If the child is male, inspect the penis. If you have occasion to retract the foreskin, return it to its normal position.
Inspect the scrotum. Is there any unilateral enlargement present? Suspect a hydrocele or hernia if the scrotum appears large. Use transillumination, and auscultate any scrotal mass.
Palpate the testicles. Are both present in the scrotum? In this age group, the testicles can often become retracted into the inguinal canal. If one or both testicles are not felt in the scrotum, try manipulating the testicle from the inguinal area into the scrotum. If that maneuver fails, tell the child to sit on a chair with his feet on the seat. Instruct him to grab his knees. Repeat the palpation. This additional abdominal pressure may force a retracted or undescended testicle into the scrotum. Warm hands and a warm room often aid in this procedure.
Another useful maneuver to counteract an active cremasteric reflex is to have the child lie down supine and flex his leg at the knee, placing his foot on the opposite leg. This ''tailor position'' brings the tendon of the sartorius muscle over the inguinal canal and prevents an active reflex from retracting the testicle.
Palpation for an inguinal hernia can usually be performed in children 4 years of age and older. The procedure is the same as in adults and should be performed with the child standing.
If the child is female, inspect the vaginal area. Is a rash present? Rashes may be related to bubble baths. Is a discharge present? A discharge in girls aged 2 to 6 years may be related to a foreign body in the vagina. A nasal speculum can be used by an experienced examiner to inspect the vagina for the cause of the discharge. Look for an intact hymen and a smooth vaginal opening. Be on the lookout for sexual abuse. The most important signs of abuse include difficulty walking, vaginal or anal infections, genital irritation or swelling, torn or stained underclothes, vaginal or anal bleeding, and bruises. Most children who have been sexually abused, however, exhibit no physical findings.
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