Hernias, Testicle Problems and Other Common Surgical Conditions

When to Come In

Coming to Limi? Call 0813 408 5400 on the way so the team can prepare, and have someone else drive if you can.

Where to Look

Most of these conditions are found at nappy changes and bath time. Knowing where to look helps you describe what you have seen to the doctor.

Take a photo on your phone of a lump that comes and goes, because it may have gone back in by the time you see the doctor.

Umbilical Hernia: A Bulge at the Belly Button

Before birth, blood vessels pass through a gap in the tummy muscles at the belly button. Sometimes the gap takes a while to close after birth, and a soft bulge pokes out, getting bigger when the baby cries, coughs or strains, and flattening when they are calm. It is very common in African babies and in babies born early. It does not usually hurt.

Most close by themselves by 3 to 5 years, even large ones. A surgeon advises an operation if it is still there at 4 or 5 years, if it is very large, or if it ever becomes stuck. Umbilical hernias in children rarely get stuck, but if the bulge becomes hard, painful, red or dark, or will not go back, come in now.

Inguinal Hernia: A Lump in the Groin

Before birth, each testicle travels down from the tummy into the scrotum through a channel in the groin, which should then close. If it stays open, a loop of bowel or fluid can slip down into it. This makes a soft lump in the groin or scrotum that comes and goes, often showing when the child cries or strains and disappearing when they are asleep. Girls have the same channel, and in them the lump is in the groin or the fold of the labia. Inguinal hernias are more common in boys and in babies born early.

An inguinal hernia does not close by itself, and it can become stuck (incarcerated). So every inguinal hernia needs an operation, which is usually planned soon after the diagnosis — sooner for young babies, who have the highest risk of the hernia getting stuck. The operation closes the channel through a small cut in the groin, and many children go home the same day.

Hydrocele: A Fluid-Filled Scrotum

A hydrocele is fluid around the testicle. It makes the scrotum look swollen, often on one side. It is soft, painless, and does not bother the baby. Hydroceles are very common in newborn boys and most disappear by the age of 1 to 2 years as the fluid is absorbed.

If the swelling changes size during the day — smaller in the morning, bigger in the evening — the channel in the groin is still open (a communicating hydrocele). This behaves more like a hernia and a surgeon needs to see it. An operation is usually offered if a hydrocele is still there after about 2 years, or appears in an older child. A doctor can tell a hydrocele from a hernia by examining your child, sometimes with a torch or a quick ultrasound scan.

Undescended Testis

In some boys, one or both testicles have not come down into the scrotum by birth. This is more common in babies born early. Some come down by themselves in the first few months. If a testicle is still not in the scrotum at 3 months, your baby should see a children's surgeon.

Surgery (an orchidopexy) is recommended ideally between 6 and 12 months, and by 18 months at the latest. A testicle that stays in the warmth of the tummy or groin does not develop as well, which affects fertility later. It also has a higher risk of cancer in adult life, is harder to check, and is more likely to twist. Bringing it down early gives it the best chance to develop and makes it easy to examine. Hormone injections are not recommended as a treatment.

Many boys have a retractile testis: it slips up into the groin when cold or touched, but can be brought down gently and stays for a while. This is usually normal but should be checked each year, as a few go up permanently. If neither testicle can be felt in a newborn, especially with any other difference in the genitals, the baby should be seen by a specialist in the first days.

Testicular Torsion: Sudden Pain Is an Emergency

Torsion is when a testicle twists on its cord, cutting off its blood supply. It is most common in teenage boys, but can happen at any age, including in newborns. The testicle can usually be saved if the operation happens within about 6 hours; after that, the chance falls quickly.

• Sudden, severe pain in one testicle, sometimes felt in the groin or lower tummy
• Swelling or redness of the scrotum; the testicle may sit higher than the other
• Feeling sick or vomiting
• In a baby, a swollen, dark or firm scrotum with crying

Go straight to the emergency department — do not wait until morning, do not give pain relief and see if it settles, and do not wait for a scan appointment. When torsion is likely, a surgeon operates straight away to untwist and fix the testicle, and fix the other side so it cannot twist later.

The Foreskin and Circumcision

A Foreskin That Does Not Pull Back

In baby boys, the foreskin is normally stuck to the head of the penis and cannot be pulled back. It separates slowly and naturally over many years; in most boys it pulls back easily by the teenage years. This is not a disease. Do not force it back — this causes pain, bleeding and scarring. Clean only the outside. The foreskin may balloon a little when weeing; if the stream is good and there is no pain, that is normal.

See a doctor if your son has pain when weeing, a red and swollen foreskin, repeated infections, or a tight white ring at the tip. If the foreskin gets stuck behind the head of the penis and swells (paraphimosis), come in now.

Circumcision

Many Nigerian families circumcise their sons for religious, cultural or health reasons. Whether to circumcise is a family decision. What matters most is that it is done safely:

• By a trained health worker, with clean, sterile instruments, in a clinic or hospital
• With proper pain relief — babies feel pain; a local anaesthetic should always be used
• On a healthy baby — wait if your baby is unwell, very jaundiced or born early
• Not if the opening is not at the tip of the penis (hypospadias) or the penis looks unusual in any way — the foreskin may be needed to repair it later. A surgeon should see the baby first.
• Not before telling the doctor about any bleeding problems in the family

Circumcision by untrained practitioners, with shared or unclean blades, causes heavy bleeding, infection, tetanus, and sometimes lasting injury to the penis. After any circumcision, watch for bleeding that does not stop with firm pressure, no wee for 8 hours, swelling, pus or fever — see the warning signs above.

Pyloric Stenosis: Forceful Vomiting in Young Babies

The pylorus is the muscle at the outlet of the stomach. In some babies it thickens in the first weeks of life and blocks milk from leaving the stomach. It is more common in boys, often the first-born.

• Starts usually between 2 and 8 weeks of age
• Projectile vomiting — milk shooting out forcefully, sometimes across the room — after most feeds, getting worse over days
• The vomit is milky or curdled, not green
• The baby is hungry and wants to feed again straight after vomiting
• Fewer wet nappies, fewer stools, weight loss, and later sleepiness

It is different from ordinary posseting, where small amounts of milk dribble out. A baby with forceful vomiting after feeds needs to see a doctor the same day, and to come in now if they have fewer wet nappies or are sleepy. Pyloric stenosis is confirmed with an ultrasound scan. Babies first get fluids through a drip to correct dehydration and salt levels, then a short operation (pyloromyotomy) to loosen the muscle. Most babies feed normally within a day or two and have no further problems.

Green vomit is different and may mean a twisted or blocked bowel. At any age, green vomiting means come in now.

Intussusception: Bouts of Screaming

Intussusception is when one part of the bowel slides into the next, like a telescope, causing a blockage. It is most common between about 6 months and 2 years, but can happen from 3 months to older children. It is an emergency.

• Sudden bouts of severe crying or screaming, with the knees drawn up to the tummy, often every 15 to 20 minutes
• Between bouts, the child may seem well, or pale, quiet and floppy
• Vomiting, which may become green
• Poo with blood and mucus that looks like redcurrant jelly — this is often a late sign, so do not wait for it

It is diagnosed with an ultrasound scan. Many children are treated without an operation, using air or fluid passed gently into the bowel through the bottom, under X-ray or ultrasound, to push it back. If that does not work, or the child is very unwell, an operation is needed. The sooner it is treated, the more likely it can be fixed without surgery.

What People Say, and What Is True

Questions Parents Ask

At Limi, paediatric surgery and paediatric urology work under one roof with the NICU, the PICU and emergency assessment day and night. Read about the children's surgery service and paediatric urology at Limi.