Paediatric Surgical Conditions

See also undescended testes (kept as its own page under Genitourinary), and hirschsprungs disease.

Referral timeframes at a glance

Condition	Referral timing
Inguinal hernia — neonate	1 week
Inguinal hernia — infant	2–4 weeks
Inguinal hernia — child	1–3 months
Phimosis — pathological	1–3 months
Undescended testis	3–6 months
Umbilical hernia	After 3 years of age
Epigastric hernia	After 3 years of age
Phimosis — physiological	After 7 years of age

The vomiting baby

• Check for a hernia (inspect and palpate); ask specifically about bilious vomit — yellow (fast transit) vs green (pooling in the stomach) vs orange.
• Feel for a “sausage-shaped” mass.
• A well baby with bilious vomiting may still (rarely) have malrotation — babies with malrotation can look surprisingly well.

Intussusception

Telescoping of a bowel segment into the adjoining distal segment — may follow a pathological lead point (e.g. Meckel diverticulum).

• Demographics: 3 months–4 years (peak 6–7 months), can occur birth–school age. Occurs more frequently in boys than in girls, with a ratio of approximately 3:1. Lower incidence in breastfed infants.
• Classic triad: pale child + severe colic + vomiting.
• History: sudden-onset pain with a shrill cry; episodes lasting 2–3 minutes every ~15 minutes; vomiting, colicky abdominal pain, intermittent lethargy/pallor, blood in stools, diarrhoea, often with a concurrent viral illness. Red-currant jelly stool is a late sign — don’t wait for it.
• Examination: a sausage-shaped mass may be palpable, though not always tender — especially during an attack; often suspected based on an examination, including observation of the Dance sign (evaluating the right lower quadrant for retraction).
• Investigations: ultrasound — the target or doughnut sign, usually around 3 cm in diameter, confirms the diagnosis.
• Management: surgical, or usually successfully treated with barium, water-soluble, or an air-contrast enema, which both confirms the diagnosis and successfully reduces it. May result in small bowel obstruction if untreated.

Pyloric stenosis

Birth–3 months. Look for visible gastric peristalsis in a warm room after feeding.

Inguinal hernia, hydrocele & undescended testis

Inguinal hernia occurs in 3–5% of full-term infants (13% if born <33 weeks) — underlying pathology is a patent processus vaginalis (PPV), wide enough to herniate bowel/omentum (and, in girls, ovary — 90% of female inguinal hernias contain an ovary; do not reduce these). A hydrocele’s PPV is narrow, transmitting only fluid. A 2020 AJGP review of paediatric inguinal hernia gives a similar incidence range. Inguinal hernia is six times more common in boys. The incidence of right-sided hernias is more than three times that of left-sided hernias. Bilateral hernias are more common in premature infants. In a female full-term infant, bilateral inguinal hernias that may contain ovaries should prompt investigation for possible androgen insensitivity syndrome. An ovary in the inguinal canal does not itself mandate urgent repair (some spontaneously reduce, allowing elective repair when the child is older) — but a tender ovary is a surgical emergency (possible torsion).

Examination feature	Inguinal hernia	Hydrocele	Encysted hydrocele of the cord	Undescended testis
Reducible?	Yes (unless incarcerated)	No	No	No
Skin changes	Oedema/erythema if incarcerated	No	No	No
Tender?	Yes, if incarcerated	No	No	No
Can you get above it?	No	Yes	Yes (moves with cord traction)	Yes
Transilluminates?	No (except thin neonatal bowel wall)	Yes brilliantly	May, not always	No
Management	Refer to paediatric surgeon	Observe — usually resolves by age 2; refer if persists	As for hydrocele	Refer if persists >3 months

Common confusers on examination: a hydrocele often presents for the first time with a concurrent viral illness, since this increases the amount of intraperitoneal fluid, while coughing increases intra-abdominal pressure. A hydrocele is usually irreducible but after a period of inactivity, such as overnight, may reduce. Inguinal lymphadenopathy may be confused with an inguinal hernia. Idiopathic scrotal oedema may be recognised by a subacute redness and swelling that is not usually painful. In the scrotum, a testicular tumour is firm, not reducible, and — unlike a hernia or hydrocele — the examiner can get above it; testicular torsion is suggested by an absent cremasteric reflex, an erythematous/swollen testis and abnormal lie.

• Inguinal hernia: watch and see” is not advised in Australia — incarceration morbidity and low spontaneous-PPV-closure rates mean all cases need inguinal herniotomy (PPV ligation). No investigation needed — ultrasound is often unnecessary and may just delay management. Non-reducible, vomiting or tender/irritable → urgent repair; reduction attempts should be gentle and brief. “Urgent referral to a paediatric surgeon is required for children aged <3 months with a hernia — these children should usually be seen within a week. Infants aged <1 year may have an increased risk of strangulation up to two-fold, with the highest risk in the first few months of life. A non-reducible or tender hernia needs ED referral, with simple analgesia while attempting reduction. Reduction technique: warm environment, parental consent, use one hand’s thumb and index finger to create a funnel at the superficial inguinal ring while the other hand applies gentle circular pressure guiding the hernia toward the internal ring (displacing the scrotum medially can help); if unsuccessful, refer urgently to the paediatric ED. There has been much debate over the benefits of laparoscopic versus open inguinal hernia repair, but overall there is little difference in clinical outcomes. Laparoscopy may lower the risk of cord damage/testicular atrophy and some postoperative complications, and allows inspection (and, if needed, repair) of an asymptomatic contralateral patent internal ring without a second incision — but needs specialist equipment not available everywhere, and involves entering the peritoneal cavity (small added risk of intra-abdominal viscus injury and later adhesive bowel obstruction).
• Infantile hydrocele: the straw-coloured fluid gives a “blueish hue” through the skin, often mistaken for something sinister — it’s benign. ~90% resolve by age 3 via spontaneous PPV closure; defer referral until after 3 years unless it’s increasing in size (suggests it’s actually a hernia) or the child becomes irritable.
• Varicocele: varicosity of the pampiniform plexus, present in ~15% of males; impairs testicular thermoregulation (risk of atrophy/subfertility). Mostly asymptomatic; occasional testicular ache. Almost always left-sided (venous anatomy). Feels like a “bag of worms”; examine standing then lying (empties lying down, refills with Valsalva). Ultrasound confirms and measures testicular volume — rarely, a retroperitoneal malignancy presents this way, but clinical assessment for a renal mass/hypertension/haematuria matters more than routine renal ultrasound. Refer (non-urgent) if symptomatic. A clinically significant, high-grade varicocele associated with failure of testicular development and growth in adolescent males, defined as >20% difference in testis size (not the >10% sometimes quoted), is also an indication for repair. Asymptomatic varicoceles in fertile males with normal testosterone levels do not need treatment. Correction is by laparoscopic ligation (Palomo procedure), open subinguinal/inguinal ligation, or interventional radiology (antegrade scrotal sclerotherapy/embolisation) — approaches have broadly similar success and complication rates. Repair of a clinically significant adolescent varicocele can allow catch-up testicular growth and is intended to protect future fertility, not just relieve symptoms.

Non-retractile foreskin (phimosis)

May be physiological (normal congenital preputial adhesions — ballooning with voiding, discomfort with erections, periodic focal inflammation with white “smegma” discharge are all normal and often mistaken for pathology). Resolves by age 5 in >90% of boys, but can persist into the teens. Pathological phimosis features scarring ± dysuria/straining/haematuria — consider balanitis xerotica obliterans (BXO), related to lichen sclerosus, uncommon before age 5. BXO is rare under age 5 but its childhood incidence peaks between 9 and 11 years; onset is insidious and it can present with irritation, dysuria, bleeding or (rarely) acute urinary retention before atrophy/meatal stenosis develop — this is distinct from the harmless ballooning/discomfort of physiological phimosis.

• No investigation needed. A 4-week trial of topical corticosteroid (e.g. betamethasone 0.1% BD to the phimotic segment with gentle retraction) can avoid the need for referral. A 2024 Cochrane review of topical corticosteroids for phimosis found, compared with placebo or no treatment, that topical corticosteroids may increase the complete resolution of phimosis after four to eight weeks of treatment (RR 2.73, low-certainty evidence). Compared with placebo, topical corticosteroids may also increase the long-term complete resolution of phimosis six or more months after treatment (RR 4.09, low-certainty evidence). There may be little or no difference in the risk of adverse effects between topical corticosteroids and placebo or no treatment. The review authors were uncertain of the effect of topical corticosteroids on retractability score specifically, reflecting poor reporting of study methods and important clinical heterogeneity between trials.
• Circumcision in the public system is generally reserved for surgical indications (e.g. BXO, recurrent balanitis, urosepsis) — cosmesis alone is not funded. Boys <7 years need referral only if pathological phimosis or another surgical indication exists; >7 years failing topical steroid may warrant referral, though many still avoid surgery.
• Preputioplasty (retains the foreskin, restores retractability) is an alternative to circumcision.

Umbilical & epigastric herniae; divarication of recti

• Umbilical hernia: present in 1 in 5 births, often more prominent in the first months. Usually asymptomatic; incarceration is rare. 80–90% close spontaneously by age 3–5 (especially if <1 cm at 1 year) — defer referral until 2–3 years; closure can be deferred further in children of African descent (later spontaneous closure is well recognised in this group).
• Epigastric hernia: a pea-sized midline lump above the umbilicus (extraperitoneal fat herniating through the linea alba) — best seen standing. Usually asymptomatic, occasionally causes vague epigastric discomfort (fat incarceration — not dangerous, unlike bowel incarceration). Defer referral until after age 3; leaving it uncorrected is a valid option if asymptomatic.
• Divarication of the recti: a physiological midline ridge from xiphisternum to umbilicus on straining, from normal linea alba laxity in infancy — no investigation, no referral, resolves as abdominal wall tone develops.

Non-specific abdominal pain — red flags for early ultrasound

Pain localised away from the midline; night pain; early nausea/vomiting/ bile → arrange an early ultrasound.

Appendicitis

Red flags: abdominal distension, tachycardia. Diarrhoea can occur in appendicitis — don’t let it falsely reassure you toward gastroenteritis.

Bruising in the scrotum

Isolated scrotal bruising without a clear traumatic mechanism should raise suspicion of non-accidental injury, IgA vasculitis (Henoch-Schönlein purpura), or testicular torsion.