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NICU guideline identifier

Genital, inguinal and scrotal problems in the neonate

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Examination after birth frequently reveals abnormalities in the inguinal, scrotal, or genital regions. Some of these abnormalities require urgent attention; others require non-urgent referral, or parental reassurance.

Hydrocoele

Hydrocoele

Persistence of the processus vaginalis results in peritoneal fluid in the scrotum around the testis or spermatic cord

Clinical findings

  • Swelling in the scrotum 
  • Can be unilateral or bilateral
  • Skin may have bluish discolouration if large
  • Can fluctuate in size (if communicating)
  • Has a distinct upper margin
  • Transilluminates
  • Non-tender
  • Rare in females
  • Careful examination to ensure that testis is present and that there is no inguinal hernia

Management

  • Reassurance
  • Surgical review if still present at 18 months or diagnostic uncertainty at any age

Inguinal hernia

Inguinal hernia

Swelling in inguinal region (can extend to scrotum in males, or to labia in females) secondary to persistence of a wide processus vaginalis, with herniation of bowel (or, in females, the ovary). More common in premature infants and infants with raised intra-abdominal pressure

Clinical Findings

  • Inguinal swelling (can extend to the scrotum in males or labia in females)
  • Difficult to define the upper margin of the swelling (unlike hydrocoeles)
  • Usually reducible
  • Will be firm and tender if incarcerated
  • May transilluminate

Management

  • If reducible and infant in NICU - non-urgent surgical referral for surgical repair prior to discharge
  • If reducible and infant at home - discuss with surgical registrar (will usually be repaired within 1-2 weeks)
  • If incarcerated, urgent surgical referral

Undescended testes (cryptorchidism)

May affect 2% of males. Testes should be in the scrotum by birth/term. In these infants a testis can be said to be undescended by 3 months. In preterm infants this can be confidently diagnosed by 6 months post delivery

Clinical Findings

  • The scrotum may be smooth and underdeveloped or may look normal
  • Assess penile size and any abnormalities (note: undescended testes and hypospadias indicates an intersex disorder till proven otherwise)
  • Examine infant for other abnormalities (association with other syndromes, e.g. Smith-Lemli-Opitz, Oto-Palato-Digital, Prune Belly Syndrome)

Management

  • If possible intersex disorder, refer to the ambiguous genitalia guideline
  • For males with undescended testes, refer to paediatric surgical clinic
  • If remain undescended, orchidopexy usually performed within the first year. If associated with a hernia refer as per hernia guidelines

Testicular torsion

In neonates, testicular torsion is typically perinatal in origin. Is also associated with undescended testes

Clinical Findings

  • Tender, red firm and enlarged testis
  • Will not transilluminate
  • Usually unilateral (but can be bilateral)
  • Differential includes testicular tumour

Management

  • Urgent referral to paediatric surgery
  • Imaging (ultrasound with Doppler) may be useful but should not delay surgical referral

Torsion of the testicular appendages

May mimic testicular torsion. Testicular appendages are only palpable when torsion has occurred

Clinical Findings

May see a blue dot (ecchymosis) on the scrotum

Management

Urgent referral as per torsion with no ultrasound

Penile torsion

Counterclockwise (usually) rotation of the penile shaft, with meatus pointing obliquely.

Clinical Findings

  • Median raphe of the penis spirals to the meatus
  • May be associated with hypospadias

Management

Non-urgent referral to paediatric surgery

"Buried" penis

Penile shaft is hidden under the pre-penile skin

Clinical Findings

  • Penis is buried under the suprapubic fat pad
  • Ensure penile length is normal

Management

Non-urgent referral to paediatric surgery

Hypospadias

See hypospadias guideline

Microphallus

See ambiguous genitalia guideline

Other causes of groin/ scrotal swelling

A range of other conditions may cause scrotal swelling including:

  • Ectopic or strangulated gonads
  • Varicocoele (not in neonates)
  • Intra-abdominal (e.g. adrenal) haemorrhage
  • Pneumoperitoneum
  • Calcifications following healed meconium peritonitis
  • Testicular tumour
  • Epididymitis (in association with UTI)

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Document Control

  • Date last published: 31 March 2015
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years