Hernias and Hydroceles

DOI: 10.1542/pir.34-10-4572013;34;457Pediatrics in Review

Lane S. PalmerHernias and Hydroceles

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Hernias and HydrocelesLane S. Palmer, MD*

Author Disclosure

Dr Palmer has

disclosed no financial

relationships relevant

to this article. This

commentary does not

contain discussion of

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investigative use of

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device.

Practice Gap

Medical management of hernias and hydroceles has changed; pediatricians need to

be aware that the urgency to surgically correct these entities depends on the nature

of the hernia or hydrocele and the likelihood of incarceration or spontaneous

resolution.

Objectives After completing this article, readers should be able to:

1. Derive the differential diagnosis of a mass in the inguinal area in an infant: hydrocele,

inguinal hernia, trauma, or tumor.

2. Understand the history and physical examination differences between an inguinal

hernia and a hydrocele.

3. Plan the evaluation of a patient with a mass in the inguinal area.

4. Appreciate the principles in the surgical management of the hernia and hydrocele in

infants and children.

Hernias and hydroceles present within embryologic and clinical continuums that are com-monly encountered by pediatricians. These conditions are typically discovered by pediatricianson routine physical examination or after a bulge in the groin and/or scrotum is noted by thechilds caretaker. The common nature of the inguinal hernia-hydrocele is documented by au-topsy studies reporting an incidence of a patent processus vaginalis in 80% to 94% in newborninfants. The importance of identifying these conditions based on the history and physical ex-amination ndings lies in averting their complications and ensuring proper referral for furthermanagement.

Embryology of the Inguinal CanalInguinoscrotal abnormalities in children are best understood by reviewing the under-lying embryology of testicular descent and the inguinal region development. At approx-imately 6 weeks of gestation, the primitive germ cells migrate from the yolk sac to thegenital ridge located high on the posterior wall of the abdomen where they differentiateinto a testis or an ovary during the next 2 weeks. During the next few weeks of fetalelongation, the gonad becomes located near the internal inguinal ring at 3 monthsof gestation. During the third month and before testicular descent, the peritoneumbulges into the inguinal canal as the processus vaginalis. The gubernaculum forms fromthe caudal end of the mesonephros and is attached to the lower pole of the testis, whereit serves to guide its descent into the scrotum. Starting in the seventh month of gesta-tion, the testes descend through each inguinal canal, pushing the vaginalis ahead of ittoward the scrotum during a few days, and then migrate from the external ring to thelower scrotum during the next 4 weeks.

The process vaginalis obliterates after testicular descent is complete. The portion of theprocessus vaginalis that is adjacent to the testes becomes the tunica vaginalis. Failure of theprocessus vaginalis to obliterate leads to the clinical entities described below.

In girls, the canal of Nuck, corresponding to the processus vaginalis in girls, usually ob-literates earlier and enters into the labiummajora. The gubernacular remnant in girls becomesthe ovarian and uterine ligaments.

*Departments of Urology and Pediatrics, Hofstra North Shore-LIJ School of Medicine, and Department of Pediatric Urology, Cohen

Childrens Medical Center of New York, Long Island, NY.

Article genital system disorders

Pediatrics in Review Vol.34 No.10 October 2013 457

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DefinitionsIndirect Inguinal Hernia

Complete failure of the processus vaginalis to obliterate leadsto a large communication between the abdomen at the levelof the internal ring and the testis (Figure 1). The protrusionof intra-abdominal contents into the peritoneal sac denesthe hernia. These contents include omentum/bowel orovary/fallopian tube, and they may extend distally fromthe inguinal region to the scrotum or labia. Therefore, mostindirect inguinal hernias are congenital.

Communicating HydroceleCommunicating hydrocele is the presence of peritonealuid in a patent processus vaginalis that protrudes acrossthe internal inguinal ring and extends distally endingalong the inguinal canal or reaching the scrotum.

Hydrocele of the Spermatic CordHydrocele of the spermatic cord is a uid collection presentalong the spermatic cord between the obliterated portionof the processus vaginalis proximally from the internal ringand distally to the tunica vaginalis surrounding the testicle.

Scrotal HydroceleScrotal hydrocele is the presence of uid surrounding thetesticle that is contained by the tunica vaginalis while theprocessus vaginalis is obliterated from the internal ring tothe upper extent of the tunica vaginalis.

EpidemiologyThe incidence rate of inguinal hernias is roughly 1% to 4% orapproximately 10 to 20 per 1000 live births. The incidence

is highest in neonates and infants anddecreases with age. Hernias are re-ported in up to 30% of prematurehernias. Among full-term infants,the incidence of hernias is highest inthe rst year of life, peaking with ap-proximately one-third presenting inthe rst 6 months, predominantlyin the rst few months. Several stud-ies report a male predilection (6:1).The predilection for a right-sided(56.2%) patent processus vaginalisis likely related to later descent ofthe right testis and obliteration ofthe processus vaginalis. Left-sided(27.5%) hernias are more likely tobe associated with an occult right-

sided hernia. Hernias are present bilaterally in 16.2%;the incidence rate of bilateral congenital inguinal herniabased on a range from several retrospective and a few pro-spective studies is approximately 15% to 25%. A familyhistory of inguinal hernias is reported in approximately20% of probands, and similarly there is a higher incidenceamong twins. Although an inguinal hernia is usually anisolated nding, there are several associated conditionsof which the pediatrician should be aware (Table 1).

Signs and SymptomsAn inguinal hernia and a communicating hydrocele typ-ically present as a painless bulge localized to the groin orextending along the cord structures to the hemiscrotumor into the vulva in girls (Figure 2). The bulge is usually

Figure 1. Hernia and hydroceles. From Palmer LS. Scrotal swelling and pain. In: McInernyTK, Adam HM, Campbell D, Kamat DK, Kelleher KJ, eds. American Academy of PediatricsTextbook of Pediatric Care. Elk Grove Village, IL: American Academy of Pediatrics;2009:17171724.

Table 1. Conditions AssociatedWith an Inguinal Hernia

PrematurityPositive family historyPresence of a ventricoperitoneal shuntCystic fibrosisAscitesCongenital dislocation of the hipUndescended testisHypospadiasDisorders of sexual differentiationExstrophy-epispadias complexPrune belly (triad or Eagle-Barrett) syndromeEhlers-Danlos syndromeHunter-Hurler syndromeMarfan syndrome

genital system disorders hernias and hydroceles

458 Pediatrics in Review Vol.34 No.10 October 2013


painless and may be present at all times or only duringperiods of increased intra-abdominal pressure, such asduring crying or bowel movements. The bulge maynot be detectable when the child is supine and the peri-toneal uid or intra-abdominal contents spontaneouslypass back into the abdomen. It is helpful to determinewhether the bulge is smallest during sleep and largerwhen the child is standing. This intermittent presenceof the bulge distinguishes the reducible inguinal herniaand communicating hydrocele from a scrotal hydroceleor hydrocele of the spermatic cord. The child with an in-carcerated inguinal hernia will have a bulge that does notreduce spontaneously. With incarceration, the child maybe irritable or inconsolable, have decreased appetite, andpresent with signs of bowel obstruction (abdominal dis-tention, vomiting, and lack of atus or stool).

The scrotal hydrocele may be present from birth or ap-pear after an inammatory or infectious process or afterscrotal trauma. The size of the hydrocele may vary andeven extend proximally though the inguinal canal tothe internal ring, making it difcult to distinguish froma hernia or communicating hydrocele. The hydrocele ofthe spermatic cord is also generally painless and variablein size. It may be confused for the testis because of itsround-oval shape.

Physical ExaminationAlthough the history is important, the physical examina-tion is vital in determining the nature of the inguinoscro-tal abnormality. Because most of these children are notyet walking, most examinations start with the child inthe supine position. The older child should rst be

examined in the standing position.Inspection should start at the lowerabdomen in the area of the lowerskin creases and then proceed alongthe inguinal canal into the scrotum.The presence of a bulge or asymme-try between the 2 sides should besought. If the child is crying, the ex-aminer should try to assess whethera bulge becomes present or in-creases during that time and im-proves or disappears when the childis consoled. Having the older childjump up and down several timesmay facilitate protrusion of thebulge.

Palpation moving systematicallyin a craniocaudal direction should

start on the asymptomatic side followed by the reportedsymptomatic side. Gentle palpation to determine pres-ence of swelling begins by using 1 to 2 ngers rst inthe area superior and lateral to the pubic tubercle, pro-ceeding along the cord structures of the inguinal ringand ending in the scrotum. The proximal and distal ex-tent of the swelling needs to be determined, if possible,to help make the diagnosis. Hernias and communicatinghydroceles start at the level of the internal ring and canend at variable locations. Applying gentle pressure up-ward and slightly laterally can frequently reduce the con-tents of the hernia sac. The palpation of a silk-stockingsign implies thicker cord structures (ie, the presence ofa hernia) and is sought by rubbing the cord structuresside to side near the pubic tubercle. The sensation is thatof rubbing silk together. A hydrocele of the spermaticcord may feel like a testis because of its shape. The exam-iner should be able to palpate cord structures both aboveand below the round-oblong hydrocele and a separate tes-tis distally. Scrotal hydroceles vary in size and may be dif-cult to distinguish from a hernia when a scrotal hydroceleextends up to the internal ring. In general, the examinershould be able to palpate the cord structures above thesuperior aspect of the hydrocele. The uid surroundingthe testicle contained by the tunica vaginalis should trans-illuminate using a bright light; however, neonatal bowelmay also transilluminate, leading to uncertainty as to thediagnosis. The examiner should assess the presence andnature of the 2 testes. The palpation of a normal testisand the bulge above it indicates the entity to be a herniaor hydrocele of the cord. In a hydrocele, the testis may bepalpable within the surrounding uid unless the hydroceleis tense, in which case the testis may not be discerned.

Figure 2. Inguinal bulge present in the upper right hemiscrotum in a male (left) and intothe right in a girl (right).




Laboratory and Radiologic ImagingThe accurate diagnosis of a hernia and/or hydrocele ismost commonly made based on the history and physicalexamination, thus making the use of adjuvant studies rel-atively unnecessary. Serum studies should be orderedwhen there is concern for bowel obstruction of an incar-cerated hernia. Imaging is often of limited utility. Her-niorrhaphy is of historical interest in which water solublecontrast was injected infraumbilically into the abdomenand delayed pelvic radiographs were taken to see contrastin a hernia sac. Ultrasonography can be helpful in identify-ing an elongated echolucent area from the groin that ex-tends anteromedially in the spermatic cord. However,this is not commonly found when the hernia sac is small.Other times omentum or bowel with its attendant peristalsiscan be identied in a large hernia sac. In the presence ofa presumed hydrocele, a sonogram can be helpful to identifythe presence of an unpalpable testicle surrounded by hydro-cele uid. Ultrasonography is useful in identifying the pres-ence of blood surrounding the testis in a child with a historyof scrotal trauma or the presence of a solid testicular mass.

IncarcerationIncarceration of the hernia, or the inability of the hernia tospontaneously reduce, occurs in 6% to 18% of patients andin 30% of infants younger than 2 months. This high inci-dence emphasizes the need to repair a hernia fairly promptlyin young children. Structures that may become incarceratedinclude small bowel, appendix, omentum, colon,Meckel di-verticulum, ovary, or fallopian tube. The signs and symp-toms of incarceration include a hard bulge present in thegroin with or without pain, irritability, and redness. An at-tempt at reducing the incarcerated hernia by applying gentlepressure from the bottom of the hernia toward the internalring should be undertaken but may require conscious seda-tion to facilitate muscle relaxation and to provide analgesiato achieve successful reduction. Sedation or narcotic analge-sia must be used judiciously and with appropriate monitor-ing in neonates and ill-appearing children. The onlyexception to attempting to perform reduction is in the caseof a long-standing incarceration with signs and symptomsof peritonitis and strangulation of the hernia.

Differential DiagnosisAlthough the primary components of the differential di-agnosis are those dened above (hernia, communicatinghydrocele, hydrocele of the spermatic cord, and hydro-cele), additional diagnoses should be kept in mind andruled out (Table 2). Lipoma of the spermatic cord may

be difcult to differentiate from a hernia lled with omen-tum on both physical examination and ultrasonography,thereby requiring surgical exploration to differentiate.The incidence of torsion of the testis is highest duringthe neonatal period and adolescence. In neonatal torsion,the hard testis is painless and the cord is normal on pal-pation. Torsion of the testis or a testicular appendagepresents as an acute process that in adolescents is painfuland may be confused with acute pain from an incarcer-ated hernia. The scrotal examination should allow the ex-aminer to distinguish torsion from an incarcerated hernia;in the latter the proximal cord cannot be discerned butthe testis can, whereas in the former fullness of the distalcord may be palpable, indicating the point of torsion.Prolonged torsion may be associated with the develop-ment of a hydrocele, making the testis difcult to palpate.The diagnosis may be very difcult in the undescendedtestis that undergoes torsion. The blue-dot sign maybe seen, indicating the presence of a necrotic testicularappendage seen through a hydrocele and the scrotal skin.Trauma to the testis may result in painful swelling of thescrotum, often with associated ecchymosis. The historyshould lead to the performance of ultrasonography to assessthe presence of hematocele around the testis and the integ-rity of the testis. Testes tumors often present as painless tes-ticular masses without any palpable abnormalities of thecord or inguinal canal that should be determined on phys-ical examination, ultrasonography, and ultimately surgicalexploration.

Indications for SurgeryInguinal Hernia

Surgical repair of an inguinal hernia is generally advisedshortly after its diagnosis is made given the signicant rate

Table 2. Differential Diagnosis ofan Inguinoscrotal Swelling

Inguinal herniaCommunicating hydroceleNoncommunicating hydroceleHydrocele of the spermatic cordTorsion of the testis or a testicular appendageLipoma of the spermatic cordHematoceleEpididymitisVaricoceleTesticular tumorsSuppurative inguinal lymphadenitis




and risk of associated complications. In the absence of in-carceration or for an easily reducible hernia, outpatientsurgery can be performed within a few weeks. Surgeryshould be performed more urgently if there is moderatedifcultly in successfully reducing the hernia. In eithercase, the parents should be advised to return if signsand symptoms of incarceration occur. For hernias thatare difcult to reduce or require sedation, surgery shouldbe performed with even greater urgency; an irreduciblehernia requires immediate exploration. Hernias in prema-ture infants can be repaired before hospital discharge.However, surgery may need to be delayed in extremelylow-birth-weight (

because nonviable bowel is unlikely to reduce spontane-ously. However, if there is cloudy or bloody uid or a foulodor after opening the sac, the reduced bowel should beidentied and inspected for viability. If viable bowel re-mains entrapped, it can be reduced. If the bowel is ische-mic or discolored, it is covered with warm, saline-soakedsponges and then examined after several minutes forsigns of viability. If the viability of the bowel is uncertainor if there is necrosis present, the segment of bowelshould be resected. Bowel resections are reported in1.4% to 1.8% of incarcerated hernias and in 4% to 7%of irreducible cases.

Exploration of the Contralateral SideIn the child with a unilateral hernia, the need to explorethe contralateral side remains controversial. Infants withunilateral inguinal hernias have a patent contralateralprocessus vaginalis in 60% during the rst few monthsof life. By age 2 years, 20% of these hernias are obliter-ated, and half of the remaining 40% became clinical her-nias. The goal of contralateral exploration is to avoidasynchronous hernia development and its attendant risksand costs. However, surgical exploration can result in in-jury to the vas deferens, testes, and ilioinguinal nerve andmay be unnecessary. Historically, routine bilateral explo-ration was undertaken because of the reported 60% to70% incidence of a contralateral patent processus vaginalis.In a recent survey (4) 51% of surgeons perform routine con-tralateral exploration in premature infants, 40% perform

exploration in boys younger than 2 years, and 13% performexploration in boys ages 2 to 5 years. In female patients,routine contralateral exploration was performed by 39%of surgeons in those younger than 5 years.

Several methods attempt to avoid contralateral explo-rations with negative results, such as probing, herniorrha-phy, and inducing a pneumoperitoneum to delineatestructures. However, these attempts have insufcient ac-curacy. In contrast, transperitoneal diagnostic laparos-copy offers a rapid, direct, and accurate inspection ofthe contralateral internal inguinal ring by passing a 30or 70 oblique scope through the open hernia sac(Figure 5). A meta-analysis of 964 laparoscopic evaluationsidentied a sensitivity of 99.4% and specicity of 99.5%. (5)One-third to half of children have a patent contralateralprocessus vaginalis, with higher rates in infants youngerthan 1 year. However, a patent processus does not neces-sarily infer a clinically signicant hernia; the reported risk ofdeveloping a metachronous contralateral inguinal hernia af-ter open unilateral hernia repair in children is 7.2%. (6) Thequestion of exploring the contralateral side, however, re-mains unanswered because no study has followed up chil-dren with a known open contralateral internal inguinal ringand determined the rate of progression to a clinical hernia.

ComplicationsComplications after inguinal hernia repair are unusual andmaybe related to technical factors (recurrence, iatrogenic cryptor-

chidism) or to the underlying processof incarceration (bowel ischemia, go-nadal infarction, and testicular atro-phy). Wound infection, although lessthan 1% of all reported series, is muchmore common in irreducible cases.

Recurrent HerniaThe recurrence of an inguinal herniaafter an uncomplicated open her-niorrhaphy occurs in 0.5% to 1% ofcases, up to 2% when performed inpremature infants and in 3% to 6% af-ter repair of an incarcerated hernia.Recurrences generally occur within1 year (50%) or 2 years (75%) afterthe original surgery. (7) Recurrenthernias may result from failure toidentify or to securely ligate the her-nia sac at the original surgery, liga-tion of the sac distal to the internalring, a tear in the sac in which

Figure 5. Intraoperative image through a 70 lens placed though the hernia sac dem-onstrating a closed (A) and open (B) contralateral internal inguinal ring. The ring islocated at the junction of the vas deferens coming in medially and the descendinginternal spermatic ring.




a peritoneal strip remains along the cord structures, or thepresence of increased intra-abdominal pressure, such asfrom a ventriculoperitoneal shunt. Recurrent hernias re-quire additional surgery for repair.

Iatrogenic CryptorchidismIatrogenic cryptorchidism can occasionally result afterhernia repair. It is important for the surgeon to ascertainthe proper position of the testis before concluding sur-gery. If an undescended testis is observed preoperatively,a concurrent orchiopexy should be performed.

Testis InfarctionTesticular infarction and its subsequent atrophy occurs in4% to 12% of cases of an incarcerated hernia and in evenan higher percentage when the hernia is not reducible.The mechanism is presumably due to compression ofthe gonadal vessels by the irreducible hernia, althoughsome atrophic testes develop as a result of damage in-curred during repair of a difcult incarcerated hernia.During surgery, if viability is unclear, the testis couldbe left in place and its viability assessed later.

References1. Schier F, Montupet P, Esposito C. Laparoscopic inguinalherniorrhaphy in children: a three-center experience with 933repairs. J Pediatr Surg. 2002;37(3):3953972. Wang KS, Committee on Fetus and Newborn, and Section onSurgery. Assessment and management of inguinal hernias in infants.Pediatrics. 2012;130(4):7687733. Alzahem A. Laparoscopic versus open inguinal herniotomy in infantsand children: a meta-analysis. Pediatr Surg Int. 2011;27(6):6056124. Levitt MA, Ferraraccio D, Arbesman MC, Brisseau GF, CatyMG, Glick PL. Variability of inguinal hernia surgical technique:a survey of North American pediatric surgeons. J Pediatr Surg.2002;37(5):7457515. Miltenburg DM, Nuchtern JG, Jaksic T, et al. Laparoscopicevaluation of the pediatric inguinal herniaa meta-analysis.J Pediatr Surg. 1998;33(6):8748796. Ron O, Eaton S, Pierro A. Systematic review of the risk ofdeveloping a metachronous contralateral inguinal hernia in chil-dren. Br J Surg. 2007;94(7):8048117. Wright JE. Recurrent inguinal hernia in infancy and childhood.Pediatr Surg Int. 1994;9:164

Suggested ReadingsHolcomb GW III, Brock JW III, Morgan WM III. Laparoscopic

evaluation for a contralateral patent processus vaginalis.J Pediatr Surg. 1994;29(8):970974

Krieger NR, Shochat SJ, McGowan V, Hartman GE. Early herniarepair in the premature infant: long-term follow-up. J PediatrSurg. 1994;29(8):978982

Misra D, Hewitt G, Potts SR, Brown S, Boston VE. Inguinalherniotomy in young infants, with emphasis on prematureneonates. J Pediatr Surg. 1994;29(11):14961498

Rowe MI, Copelson LW, Clatworthy HW. The patent processusvaginalis and the inguinal hernia. J Pediatr Surg. 1969;4(1):102107

Summary

Inguinoscrotal abnormalities in children are bestunderstood by understanding the embryology oftesticular descent and the failure of the processusvaginalis to properly obliterate.

The inguinal hernia, communicating hydrocele,hydrocele of the spermatic cord, and scrotal hydroceleshould be differentiated based on a history andphysical examination in most cases, with selective useof ultrasonography.

The urgency to surgically correct these entitiesdepends on the nature of the hernia or hydrocele andthe likelihood of incarceration or spontaneousresolution.

Open standard herniorrhaphy remains the mostcommon surgical approach, and concurrenttransinguinal laparoscopy allows quick and accurateinspection of the contralateral internal inguinal ringand the need for bilateral repair of an inguinal hernia.

Parent Resources From the AAP at HealthyChildren.org

English: http://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Inguinal-Hernia.aspx Spanish: http://www.healthychildren.org/spanish/health-issues/conditions/abdominal/paginas/inguinal-hernia.aspx




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1. You have just examined a 3-month-old boy for the first time. You notice the right hemiscrotum is larger thanthe left. There is a firm mass in the right hemiscrotum that is nontender and nonreducible, but you can palpatea testicle within the mass. A normal spermatic cord is palpable above the mass. The parents tell you the masshas been present since birth, does not vary in size throughout the day, but has become somewhat smaller sincebirth. Which of the following is the most likely diagnosis?

A. Hydrocele of the spermatic cord.B. Inguinal hernia.C. Scrotal hydrocele.D. Testicular tumor.E. Testicular torsion.

2. Which diagnostic modality is the most useful in diagnosing an inguinal hernia in a child?

A. Computed tomography.B. Physical examination.C. Radiographic herniogram.D. Scrotal ultrasonography.E. Transillumination.

3. A 13-year-old boy presents with a 2-hour history of right scrotal pain that began acutely. There is no history oftrauma and no similar past episodes. Physical examination reveals tenderness to direct palpation of the upperportion of the testicle and epididymis, although the spermatic cord above the testicle is normal and nontender.The testicle is in a normal position in the scrotum. A blue dot is noticed in the upper scrotum overlying thepoint of maximum tenderness. The most likely diagnosis is:

A. Acute hydrocele.B. Epididymitis.C. Incarcerated inguinal hernia.D. Testicular torsion.E. Torsion of an appendix testis.

4. The scenario in which you would most likely find identical pathologic findings on the contralateral side is:

A. Communicating hydrocele.B. Hydrocele of the cord.C. Male left-sided inguinal hernia.D. Male right-sided inguinal hernia.E. Noncommunicating hydrocele.

5. Which of the following is most likely to resolve spontaneously?

A. Female inguinal hernia.B. Hydrocele.C. Hydrocele of the spermatic cord.D. Male inguinal hernia.E. Testicular torsion.




DOI: 10.1542/pir.34-10-4572013;34;457Pediatrics in Review

Lane S. PalmerHernias and Hydroceles

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