Paediatric Acute care Guidelines PMH Emergency Department

Background 

  • Inguinal hernias may present in both sexes, and may present insidiously or as an emergency
  • Any acute swelling or pain of the scrotum warrants urgent review by a surgeon since torsion of the testis and incarcerated hernia are both surgical emergencies – refer to Scrotal Pain or Swelling

Incidence

  • Ranges between 1-5%
  • Incidence is higher in premature infants: 15-25%
  • Boys are effected 9 times more than girls
  • Right sided predominance is well established (60% vs 30%)
  • 10% are bilateral in full term infants and nearly 50% in premature & low-birth-weight infants

Assessment  

  • Infants develop a bulge/swelling in the inguinal region that does not reduce spontaneously 
  • There is usually a cough impulse
  • When the child relaxes the hernia either reduces spontaneously or can be reduced with gentle pressure, firstly posteriorly to free it from the external ring, and then upward toward the peritoneal cavity
  • If testis is not in the scrotum, groin swelling may contain the retractile or undescended testis resembling a hernia
  • In girls, an ovary may be present in the hernia sac (risk of torsion/infarction); do not attempt reduction
  • Infants with incarcerated hernia are often irritable and crying due to discomfort and pain

Management 

  • Analgesia (e.g. morphine) 
Bowel Compromised
  • Tender tense swelling with redness and induration, with no impulse on crying in a distressed infant. 
  • Resuscitation 
  • Urgent surgical consult. Do not attempt to reduce the hernia in the ED
  • Prepare for theatre
  • Admit
Bowel Not Compromised 
  •  Gentle manual reduction can be attempted in the Emergency Department after appropriate analgesia is provided (e.g. morphine) 

< one month of age

Neonates have a greater risk of complications from inguinal hernias. Even if the hernia is easily reduced – 

  • Discuss with surgeon regarding possible admission and surgery

> one month of age

  • Hernia is irreducible
    • Urgent surgical consult
  • Hernia reduced with difficulty
    • Surgical consult
  • Hernia Easily Reduced
    • Discharge home
    • Outpatient surgical review for elective surgery 

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