As summer is upon us many pediatricians and family practice doctors will be doing sports and camp physicals. I am often amused by the various reactions of adolescent boys when it is time for the “hernia exam”. This reaction is greatly amplified should there be a twin or another brother in the room at the time.

 

Upon completing my exam the young man is usually in his underpants or boxer shorts. I have him stand up facing me to be sure the alignment of the legs is normal. Next, he squats down like a baseball catcher, then stands back up to check the knees. Then he turns around and faces the opposite wall with feet together, bends over, and tries to touch his toes. This is to check the back for scoliosis. Now I have him turn around and face me. Knowing what is inevitably to come next, some boys lose it at this point and start laughing or giggling, getting all silly. This is tremendously augmented by a sibling who is in the room. There is snickering, laughing and pointing at the brother who is the poor victim. I have found that when I say to the taunting sibling, “It’s OK. Laugh now, but YOU are next,” the giggling suddenly stops and it isn’t quite as funny anymore. But they certainly knew this moment was coming. They had talked about it all week long and had dreaded this time.

 

What really helps diffuse this nervous part of the exam is to explain to them what I am actually checking for and why.

 

I have found that this is more meaningful to many parents as well. First, I look at the genital area to determine the stage of sexual development. There is a standard system known as the Tanner Stage for both boys and girls. It goes from Tanner Stage I (no secondary sexual characteristics) to Tanner Stage V (adult sexual characteristics). It is important that the Tanner Stage be consistent with his chronological age. Next, I palpate the groin to be sure that there are no enlarged lymph nodes in the inguinal area. The scrotal is then palpated to assess that both testicles are properly situated in the scrotum and are the appropriate size for age. Some testicles can “ride high” and be up in the inguinal canal. This is not an issue if it can easily be brought down into the scrotum. I also want to be sure there is not a varicocele, hydrocele or a hernia.
 

There are two large veins in the scrotum that carry blood back to the heart. Both veins have a network of smaller veins called the pampiniform plexus.

 

These smaller veins can become dilated and enlarged. This is what a varicocele is. It feels like a ropy bag of worms but is not painful or tender, and does not cause any symptoms. A potential problem with a varicocele is if it is large enough it may hamper the growth of the testicle on that side and may decrease the actual sperm count. If a varicocele is discovered the patient should see an Urologist to determine if anything should be done to treat it.

 

A hydrocele is a benign collection of fluid in a sac-like structure that occurs within the scrotum. It is not dangerous or serious. But if it is large enough it may cause some discomfort. Most of these can simply be observed, but if there is pain or discomfort an Urologist should be seen.

 

It goes without saying that when doing a scrotal exam we are ALWAYS on the lookout for any tumors or masses that may potentially be cancerous.
 

Lastly is a hernia.

 

In a developing fetus both testicles are within the abdomen. They migrate down into the scrotum by passing through a tube-like structure known as the inguinal canal. After this occurs the opening of the canal in the scrotum completely closes. If this opening does not close there remains a communication between the abdomen and the scrotum. This is what a hernia is. This can be a problem if a portion of the intestine bulges into the scrotum. It can get trapped and the blood supply to the intestines can be compromised. This can lead to a surgical emergency (incarcerated hernia).
 

The way we check for a hernia is to feel the area where the canal opening would be with our index finger.

 

Then the patient coughs or strains to see if any intestine can be felt in the scrotum. By coughing or straining the intra-abdominal pressure is increased making a hernia obvious. Anyone who has a hernia can find that strenuous weight lifting or intense athletic sports could lead to serious complications.

 

Less commonly, lichen stratus may involve the nail of a finger or toe.

 

This may cause the nail to become ridged, split, discolored or may actually fall off. This would involve only the nail and not the skin of the finger. This is quite rare with only 30 cases reported in the literature as of 2020. This, too, will completely resolve in time. However it may take well over a year. When it does resolve, a perfectly normal nail should grow back.

 

This usually concludes my physical exam.

 

It is often met with a big “whew” by the relieved patient. Then follows a deep groan by the sibling who is next. What is most rewarding is the reaction of many parents who confess that they never really understood what a hernia actually was or what we were looking for during this part of the exam.