Paediatrics

at a Glance

Lawrence Miall, Mary Rudolf, Dominic Smith

Case Studies

Case 7: A swelling in the groin

A 9-year-old boy is at home with his parents when he suddenly complains of a pain in his right groin. He has been playing football all afternoon. As a baby he had a hydrocele on the right side of his scrotum but this disappeared when he was about 12 months old. His father has a look at his groin area and noticed the right side of his scrotum is swollen and extremely tender. He telephones the family doctor for advice as to what he should do next.

  • (a) List four conditions that should be in the GP’s differential diagnosis for this presentation?

    Show Answer

    Hydrocele, inguinal hernia, testicular torsion, trauma to the testes.

  • (b) What features on examination will differentiate between them?

    Show Answer

    • A hydrocele will transilluminate light from a pen-torch or otoscope, due to the presence of fluid around the testes. It is unusual for a hydrocele to recur having resolved in early childhood.

    • An inguinal hernia will become more prominent on coughing and it is difficult to delineate the upper margin of the swelling. It is not normally painful unless incarcerated.

    • Testicular torsion tends to occur in teenage boys and is acutely painful with a red tender mass present in the scrotum.

    • Trauma may be caused by a direct blow to the scrotum, although there would normally be a clear history of this.

    • Mumps is a viral infection that is now rare due to the MMR (mumps, measles, rubella) vaccine. It presents with malaise, fever and parotid swelling. It can be associated with orchitis (testicular inflammation) and can lead to subfertility.

  • (c) If the boy had complained of a headache, a swollen face and a fever in the preceding days, what other condition might you consider?

    Show Answer

    These are the features of an incarcerated inguinal hernia. The fact that you cannot get above the swelling is because the hernia sac (usually containing bowel) is coming down the inguinal canal. If there is doubt an ultrasound can be helpful. The treatment is surgical reduction, with closure of the internal ring of the inguinal canal.

  • The GP sends the boy to the local hospital for review by a paediatric surgeon. The surgeon finds a tense red swelling in the right scrotum and inguinal canal. It is difficult to ‘get above it’ and the testis is not easily palpable on that side. The swelling is not reducible.

    • (d) What is the diagnosis and what is the treatment?

      Show Answer

      These are the features of an incarcerated inguinal hernia. The fact that you cannot get above the swelling is because the hernia sac (usually containing bowel) is coming down the inguinal canal. If there is doubt an ultrasound can be helpful. The treatment is surgical reduction, with closure of the internal ring of the inguinal canal.

    • (e) What is the danger of delaying treatment?

      Show Answer

      The danger of delayed treatment is if the incarcerated (irreducible) hernia contains bowel which is strangulated and becomes ischaemic. This can lead to necrosis or perforation of that segment of bowel, requiring resection and anastomosis.

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