children, mainly in premature infants). In girls, this pathology occurs approximately four times less often.

Inguinal hernias in children most often turn out to be congenital, and their cause is the abnormal development (and genetically determined) of the abdominal wall of the unborn child during the woman’s pregnancy. In addition to hereditary factors, there are other factors that contribute to this pathology: excess weight in the baby, injuries in the abdominal area (more precisely, the abdominal wall), excessive physical stress.

Inguinal hernias in children of the acquired type are observed much less frequently, but more often in boys aged about ten years with weak abdominal wall muscles in combination with excessive physical activity.

Symptoms of inguinal hernia

Congenital inguinal hernias in children are most often detected during the period of life from several weeks to several months after birth, and most often in premature or weakened children. Usually, parents very quickly notice a small formation, such as a swelling, in the baby’s groin area. During physical stress of the body (coughing, crying, sharp screams), this area protrudes even more, but parents are “reassured” by the fact that this protrusion disappears (reduces) when the child is calm and lying down, or is in a warm bath. However, if this phenomenon is repeated, then the strange swelling gradually increases and reaches significant and frightening sizes. If, in this case, the inguinal hernia in a child (boy) reaches the scrotum area (i.e., descends), then the child’s general well-being may deteriorate.

The difficulty is that the initial stage of inguinal hernias in children usually does not bother them. With a small inguinal hernia, the baby may sometimes complain of temporary pain, colic, a bloated abdomen, and constipation may be observed. But when an inguinal hernia is strangulated, the symptoms become so pronounced that parents often belatedly regret that they did not contact a pediatric surgeon at the clinic or pediatrician in time with a strange, but from time to time, swelling.

Symptoms of a strangulated inguinal hernia in a child. Incarceration (or pinching) of a hernia can have many causes and many types, but in fact means isolation of the hernial contents with all the ensuing consequences - necrosis (necrosis) of a section of organ tissue in a few hours due to compression by the hernial ring, inflammatory processes (peritonitis), intestinal gangrene. A characteristic local symptom is that the hernia cannot be reduced in any position, the hernial contents become dense. General symptoms are pain (the child constantly jerks his legs, cries, shows severe anxiety), nausea in the child, vomiting, possible loss of consciousness and fever. Inguinal hernia strangulation in children - treatment requires prompt surgical intervention; delayed treatment can result in death.

Causes of inguinal hernia in children

The formal and generalized cause of an inguinal hernia in a child is a certain pathological development of the muscle tissue of the anterior abdominal wall. Hernial protrusion (extrusion) of the internal organ occurs together with the peritoneum enveloping it, through the inguinal canal, which is located in the groin area and conventionally represents a kind of intermuscular gap in the abdomen. An inguinal hernia in children consists of a hernial orifice (which is actually the inguinal canal), a sac (part of the peritoneum, the sac has an mouth, neck, body and bottom) and contents (part of an internal organ, for example, a loop of the small intestine).

The “driving force” of hernial protrusion is an excessive increase in intra-abdominal pressure with constipation, strong and frequent screaming and crying, severe coughing, and difficulty urinating.

Types of inguinal hernias in children. Hernias in boys and girls

There are several types of inguinal hernias in children:

• oblique (can be congenital or acquired; the most common type, and occurs mainly in boys);
• direct (usually acquired; rare);
• femoral (protrusion in the upper thigh into the subcutaneous tissue; extremely rare).

In terms of its location, the indirect hernia is lower than the direct hernia, and the small intestine (more precisely, its loop; the contents of the hernia) in boys can reach the scrotum area and protrude into it.

Inguinal hernias in boys and girls differ somewhat in their primary causes, although in general their development and visible symptoms are similar. Inguinal hernia in boys. It can form during the physiological descent of the testicles into the scrotum through a space (flaw) in the anterior abdominal wall. Moreover, first the left testicle descends physiologically, and after it - the right one, and then dynamic movement of other organs can occur (therefore, congenital inguinal hernias in them more often, in 60% of cases, occur on the right side, on the left side - in 25%, and in 15% - double-sided). The hernial sac, most often containing part of the small intestine (loop), may descend into the scrotum, but not reach the descended testicle, and may surround it. Inguinal hernia in girls. During the period of intrauterine development of a girl’s body, the uterus is located higher than in the usual position, but after birth it gradually begins to descend. At the same time, it pulls part of the peritoneum along with it, and if the abdominal wall (anterior muscles) is weak, this fold of peritoneum moves into the inguinal opening and creates the potential for the formation of an inguinal hernia. Accordingly, the contents of the hernial (inguinal) sac may be an ovary or part of the fallopian tube.

Inguinal hernia in children: treatment

If a child is diagnosed with an inguinal hernia, surgery is almost always required. Usually surgery (open or closed, laparoscopic) is performed when the child reaches the age of six months. Doctors strongly do not recommend delaying the operation, since an inguinal hernia may be strangulated at any time. In the latter case, emergency surgery is required, usually no later than 6-12 hours after diagnosing the strangulation (the delay time depends on the child’s condition), which is already much more complex and may require a long recovery period for the child.

The operation is performed under general anesthesia (anesthesia) and if it is planned, not emergency, it lasts on average 15 minutes. Surgical treatment of inguinal hernia in children is highly effective (for example, according to statistics, when treating inguinal hernia in children in Moscow, relapses are rare, no more than 4% of cases) and is usually well tolerated by the child.

Since short-term anesthesia is used for surgical treatment of inguinal hernia in children, there are temporary contraindications for its implementation: acute infections in a child, pathologies of the heart and kidneys, skin damage in the area of ​​the hernia. In such cases, preliminary measures are taken to stabilize the child’s condition and remove identified contraindications.

Inguinal hernia in children: treatment without surgery

Treatment of an inguinal hernia in children without surgery (that is, conservative treatment) can be prescribed only in some cases, for example, in case of recurrence of an inguinal hernia after surgery, for weakened or premature children. So far, there is only one purely technical method of conservative, temporary treatment - the use (wearing) of a special bandage, which the child has to get used to for a certain period.

Sometimes, for premature babies and weakened children, methods are used, but only at first, that in some cases make it possible to “repair” the hernia by using certain medications in combination with the prescription of warm heating pads and baths. But, according to pediatric doctors, a clear positive effect is not observed in all cases and elective surgery cannot be avoided using these methods.

Treatment of inguinal hernia in children without surgery using the so-called. “folk remedies” are absolutely excluded. For example, the use of various compresses based on acetic acid, decoctions of oak leaves, medicinal herbs, and ingestion of various infusions to strengthen muscle tissue. Such funds, at best, can be used only as preliminary measures to stabilize and strengthen the child’s body before a planned operation, and only after preliminary consultation with a pediatrician.

Symptoms of a hernia in the scrotum

In both infants and adults, a scrotal hernia appears as a soft swelling in the scrotum that becomes more pronounced with coughing, straining, or defecation (and in men also after prolonged standing and heavy lifting). A characteristic feature is that the bulge rarely comes back.

In addition to a bulge in the scrotum, symptoms such as burning, pain and a "tightening" feeling are common. The pain may spread to the testicle, especially when the swelling is under pressure. The baby reports discomfort and cries.

How to recognize a hernia - symptoms of a hernia in men

Some inguinal hernias do not cause any symptoms and may be discovered during a medical examination. When a scrotal hernia has already formed and the intestines have descended into the scrotum, the hernia is visible as a swollen testicle.

The greatest danger is a compressed hernia (entanglement of the intestines in the scrotum).

In children, hernias on the testicles occur due to congenital weakness of the connective tissue of the inguinal canal.

Symptoms of hernia in men:

• swelling in the groin - more noticeable when standing or straining;
• groin pain – most severe during times of increased abdominal pressure, such as after coughing or during physical activity, such as lifting weights;
• pressure and feeling of heaviness in the groin;
• weakness in the groin;
• swollen testicle;
• pain in the left or right testicle;
• fatigue;
• tingling in the legs.

Diagnosis of scrotal hernia

A scrotal hernia, like other hernias, is diagnosed during a physical examination in a doctor's office. In this case, you need to contact a urologist or andrologist. To rule out other possible causes of the tumor, the doctor will do an ultrasound of the scrotum and possibly refer you for an x-ray.

Ultrasound

Hydrocele of the testicle (hydrocele) in children

After the birth of a child, parents often pay attention to the enlargement of one or both halves of the scrotum in boys. This may be testicular hydrocele, inguinal or inguinal-scrotal hernia. Today we will talk about hydrocele.

Hydrocele of the testicle and spermatic cord is an accumulation of fluid in the membranes of the testicle or along the spermatic cord, which leads to enlargement of the scrotum, and sometimes swelling in the groin area. What types of dropsy are there? Depending on the type, dropsy differs as follows:

1. isolated hydrocele of the testicular membranes (photo 1) or spermatic cord, when the fluid surrounds the testicle or in the form of a spermatic cord cyst, and cannot pass into other cavities;

hydrocele (isolated) on both sides.

Communicating dropsy on the left.

2. communicating dropsy (photo 2) - fluid can flow into the abdominal cavity and back through a special duct - the vaginal process of the peritoneum. There is also congenital and acquired dropsy. The vast majority of children have congenital hydrocele.

The term communicating hydrocele of the testicle or communicating hydrocele means that there is a communication between the cavity surrounding the testicle and the abdominal cavity - an open vaginal process of the peritoneum, through which fluid from the abdominal cavity enters the scrotum and back. During fetal development, the testicle descends into the scrotum through the inguinal canal. Together with it, the processus vaginalis descends into the scrotum - an outgrowth of the peritoneum that envelops the testicle and, thus, forms the two shells closest to the testicle. By the time of birth or during the first months of life, normally the processus vaginalis of the peritoneum is overgrown, and the connection between the testicular membrane and the abdominal cavity disappears. The lower part of the processus vaginalis of the peritoneum forms a slit-like cavity around the testicle, which in case of dropsy serves as a reservoir for fluid. The main reason for the occurrence of communicating hydrocele of the testicle is non-fusion of the vaginal process of the peritoneum, which serves as a duct for moving peritoneal fluid from the abdominal cavity into the membranes of the testicle. Many theories explain non-fusion of the vaginal process of the peritoneum. One of them, in the open processus vaginalis of the peritoneum, smooth muscle fibers were found, which are not found in normal peritoneum. Smooth muscles can prevent fusion of the peritoneal process. Another reason for hydrocele lies in the increase in intra-abdominal pressure, which is observed during resuscitation measures, with frequent restlessness of the child or during physical exercise.

The testicle is extremely sensitive to changes in temperature and can only function normally in a temperature range five degrees below normal body temperature. An increase in testicular temperature even by tenths of a degree disrupts the development and function of the testicle. Hydrocele is an additional layer around the testicle that prevents heat transfer and leads to overheating of the testicle. As a result, spermatogenesis and hormonal function of the testicle are disrupted, which is the cause of infertility.

Acquired dropsy most often occurs in adolescents after surgery for an inguinal hernia or varicocele. In both cases, the cause of the development of testicular hydrocele is a violation of the outflow of lymph from the testicle, caused by damage (in the case of varicocele) or compression (in the process of herniotomy) of the lymphatic vessels of the testicle. Therefore, such dropsy is called lymphocele. In such cases, stagnation of lymph occurs not only in the membranes of the testicle, but also in the testicle itself (testicular lymphostasis). Less common is post-traumatic dropsy, when the testicle or epididymis becomes inflamed (orchitis, erpididymitis). Isolated dropsy in adolescents usually requires conservative treatment for 3-6 months, mandatory observation and examination. If dropsy persists, surgical treatment is performed.

Spontaneous fusion of the peritoneal process and self-healing of communicating hydrocele of the testicle is often observed in the first months of life and very rarely later than 1 year (no more than 5% of observations). Most children with communicating hydrocele of the testicle require surgical treatment, which is recommended at the age of 1.5–2 years. Failure to follow these recommendations leads to testicular underdevelopment and reduced chances of having children.

What to do? It is necessary to seek advice from a pediatric surgeon or uroandrologist.

To establish the correct diagnosis, ultrasound is used - ultrasound examination of the inguinal canals and scrotal organs and duplex examination of testicular vessels. Ultrasound often makes it possible to detect a problem from the other side - for example, an inguinal hernia or spermatic cord cyst that is invisible during examination. Sometimes enlargement of the scrotum and groin area appears and disappears, and may be absent upon examination by a doctor. Then a photograph taken when a swelling appears in the scrotum or groin area, taken by the parents, helps resolve the issue of diagnosis.

Hydrocele in children under 1 year of age requires observation by a pediatric surgeon or urologist-andrologist. Communicating hydrops with a narrow peritoneal process is usually observed up to 2 years. Observation is also required for traumatic dropsy that occurs as a result of a bruise without compromising the integrity of the testicle. As a rule, 3 months are enough to assess the dynamics of the process and, if there is no improvement, prescribe surgical treatment. The same applies to hydrocele formed after inflammation.

The most difficult is the management of patients with lymphocele that forms after surgical treatment of an inguinal hernia and varicocele. In this case, prematurely performed surgery has little chance of success. For 6-12 months, it is necessary to monitor the condition of the testicle according to ultrasound and duplex examination of the scrotal organs in order to assess the dynamics of the process and the effectiveness of the therapy.

Operations for communicating hydrocele of the testicle are most often performed in children aged 1.5-2 years.

The type of operation depends on the age of the patient and the characteristics of the dropsy. For communicating dropsy, as a rule, the Ross technique is used (performed for children under 10 years of age) - isolation from the elements of the spermatic cord, excision and ligation of the peritoneal (vaginal) process at the internal inguinal ring (photo 3), as well as the formation of a “window” in the membranes of the testicle .

The operation is performed through a small incision in the groin area. In our clinic, a cosmetic suture is applied, which does not need to be removed, so as not to psychologically traumatize the child in the future (photo 4). Laparoscopic operations are sometimes used for testicular hydrocele, but the morbidity, risk of relapses and complications when using them are higher, and the duration of anesthesia is longer, so they are not widely used.

Isolated hydrocele and lymphocele in adult children are indications for Bergmann's operation - excision of the inner membranes of the testicle from the scrotal access. In cases of large hydroceles and lymphoceles, drainage is often left in the wound and pressure bandages are applied. Winkelmann operation (performed for children over 10 years of age) – dissection of the testicular membranes in front and suturing of the resulting edges of the membranes behind the epididymis. Currently used rarely due to changes in the appearance of the scrotum and testicular contours.

Among the complications, the most common is recurrence of dropsy (5-20%), which in case of lymphocele can reach 70%. A particularly high percentage of relapses is observed when operations are not performed on time. Surgeries for dropsy are usually well tolerated by children and do not significantly interfere with their movements. However, with sudden movements or constipation as a result of increased intra-abdominal pressure or direct impacts, the formation of hematomas in the scrotum and groin area is possible. Therefore, children should limit their activity until the postoperative wound heals and follow a diet. For 2 weeks after surgery, do not wear underwear that compresses the scrotum to avoid pushing the testicle up toward the inguinal canal, due to possible fixation of the testicle above the scrotum. School-age children are exempt from physical education for 1 month.

If the timing of surgical treatment is observed and the operations are technically flawless, the prognosis for health and the ability to have children is favorable in the vast majority of cases.

In our clinic, on the day of treatment, the child receives qualified advice and the necessary surgical care from the following specialists:

• pediatric surgeon,
• urologist-andrologist,
• orthopedist-traumatologist,
• gynecologist.

After clarifying the diagnosis and collecting the necessary tests (all tests can be taken in our center), the child is admitted to the one-day surgical hospital as soon as possible, where the necessary surgical treatment is carried out, and, on the same day, a few hours after the operation, he is sent home. If necessary, the child comes for dressings.

Head of the surgical department (one-day hospital) of the Federal State Institution "National Medical Research Center for Children's Health" of the Ministry of Health of Russia, candidate of medical sciences, pediatric surgeon, urologist-andrologist, doctor of the highest category, Abramov Karaman Sergeevich For all questions, please call

Scrotal hernia: treatment

A scrotal hernia, unlike, for example, an umbilical hernia, does not reduce or heal on its own, so surgery is necessary.

• In children, operations are performed when the child is one year old.
• A man should consult a urologist if he notices the above symptoms immediately. The operation must be done within the time frame specified by the doctor, without delay.

The traditional method of surgical treatment of hernias, including scrotal hernia, is hernioplasty using the Bassini method (using your own abdominal wall tissue). The recovery period lasts from 4 to 12 weeks.

Bassini hernioplasty carries a risk of recurrence of the hernia, so it is recommended to perform the Lichtenstein procedure, during which the doctor protects the operated area with a polypropylene mesh. After such an operation, the risk of hernia recurrence is significantly reduced. The recovery period is also shorter, lasting 1-3 weeks.

Endoprosthesis for hernioplasty

Invasive treatment also uses laparoscopic techniques, in which special guides are placed in the groin through which surgical instruments are inserted. Using mini instruments, the operation is performed and a protective mesh is sewn in.

Acute diseases of the scrotal organs in newborns

Shchedrov D.N.1, Medvedev N.A.2

1 GBUZ YAO "Regional Children's Clinical Hospital", Russia, Yaroslavl

2 OGBUZ "Kostroma Regional Children's Hospital", Russia, Kostroma Address: 150042, Yaroslavl, st. Tutaevskoe highway, 27, tel. (4852)773915 Email, [email protected]

Introduction

Acute diseases of the scrotum are among the most common in pediatric surgical practice and occur in various age groups. However, it is known that there are two peaks in the occurrence of this nosological group - the first year of life, as well as the pre- and pubertal periods, this is facilitated by certain anatomical and physiological prerequisites. The neonatal period, especially its initial part, is the most difficult for timely diagnosis of acute scrotal syndrome, taking into account the interpretation of the clinical picture and not always sufficient information content of instrumental examination methods, which often leads to a delay in surgical intervention and significant reproductive damage in the future. The course of acute diseases of the scrotum is also significantly influenced by the anatomical features of the neonatal period - a clear separation of the testicular membranes, the relative severity and hypertonicity of m. cremaster, causing significant mobility of the gonad, non-fusion of the processus vaginalis in 70-90% of boys [1]. What complicates the diagnosis of this category of conditions in newborns is their certainly rare frequency at this age - no more than 0.7-1.2% of all cases of acute scrotal syndrome. It is rare that authors describe more than a dozen observations [2], and a number of diseases - thrombosis of the spermatic cord, compression of the testicle by a hernia are described as casuistic situations [3]. All this leads to a worse prognosis regarding the preservation of the gonad and fertility in the future in comparison with older children [4]. Thus, according to Yerkes [5], the vast majority of cases of acute scrotal syndrome in newborns - up to 90-100% - lead to the loss of the affected gonad. Thus, improving the results of treatment of acute diseases of the scrotum and preserving the reproductive potential of newborns are an urgent task in pediatric urology.

Materials and research methods

We observed in the clinic of the Regional Children's Clinical Hospital of Yaroslavl for 12 years 33 newborns with acute scrotal syndrome, which amounted to 0.6% of all patients with acute testicular disease syndrome (ATS) and 0.5% among all newborns with surgical pathology . Among them, children in the first day of life made up the majority - 20 people. The nosological composition of the lesions is presented in Table 1.

Table 1. Nosological composition of acute gastrointestinal tract

The patients were examined by a neonatologist, an obstetrician, and an ultrasound scan of the scrotal organs was performed. All children were transferred to a specialized department from maternity hospitals upon diagnosis. In a number of cases, it was not possible to accurately determine the date of onset of the disease due to the lack of complaints and the severity of the clinical manifestations. In such cases, the time of onset of the disease was not determined precisely (the period between examinations); the starting point was considered the time of the last examination.

All results of the study were processed statistically using computer programs “Excel” and “Biostat”. Arithmetic means were calculated using Student's t-test. Differences were considered significant at p < 0.05.

Research results

Testicular volvulus was the most dangerous pathology in terms of its outcomes. In all cases, the onset of the disease is conventionally attributed to the first hours of life and the intranatal period, because the line between pre- and postnatal volvulus is very difficult to clearly define. The period before admission to a specialized hospital ranged from 12 hours to 6 days (25.3±11.4 hours). All children were referred from medical institutions immediately after examination by a neonatologist. However, only in two cases was a diagnosis of testicular volvulus established; the remaining children were admitted with suspicion of testicular necrosis, orchitis, strangulated hernia, hydrocele, etc. In one case, bilateral testicular volvulus was observed. It should be noted that there was no characteristic clinical picture, the time of onset of the disease was determined with an accuracy of several hours (the period between examinations), the pronounced swelling of the scrotal membranes, which occurs very quickly in newborns, did not allow a detailed assessment of local symptoms and clarification of the diagnosis. Thus, typical symptoms are an acute onset, severe pain, testicular tightening, irradiation of pain, etc. could not be assessed. The clinical picture became clear when nonspecific symptoms appeared at an already advanced stage of the disease. This situation fully applied to other nosological forms of the group of diseases under discussion. In general, clinical signs do not always allow us to clarify the nosological form, perhaps, except in cases of trauma to the scrotal organs and hematocele, but taking into account the palpable density of the testicle and palpation of the dense spermatic cord, they allow us to assess the severity of the lesion and the urgency of the situation. Ultrasound examination with Doppler sonography was performed in all patients. There was a lack of blood flow in the testicle, and necrotic changes were suspected.

At the same time, there were no typical ultrasound symptoms of volvulus - tortuosity of the spermatic cord, transverse position of the testicle, testicular tuck-up, cessation of blood flow at the site of spermatic cord strangulation. All patients were operated on as an emergency to stabilize physiological neonatal conditions; the period from admission to surgery was 2.1 ± 0.8 hours. We consider the tactics of performing the operation urgently in the first 24 hours and delayed for a longer period, adopted by a number of authors [6], to be untenable in relation to newborns, because The duration of the disease is determined conditionally with a significant spread in time. The inversion ranged from 360º to 1440º (440 ± 41º), which is slightly less than in the older age group (525 ± 59º). In nine cases, necrosis of the gonad was detected, which forced orchiectomy; in two cases (disease duration 17 and 22 hours), in the absence of blood flow according to ultrasound, viability was clinically assessed as doubtful, the testicles were left; during subsequent follow-up, blood flow in the parenchyma was noted, testicles saved. In all cases, we performed fixation of the contralateral testicle using the original method (priority certificate No. 2013116240), taking into account the severity of the outcomes, while in older age, in the absence of clinical prerequisites, we considered it possible to refrain from prophylactic surgery. Thus, attention is drawn to the fatal duration of the disease in most cases, which leaves little chance of preserving the testicle and the difficulty of establishing an accurate diagnosis before surgery.

Figure 1. Bilateral thrombosis of the vessels of the spermatic cord

At the same time, ultrasound with Doppler Doppler, which is the gold standard for diagnosing diseases of the scrotum, shows low efficiency and a significant number of overdiagnosis cases [7] due to the difficulty of echolocating vessels of very small diameter and the presence of low-speed blood flow, not allowing it to be clearly recorded. We believe that one of the reasons for the low information content of the study is the hydrophilicity of newborn tissues, including testicular tissue. Four patients with thrombosis of the vessels of the spermatic cord were hospitalized on the first day of life; in one observation, a casuistic case of bilateral vascular thrombosis was noted (Fig. 1). In all cases, the diagnosis of testicular necrosis was made based on the results of ultrasound and doppler ultrasound before surgery, but thrombosis itself was not diagnosed and was an intraoperative finding. When conducting echolocation in patients, in no case were tortuosity of the spermatic cord or intermittency of blood flow in it noted. It is noteworthy that all children had true hypervolemic polycythemia to a pronounced degree, due to various reasons, the hematocrit level averaged 78% ± 11%, which made it possible to interpret this situation as a manifestation of neonatal polycythemia syndrome [8]. Preoperative period in This category of patients was complicated by the need for partial exchange transfusion, which delayed the operation for several hours. In all cases, orchofuniculectomy was performed due to testicular necrosis, which indicates a clearly prenatal nature of the thrombosis, which left no chance of preserving the gonad. At the same time, we believe that it is possible to assume a true diagnosis in this group of patients based on a comparison of anamnesis, clinical, ultrasound and laboratory data, and the fatality of the situation allows the operation to be performed somewhat delayed after appropriate preparation, correction of background and transient neonatal conditions.

Epididymo-orchitis occurred in nine children. All children were admitted over 7 days of age. Among the features of the clinic, a subacute onset of the disease was noted with the definition of manifestation accurate to within a day. The clinical picture was nonspecific due to the severity of local inflammatory changes. In six out of nine cases (66.7%), children had a urinary tract infection, which proves its connection with epididymitis with a slightly higher frequency than in older children [9]. Ultrasound and Doppler sonography were highly informative in diagnosis, making it possible in all cases to exclude testicular torsion and make a correct diagnosis, as well as assess the nature of the inflammatory process in the scrotum. In assessing the indications for the treatment method, we used previously accepted clinical criteria for the method of choice for older children [10]. The nature of the inflammatory process was more aggressive than in older patients; a more severe course of the disease was noted with a predominance of destructive forms, which determined a more active surgical tactic. The duration of the disease at the time of admission after a detailed study of the anamnesis also turned out to be longer than in older patients. Most patients were operated on due to the development of purulent forms and the need for sanitation of the serous cavity of the scrotum and decompression of the testicle. In two cases, preservation of the gonad was impossible due to its necrotic lesions.

It is noteworthy that purulent complications were not noted during the treatment process, but occurred already upon admission to a specialized hospital (Table 2).

Table 2. Correlation of treatment methods and outcomes for epididymitis in children of different age groups

For all values ​​p<0.05. * - values ​​are given in hours ** - values ​​are given in percentages

Thus, a clear inverse relationship is visible between the age of the patients, on the one hand, and the severity of the disease and the number of fatal organ outcomes, on the other. Trauma to the scrotal organs with damage to the testicle was noted in five cases. The cause of the injury was a traumatic passage of the birth canal; in 4 (80%) patients, breech presentation and delivery of a large fetus were noted. All children were hospitalized in a specialized department on the first day after injury (16.5±2.2 hours). In two cases there were testicular ruptures of degrees I and III, in three cases there were subcapsular hematomas. The diagnosis was clarified in all cases by ultrasound data, which revealed a parenchymal defect and a unilateral hematocele. In cases of subcapsular hematomas, in two patients, accumulation of blood under the testicular capsule was determined; in one case, depletion of blood flow in the parenchyma was noted against the background of its compression by the hematoma; the patient was operated on urgently. We consider the indication for surgery to be a rupture of the parenchyma (the defect was sutured with a PDS 6/0 thread) or compression of the gonad by a hematoma (a gentle opening of the testicular capsule was performed); in all cases, the operation was completed by draining the scrotal cavity. Gonads were preserved in all patients. We observed compression of the testicle by a strangulated hernia in two patients, 7 and 12 days of life. In both cases, the diagnosis of a hernia was established only by the fact of its strangulation. The duration of the disease was 17 and 22 hours. Clinically, the diagnosis was beyond doubt and was confirmed by ultrasound examination, which revealed a sharp depletion of testicular blood flow, which required active surgical tactics and abandonment of conservative hernia reduction. In the first case, transient testicular ischemia was noted due to compression by hernial contents in the inguinal canal with its clear viability during the process of decompression and intraoperative observation. In the second child, with a disease duration of 22 hours, revision of the inguinal canal revealed ischemia (reversible) of the small intestinal loop and compression of the elements of the spermatic cord with testicular necrosis, which required orchiofuniculectomy. In one child, a secondary hematocele was observed against the background of traumatic hemoperitoneum. In our observation, birth trauma of internal organs (liver rupture) in a child five hours old was manifested by a drop in red blood counts, attributed to concomitant somatic perinatal pathology. The diagnosis was made after several hours by visualization of a bilateral hydrocele and a hematoma extending to the thighs and anterior abdominal wall (Figure 2). Further ultrasound examination clarified the diagnosis of abdominal injuries and excluded direct testicular injury. In this observation, we had to refrain from surgical intervention on the abdominal organs due to severe concomitant pathology (SDR, prematurity, IVH), which led to death. A puncture of the scrotum was performed with two groans and a total of 28 ml of liquid blood was evacuated. We consider leaving blood in the scrotal cavity undesirable due to the likely development of orchiepididymitis, secondary infection and adhesions in the serous cavity.

Figure 2. Clinical case of secondary hematocele secondary to traumatic hemoperitoneum

In general, in comparison with the results of treatment of acute testicular disease syndrome in other age groups, greater surgical activity and a greater number of adverse outcomes with loss of the gonad are noted [4,6] (Table 3).

Table 3. Correlation of treatment methods and outcomes of VA syndrome in newborns*

For all values ​​p<0.05

* We do not consider the older age group in detail, since it is beyond the scope of this work, giving only comparative values.

conclusions

Based on the analysis of the literature and our own material, we believe that acute diseases of the scrotal organs are a serious pathology, often leading to loss of the organ and a decrease in reproductive potential. The most accessible and informative diagnostic method, as in older age, remains ultrasound with Doppler. However, there are a significantly larger number of errors, many of which relate to the differential diagnosis of testicular volvulus and thrombosis of the vessels of the spermatic cord with the assessment of blood flow in the affected organ, due to its low-velocity nature and small diameter of the vessels, which makes it necessary to focus on indirect data from the clinic and ultrasound, and not accept ultrasound as the gold standard for diagnosis. Thus, the use of ultrasound and Doppler ultrasound in combination with a focus on clinical data can significantly increase the accuracy of diagnosis. In some cases (thrombosis of the vessels of the spermatic cord), an urgent picture develops against the background of systemic transient conditions, respectively, their timely correction is the prevention of acute pathology on the part of the reproductive organs. Inflammatory diseases of the scrotal organs are characterized by a more aggressive course and a higher frequency of destructive forms, which forces more active surgical tactics. In general, the course of all groups of diseases included in the acute scrotal syndrome is more severe and with worse outcomes, which reduces the time for diagnostic measures and justifies more active surgical tactics. In the neonatal period, more than 70% of patients are operated on and loss of the gonad is accompanied by more than 40% of operations, while in older age slightly more than 20% are operated on, and organ-removing operations account for only 7.6%. Based on the analysis of the material, we believe: improving the treatment outcomes of newborns with acute scrotal syndrome and preserving reproductive potential are possible only if the following organizational and clinical provisions are observed.

1. Greater alertness of doctors working with this group of children at the stage of primary neonatal care and rapid transfer to specialized institutions (departments)
2. Only the comprehensive use of diagnostic methods (ultrasound + ultrasound examination) in combination with the clinic and their use in a short time allows us to establish the correct diagnosis. To date, ultrasound dopplerography, in isolation from ultrasound, cannot be the “gold standard” for assessing the viability of the gonad in a newborn and a method for determining management tactics.
3. Despite the tendencies of conservatism in the treatment of acute scrotal syndrome in children, in general, active surgical tactics in newborns are fully justified and in some cases avoid testicular necrosis and inflammatory complications of the gonad leading to orchiectomy.

Literature

1. Abaev, Yu.K. Acute scrotum syndrome in newborns / Yu.K. Abaev // Medical news. 2007. - No. 2. - P.21-25.

2. Biplab, N. Neonatal testicular torsion: a systematic literature revive / N. Biplab, LN Feilim // PediatrSurdgInt. 2011. – Vol.27. – P.1037-1040.

3. Zerin JM, Testicular infarction in the newborn: ultrasound findings / JM Zerin, MA DiPietro, A. Grignon et al. // PediatrRadiol. – 1990. – Vol.20. — P.329-30.

4. John, CM Neonatal testicular torsion – a lost cause / CM John, G. Kooner, DE Mathew et al. // ActaPaediatr. 2008. - Vol.97. – P.502-504.

5. Yerkes, EB Management of perinatal torsion: today, tomorrow or never? / E. B. Yerkes, F. M. Robertson, J. Gitlin et al. // J. Urol. 2005. - Vol.174. – P.579-582.

6. Knight, PJ The diagnosis and treatment of the acute scrotum in children and adolescents / PJ Knight, LE Vassy // Ann Surg. 1984. - Vol.200. – P.664-673

7. Clinical andrology / V.B. Shill, F. Kokhmaira, T. Hargriva // M.: GEOTAR-Media. 2011. - P.800.

8. Ehrenkranz, RA Partial Exchange Transfusion for Polycythemia Hyperviscosity Syndrome / RA Ehrenkranz, MJ Bizzarro, PG Gallagher // AmJPerinatol. 2011. - Vol.28(7). — P.557-564

9. Shchedrov D.N. Optimization of diagnosis and treatment of acute epididymitis in children: Abstract of thesis. dis. Ph.D. honey. Sci. – M., 2011. – 18 p.

10. Therapeutic tactics for acute epididymitis in children / A.Yu. Pavlov, T.N. Nechaeva, D.N. Shchedrov // Urology. – 2010 – No. 4-S.78-82.

The article was published in the journal “Bulletin of Urology”. Issue No. 4/2014 pp. 25-35

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Bulletin of Urology No. 4/2014

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How to prepare for hernia surgery?

Scrotal hernia surgery is usually planned and has to wait for some time. At this time, the hernia can not only cause pain, but also increase significantly. Most types of hernias (not only abdominal, but also inguinal, umbilical, esophageal or incisional) do not pose an immediate threat to life, but if they are strangulated, serious problems can arise.

To prevent this from happening, you must follow certain rules of behavior and, in addition, you need to carefully prepare for the upcoming operation.

• Check if you are vaccinated against hepatitis B. To do this, you need to take an antibody test. If there are few of them, you need to get vaccinated.
• If you suffer from any chronic illness, take the recommended medications regularly to prevent your overall health from deteriorating.
• Avoid colds and any infections that may cause sneezing and coughing. These are situations in which abdominal pressure quickly increases, which can lead to the growth of the hernia or even strangulation.
• Don't overeat because after eating, the pressure in your stomach also increases. Before and after surgery, significantly reduce the amount of food you eat, but eat more often, 5-6 times a day.
• Avoid constipation. The pressure when attempting to defecate can be so intense that it will significantly enlarge the hernia. If you have a tendency to constipation and bloating, be sure to change your diet - eat more foods rich in fiber (vegetables, fruits, dark bread).
• Don't lift heavy objects. This is the main cause of strangulated hernias.

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About 25% of all operations performed in the world are hernia repairs. Hernias of various locations and inguinal hernias in particular are one of the most common diseases. Despite this, very often, especially in Russia, especially male patients, especially those engaged in physical labor, do not attach importance to a suddenly appearing lump in the groin area.

The appointment is conducted by a surgeon of the highest qualification category Solovyov Alexander Ivanovich

Unfortunately, social conditions and the security of a working person, the fear of losing a job, even for a short time, are a powerful inhibitor to going to a consultation with a surgeon. And when the “bump” in the groin grows to an impressive size and simply interferes with walking and performing natural needs, patients consult a doctor. It turns out that it is criminally unnecessary for men to delay the time to go to the surgeon. One of the formidable complications of any hernia is strangulation, when the internal organs emerging through the hernial orifice are compressed by the strangulation ring, and their gradual necrosis occurs. This condition often leads to fatal consequences. A less formidable, but probably more relevant, complication for young men is a disorder of reproductive and sexual function. Evidence has been obtained that a decrease in sexual activity and one of the causes of infertility in men after hernia repair is a decrease in the level of blood flow through the spermatic artery.

Based on the studies conducted, we can conclude that the degree of inhibition of blood flow in the a.testikularis is determined by:

• the period of existence of the hernia (“experience” of hernia);
• the size of the hernia (the larger the hernial protrusion, the more traumatic the operation.

It is known that one of the factors influencing spermatogenesis is the inguinal hernia itself. The main anatomically determined types of hernia are oblique and direct inguinal hernias. With an indirect inguinal hernia, the hernial sac with its contents is located in close contact with the arteries and veins of the spermatic cord, which leads to a greater negative impact on these anatomical structures. The greatest negative effect on the spermatic cord is found in the inguinal scrotum form of hernia. With a direct inguinal hernia, the hernial sac penetrates the inguinal canal outside the spermatic cord, causing a less pronounced effect on its entire neurovascular complex as a whole. Among the reasons causing dysfunction of the testicle with inguinal hernia , the following can be noted:

• 1) chronic testicular hypoxia due to prolonged compression of the arteries and veins of the spermatic cord by the contents of the hernial sac;
• 2) change in temperature in the testicle area on the side of the inguinal hernia due to venous stasis in the pampiniform plexus;
• 3) direct pressure on the testicle from the hernial contents with the frequent formation of concomitant hydrocele of the testicular membranes.

A significant factor that negatively affects testicular function during a hernia is a change in the temperature of the scrotum and, as a consequence, a violation of the thermoregulation of the testis itself. The anatomical structure of the vascular system of the testicle is an important device for maintaining constant temperature and stability of spermatogenesis in it. Spermatogenesis normally occurs at a temperature 2-3°C below body temperature. When venous outflow is disrupted due to blood deposition in the veins of the pampiniform plexus, the temperature of the testis itself increases, which negatively affects spermatogenesis

And finally, there is another important factor that significantly influences fertile function in men of reproductive age. In surgical hospitals in the city, when performing operations for inguinal hernia, tension methods of inguinal canal plastic surgery are used. In rare cases, prosthetic plastic surgery is performed using polypropylene implants. Due to their cheapness. However, many modern studies, both foreign and domestic, have proven that standard polypropylene mesh induces a severe scar process in the inguinal canal area involving the vas deferens. This phenomenon is the morphological basis for the subsequent development of obstructive azoospermia and male infertility. Routine use of this material in men of reproductive age for inguinal canal plastic surgery is UNDESIRABLE!!! The use of standard polypropylene mesh leads to the development of male infertility. The fact is that the mesh is in contact with the spermatic cord over a large area. This leads to the formation of rough connective tissue in the area of ​​the vas deferens and, as a consequence, to infertility. After implantation of the mesh into the inguinal canal, paraprosthetic granulomas are formed, the cord fuses with the mesh, and the lumen of the vas deferens narrows by 75%, with the maximum in the area of ​​the edge of the mesh. The use of polypropylene mesh cannot currently be recommended for use in young men.

Only the use of modern endoprostheses made of polyvinylidene fluoride, Uniflex, Fluorex and Reperen during inguinal canal plastic surgery does not cause gross cicatricial changes in the structures of the spermatic cord, does not affect its patency, and therefore will not cause infertility in men. The surgical department of LDC PERESVET has all the necessary consumables (modern mesh endoprostheses, suture material), and in addition, modern surgical and anesthesia equipment of the highest quality in order to assist you in such a delicate problem as the treatment of inguinal hernia in men . To do this in the most gentle way possible at a high European level.

BE HEALTHY, DEAR MEN!!!

Sincerely, surgeon Alexander Solovyov

Complication of scrotal hernia - strangulation

The most dangerous condition is when the hernia in the scrotum is strangulated. In this case, the part of the intestine that prolapses into the hole in the abdominal wall is compressed, preventing the intestine from returning to the abdominal cavity. Contents in this area cannot move further, resulting in a blockage.

The intestine itself is limited in blood supply and soon, due to ischemia, necrosis develops in this area. It is not difficult to detect pathology. The hernia, which was still soft, becomes hard and painful. The skin becomes red and hot. After a few hours, bloating, sharp abdominal pain, nausea, and sometimes vomiting appear.

Causes, mechanism of formation of pathology

There are two fundamental elements in the formation of an inguinal hernia increased intra-abdominal pressure and weakness of the muscular-ligamentous apparatus of the inguinal canal .

Under the influence of high pressure in the abdominal cavity, movable organs are displaced from their usual place and protrude through weak spots in the abdominal wall. A hernial sac with a hilum in the area of ​​the inguinal canal is visually identified. In women, the hernia may extend down into the labia majora. An inguinal hernia in men can spread into the scrotum.

The organs involved in hernia formation include the loops and mesentery of the small intestine, the cecum, the greater omentum, the ureters and bladder, the uterus, the fallopian tubes, and the ovaries.

Factors contributing to the formation of inguinal hernia in adults are the following:

• Burdened heredity;
• Exhausting physical activity with lifting heavy loads - professional weightlifting, loader profession, weight lifters;
• Multiple, multiple pregnancies, childbirth;
• Surgical treatment of prostate tumors, appendicitis;
• History of hernias of any localization;
• Loss of muscle strength and ligament elasticity with age;
• Chronic constipation;
• Prolonged paroxysmal cough;
• Anorexia, obesity 2-3 degrees.

Clinical picture

Symptoms of an inguinal hernia at the onset of the disease are not pronounced. For a long time, the pathology does not cause discomfort, does not reduce the quality of life, and progresses slowly. A small protrusion in the groin area is painless, softly elastic, and resembles an enlarged lymph node. Periodically, the swelling disappears.

As the hernial sac grows, complaints of pain when walking, physical activity, a feeling of fullness, and pressure in the lower abdomen appear. Dyspeptic symptoms are added - a feeling of heaviness, belching, nausea, vomiting; constipation, flatulence, difficulty urinating.

A characteristic sign is increased pain and discomfort when sneezing , coughing, or straining . In the case of an indirect hernia, asymmetry of the scrotum or labia majora is observed with an increase in the affected side. , a clinical picture of an “acute” abdomen appears : sharp pain in the area of ​​the hernia, the hernia ceases to be reduced.