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      Torsion of an Indirect Hernia Sac Causing Acute Scrotal Swelling in a Child

      case-report

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          Abstract

          Torsion of a hernia sac is an extremely rare condition that presents as acute scrotum in children. We report a case of a 6-year-old boy who presented with an acute scrotum and was found during surgical exploration to have torsion of an indirect hernia sac associated with hydrocele. Upon scrotal exploration, deterioration of the scrotum due to inflammatory changes was found. A necrotic cyst was recognized within a communicating hydrocele of the scrotum and was twisted at an angle of about 360°. All urologists should be aware of this special condition in the differential diagnosis of acute scrotum.

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          The incidence and investigation of acute scrotal problems in children.

          I Gollow, C Kikiros, R Pemberton … (2002)
          The true incidence of the various causes of acute scrotum in children is unclear; epididymo-orchitis (EO) is thought to be uncommon. Investigation for underlying urological abnormality in children with EO is recommended. To determine the incidence of the various pathologies in boys presenting to the emergency department with an acute scrotal condition and assess the value of further investigation of the urinary tract in a subgroup of boys with EO, a retrospective review of 100 consecutive patients admitted with a diagnosis of testicular pain was performed. Seventy had torsion of an appendix testis (TAT) and 12 had torsion of the testicle (TT). Ten boys were admitted with 11 episodes of EO; 7 had other pathologies including incarcerated hernia, varicocoele, and idiopathic scrotal oedema. The diagnosis of EO was made at operation in all 11 episodes. Escherichia coli was cultured in 4 patients; none were found to have underlying urinary tract abnormality. TAT was thus commonest causes of the acute scrotum. EO is not rare in infants, the incidence in this study being equal to the of TT. Subsequent urological investigation did not disclose any underlying abnormality. However, based on the current published literature futher investigation is recommended in selected cases.
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            Imaging of the acute scrotum.

            L Barozzi, P Pavlica (2000)
            The scrotum is a superficial structure and clinical examination is frequently not enough for making a specific diagnosis. In acute scrotal pain US can confirm the presumptive clinical diagnosis and provide additional relevant information. In testicular torsion, color-Doppler imaging has a central role since it has become possible to identify it at early stage by showing absence of perfusion in the affected testis before any gray-scale abnormality. Scintigraphy remains a satisfactory alternative in evaluating testicular torsion and should be used when color Doppler is inadequate, raising doubts about the suspected torsion. Diagnosis of torsion of testicular appendages is particularly difficult. Ischemic infarction shows a characteristic pattern at gray-scale and color Doppler imaging, whereas hemorrhagic ischemia may require MRI. Inflammatory diseases of the scrotum can be easily investigated by echo color Doppler and conventional radiography, and CT can be particularly useful in the detection of gas bubbles. In scrotal trauma, scrotal hematoma, hematocele, intratesticular hematoma, and testicular rupture can be identified using gray-scale US with very good reliability. Magnetic resonance imaging is indicated when a small tear of tunica albuginea is suspected but not visualized on US.
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              Results of Wilms' tumour management in two tertiary-care hospitals in Asia.

              K Mammen, S. Sen, M. Salti … (1997)
              In the period 1985-1995, 87 children underwent surgery for Wilms' tumour; 16 were lost to follow-up. Of the remaining children, 27 presented with stage I disease, 11 with stage II, 12 with stage III, 14 with stage IV, and 6 with stage V. One child was not staged. The histology was favourable Wilms' tumour in 44, anaplastic in 12, unclassified in 8, clear-cell sarcoma in 4, and rhabdoid tumour in 3. Although a total nephrectomy was generally performed, partial renal surgery was performed for 6 bilateral and 4 unilateral tumours, the latter including 2 fused kidneys. Preoperative chemotherapy was employed with benefit in massive tumours, tumour in fused kidneys, bilateral tumours, and preoperatively diagnosed inferior vena caval tumour thrombi. Postoperative chemotherapy, employed in all cases, consisted of actinomycin D and vincristine with the addition of adriamycin in anaplastic and advanced-stage tumours. Ten children underwent second-line chemotherapy for disease unresponsive to the above management, but only 1 of these is currently free of disease. Postoperative tumour-bed radiotherapy, used in selected cases, prevented local recurrence in stage I and II disease. However, 20% of stage I and II patients not receiving radiotherapy developed tumour-bed recurrence. Twenty-three children have died and 5 with advanced disease and incomplete follow-up are presumed to be dead. Nine children are currently on treatment; 34 have successfully completed treatment, the disease-free survival in stages I-V being 81%, 75%, 42%, 14%, and 50%, respectively. Overall disease-free survival was 69% for Wilms' tumour of favourable histology and 50% for anaplastic tumours. The 3 patients with rhabdoid tumours and 3 of 4 with clear-cell sarcomas have died. Wilms' tumour management in the developing world is compromised by cases lost to follow-up and late presentation with massive tumours and advanced stage. Preoperative chemotherapy is advantageous in a number of cases, and postoperative radiotherapy should be deployed more frequently.
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                Author and article information

                Journal
                Journal ID (nlm-ta): World J Mens Health
                Journal ID (iso-abbrev): World J Mens Health
                Journal ID (publisher-id): WJMH
                Title: The World Journal of Men's Health
                Publisher: Korean Society for Sexual Medicine and Andrology
                ISSN (Print): 2287-4208
                ISSN (Electronic): 2287-4690
                Publication date (Print): August 2012
                Publication date (Electronic): 31 August 2012
                Volume: 30
                Issue: 2
                Pages: 150-152
                Affiliations
                Department of Urology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, Yangsan, Korea.
                Author notes
                Correspondence to: Jong Kil Nam. Department of Urology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20, Geumo-ro, Mulgeum-eup, Yangsan 626-770, Korea. Tel: +82-55-360-2134, Fax: +82-55-360-2931, tuff-kil@ 123456hanmail.net
                Article
                DOI: 10.5534/wjmh.2012.30.2.150
                PMC ID: 3623525
                PubMed ID: 23596604
                SO-VID: 4b02d966-bebd-4070-af8c-5cd2e11d4d50
                Copyright © Copyright © 2012 Korean Society for Sexual Medicine and Andrology
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 07 June 2012
                Date revision received : 27 June 2012
                Date accepted : 04 July 2012
                Categories
                Subject: Case Report

                Keywords: scrotum,hernia, inguinal,torsion abnormality
                Data availability:
                Keywords: scrotum, hernia, inguinal, torsion abnormality

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