Inguinal Hernias and Hydroceles

8/10/2019 Inguinal Hernias and Hydroceles

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Chapter X.2. Inguinal Hernias and HydrocelesLeticia P. Borja, MD

November 2002

A 2 week old male infant, born at 38 weeks gestational age, presents for his first visit to a

pediatric clinic. According to his parents, he has been doing well since birth. Their onlyconcern is the persistence of a bulge in his right scrotum. On review of birth records, amoderate-sized scrotal mass had been appreciated on newborn examination with no otherabnormalities noted. According to his parents, the bulge has not changed in size since

birth and there has been no noticeable discomfort.On exam, a moderate sized right scrotal mass is palpated. It is firm, smooth, non-fluctuant and non-tender. It brilliantly transilluminates. There is no reduction withcompression of the mass. Both testes are descended. No inguinal or abdominal massesare appreciated on palpation. A diagnosis of non-communicating hydrocele is made. His

parents are reassured and counseled on the possibility of a communicatinghydrocele/complete inguinal hernia and to proceed to an emergency room if signs or

symptoms of incarceration and strangulation occur. On subsequent well child visits, theright scrotal mass is noted to minimally decrease in size. His parents continue to report nofluctuation in size during activity, crying or defecation. At his 12 month well child visit,the right scrotal mass is noted to be unchanged since his last visit 3 months prior. He isreferred to a pediatric general surgeon for evaluation. Elective surgical correction is

performed.

Inguinal-scrotal swelling is a common finding in the pediatric population. Of the possiblecauses, the most common diagnoses are hernias and hydroceles. Approximately 1-2% ofmale newborns have a hydrocele. Most are non-communicating hydroceles (1). Theestimated incidence of inguinal hernias in children is 5-50/1,000 live births. It is seen

more frequently in males than females with a ratio of about 5:1 with a definite familialtendency. About 50% of cases present before 12 months of age with most occurring inthe first 6 months of life. Approximately 99% of all inguinal hernias in children areindirect inguinal hernias. Direct hernias are rare. Most inguinal hernias are unilateral withabout 60% occurring on the right side and 30% on the left side. Ten percent are bilateral(i.e., clinically apparent at initial presentation). Of note, inguinal hernias are morecommon in premature infants with an incidence of 5-30%. Most cases are bilateral,occurring in about 62% of affected premature infants (2-5).

Normally, in the male fetus, the testes descend to the vicinity of the internal ring of theinguinal canal by approximately 28 weeks gestational age. Then, by about 29 weeksgestation, the testes descend into the scrotum. With testicular descent, the lining of the

peritoneal cavity extends into the inguinal canal and scrotum. This peritoneal canal isreferred to as the processus vaginalis. Each testis descends through the inguinal canalexternal to the processus vaginalis. In the female fetus, a similar mechanism with descentof the ovaries into the pelvis occurs. The processus vaginalis in females extends throughthe inguinal canal into the labia majoris and is referred to as the canal of Nuck (2). Inmales, a hydrocele is formed when there is patency of the processus vaginalis betweenthe scrotum and the peritoneal cavity resulting in an accumulation of fluid between thelayers of the tunica vaginalis surrounding the testis. In the weeks prior to birth or shortly


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after, the processus vaginalis closes spontaneously in the area of the internal ring,obliterating the entrance to the inguinal canal. The scrotal fluid collection that remainswithin the tunica vaginalis is referred to as a scrotal hydrocele, or a non-communicatinghydrocele. If the processus vaginalis fuses proximally and distally but remains open in

between, the isolated fluid collection is referred to as a hydrocele of the cord. This type of

hydrocele, although not in communication with the peritoneal cavity or the scrotum, isoften associated with a hernia and/or a scrotal hydrocele (6). In some older boys, a scrotalhydrocele may result from inflammation within the scrotum caused by various conditionsincluding testicular torsion, torsion of the appendages, epididymitis, and testicular cancer(1,4). When the processus vaginalis fuses distally but remains patent proximally,abdominal contents can enter the inguinal canal resulting in an inguinal hernia. However,if the processus vaginalis fails to fuse completely, there will be communication betweenthe scrotum and the peritoneal cavity through the patent processus vaginalis resulting inan inguinal-scrotal hydrocele, or communicating hydrocele. Of note, there is a rare butimportant type of communicating hydrocele called an abdominal-scrotal hydrocele. Withthis type of hydrocele, the communication is between the scrotum and a cystic loculation

of fluid within the lower abdomen. This may result in recurrent communicatinghydroceles or unusually large hydroceles. If a communicating hydrocele is large enough,abdominal contents may extend through the patent processus vaginalis to the scrotumresulting in an inguinal-scrotal hernia (complete inguinal hernia). A similar mechanismmay result in hernias in girls. The hernia sac in males and females may contain intestineor omentum, with the ileum being the most common intestinal component. However,other possible intestinal components include colon, appendix, and Meckel's diverticulum(hernia of Littre). In males with undescended testes, a testis may be contained within ahernia sac. In females, a hernia sac may contain an ovary, fallopian tube, or both (6). Ofnote, it is possible for a testis to be found in the hernia sac of a female infant if testicularfeminization (complete androgen insensitivity) is present. More than half of patients withtesticular feminization have an inguinal hernia (4).In differentiating a hydrocele from a hernia, history and physical examination can bediagnostic. The most important information elicited from parents is a history offluctuation in the volume of the mass that would be consistent with a hernia orcommunicating hydrocele. Parents may report an increase in size that is particularlynoticeable at times of increased intra-abdominal pressure (activity, crying or straining).At rest, the bulge will be noted to spontaneously decrease in size. Parents may also report

previous reduction of the mass by either themselves or another physician. A history offussiness, obvious discomfort, poor feeding, vomiting, and abdominal distention wouldsuggest incarceration. The physical examination starts with the child supine. The childshould be positioned with legs extended and arms raised over the head. This usuallyresults in crying, thereby causing an increase in intra-abdominal pressure. The mass is

palpated and evaluated for tenderness, tenseness, and associated skin discoloration that, if present, would suggest incarceration and possible strangulation. This would be anindication for immediate referral to a pediatric surgeon. If the mass is non-tender,smooth, firm and located in the scrotum, a hydrocele is likely to be present. Of note, ahydrocele may also be found in the spermatic cord. A scrotal hydrocele should be movedaway from the inguinal canal and palpation of normal cord structures superiorly should

be performed to exclude the presence of a hernia. The testes may not be palpable. If a


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patient presents with a large hydrocele or a history of recurrent communicatinghydroceles with or without a palpable ipsilateral lower abdominal mass, an abdominal-scrotal hydrocele should be suspected. If compression of the fluid-filled mass completelyreduces the size of the hydrocele, a communicating hydrocele or hernia is the likelydiagnosis. An inguinal hernia is non-tender, soft, reducible and can be located in the

inguinal canal or may extend into the scrotum (inguinal-scrotal hernia). Of note, retractiletestes, a common finding in infants and young children, can resemble an inguinal hernia.To avoid misdiagnosis, palpation of the testes should be done prior to palpation of aninguinal mass. The physical examination continues with the child erect. This raises theintra-abdominal pressure. Any fluctuation in the size of the mass should be noted. If thechild can cooperate, cough and Valsalva maneuvers (e.g., attempts to blow into anobstructed straw or a balloon) should be encouraged. An increase in size of the masswould be consistent with a hernia or communicating hydrocele.Transillumination of the mass can be attempted. A hydrocele will brilliantlytransilluminate. However, in children, inguinal-scrotal hernias and incarcerated bowelmay also brilliantly transilluminate. Thus, transillumination in the pediatric setting may

be unreliable. The internal ring of the uninvolved side should be examined before proceeding to the internal ring of the affected side. If an inguinal hernia is present,abdominal contents may be palpated extending through the internal ring (2,3,6).If there is a history suspicious for a hernia but no mass can be demonstrated onexamination, it may be helpful to empty the bladder which, when full, can block theinternal inguinal ring and mask an inguinal hernia. Otherwise, a classic history ofintermittent inguinal, scrotal or labial swelling that spontaneously reduces may be all thatis necessary for diagnosis. However, another physical examination finding that can be

present with inguinal hernias is a thickened spermatic cord with an associated "silk" sign.The spermatic cord is palpated over the pubic tubercle and a "silky sensation" isappreciated when the two layers of peritoneum are rubbed together. This finding, alongwith a history of a hernia, is highly suggestive of an inguinal hernia (2).A scrotal hydrocele that is sufficiently large and tense may cause ischemic injury to thetestis. A communicating hydrocele may enlarge and lead to development of an inguinal-scrotal hernia (6). Nine to twenty percent of inguinal hernias in children becomeincarcerated with more than half of those cases occurring in children less than 12 monthsof age. The incidence of incarceration increases in premature infants and in term femaleinfants (2,5). When incarcerated, complete manual reduction of the hernia may not be

possible. Strangulation of the hernia can occur and ischemic injury to intestine andtestis/ovary may result (3,6). Intestinal obstruction, intestinal gangrene, and gonadalinfarction occur more commonly in the first 6 months of life (4). Thus, because the riskof incarceration is high, particularly in infants, with a risk of strangulation, promptsurgical intervention is recommended as soon as the diagnosis is made.The differential diagnosis of inguinal-scrotal swelling in children (6,7) can be classified

based on acuteness of presentation, tenderness, location (intratesticular versusextratesticular), and transillumination. All hydroceles are non-acute, non-tender and theytransilluminate. They are extratesticular, but scrotal hydroceles may be difficult todistinguish from an enlarged testicle on palpation. Communicating hydroceles arecompressible (that is, they decrease in size with pressure), while non-communicatinghydroceles will not change in size.


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Inguinals hernias are usually non-acute and non-tender. They usually do nottransilluminate. Incarcerated inguinal hernias are usually acute and tender. Vomiting may

be present. Non-communicating hydroceles are frequently mistaken for incarceratedhernias, because they do not change in size with compression (seemingly non-reducible).However, scrotal hydroceles are spherical or oval in shape, while an incarcerated inguinal

hernia is usually tubular in shape (often shaped like a small banana with a slightly tapered point at the end). Additionally, hydroceles are usually softer in consistency, whileincarcerated hernias are the consistency of a refrigerated hot dog and sometimes harderthan this. A hydrocele of the cord can be very difficult to distinguish from an incarceratedhernia, but this should be suspected if the onset is non-acute, it is non-tender, and thechild's behavior appears to be normal.Other diagnoses in the differential include lymph nodes, undescended or retracted testis(smaller in size), varicocele (soft spaghetti or bag of worms consistency), andspermatocele. Other considerations include epididymal cyst, testicular cancer,

peritesticular rhabdomyosarcoma, benign soft tissue tumors, meconium sequestration,testicular torsion (tender), torsion of appendages, epididymitis, trauma, idiopathic scrotal

edema, and Henoch-Schonlein purpura.If there is uncertainty in the diagnosis, an ultrasound examination may aid indifferentiating a hydrocele from a hernia, may confirm the presence of an abdominal-scrotal hydrocele, or may rule out other causes of inguinal-scrotal swelling. In a female,ultrasound examination can be used as part of the evaluation for testicular feminization(4). It can also be used to examine both ovaries when an incarcerated ovary is suspected(6). Abdominal x-rays are unnecessary for diagnosis of an incarcerated hernia, althoughthey may be helpful in confirming an intestinal obstruction. If an incarcerated orstrangulated hernia is associated with bowel obstruction or shock, laboratory studies andvascular access are indicated (5).Treatment is usually not required for uncomplicated, simple hydroceles (non-communicating) because they tend to decrease in size with complete resolution in thefirst 2 years of life. Significant hydroceles persisting beyond 12-24 months are likely to

be communicating and are generally surgically corrected at that time (1). However, earlysurgical repair is recommended for large, tense hydroceles because they rarely disappearspontaneously, they can cause ischemic injury to the testis, and they may be difficult todistinguish from hernias. Communicating hydroceles also require early surgical repairdue to the fact that they may progress to symptomatic inguinal-scrotal hernias (6). Allinguinal hernias will eventually require surgery. In fact, inguinal hernia repair is the mostcommon surgical procedure in children (4). However, the urgency of surgical correctionvaries. In an outpatient setting, if a child presents with an inguinal hernia but is otherwisewell (no obstruction or shock), manual reduction should be attempted. About 95% ofinguinal hernias can be reduced by applying gentle but steady upward pressure on thehernia sac. If the hernia is easily reducible, referral to a pediatric surgeon should be donefor elective surgical repair. While awaiting repair, parents should be counseled to seekimmediate evaluation and treatment in an emergency department if signs and symptomsof incarceration and strangulation occur. Inguinal hernias that cannot be easily reducedare incarcerated and require immediate referral to an emergency department. In anemergency department, manual reduction can be attempted with sedation. Once the childis sedated, firm steady upward pressure can be applied to the hernia sac using one hand


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while the other hand gently guides the neck of the hernia sac into the distal ring of theinguinal canal. A Trendelenburg position may be helpful. If reduction is successful, a

pediatric surgeon should be consulted for outpatient follow-up. However, children withdifficult to reduce hernias or a history of incarceration in the past are at high risk forfuture incarceration and strangulation and should be managed more urgently. Some cases

require inpatient observation. If reduction is unsuccessful, then a pediatric surgeon must be consulted immediately. If, however, a child presents with an incarcerated inguinalhernia and symptoms of intestinal obstruction or shock, a pediatric surgeon must beconsulted emergently while resuscitation begins with intravenous fluids and nasogastrictube decompression of the stomach (5).In young females, an ovary may incarcerate in the hernia sac. This has a spherical shapeand the child is often asymptomatic with the exception of the inguinal mass. Whileincarcerated bowel is at risk for ischemia and must be surgically corrected immediately,the vascular supply to the incarcerated ovary is usually not compromised, thus, this isoften less emergent.Elective surgical repair can be safely done as an outpatient. Hospitalization may be

necessary for children at high risk for post-operative/post-anesthesia complications (e.g., premature infants 10% since thecontralateral hernia often develops later). Bilaterality is more frequent in females,children less than 12 months of age, and children with left-sided inguinal hernias. For thisreason, it is recommended that bilateral surgical exploration be done in males less than 12months of age, females less than 24 months of age, and children at high risk fordevelopment of inguinal hernias. Bilateral surgical exploration should also be stronglyconsidered in children less than 24 months of age with left-sided inguinal hernias. Ofnote, contralateral exploration can be avoided with laparoscopic herniorrhaphy. Thistechnique allows for visualization of the contralateral side during repair of the affectedside. However, the surgeon must be experienced in laparoscopic technique. In general,


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the decision to undergo bilateral surgical exploration should be based on surgicalexpertise and a child's pre-operative medical condition (2).Premature infants will often develop a symptomatic hernia while remaining hospitalizedfor prematurity. These infants should have surgical correction of the hernia prior todischarge from the hospital. Other significant risk factors for development of an inguinal

hernia include presence of a ventriculoperitoneal shunt or peritoneal dialysis catheter.These devices cause increased intra-abdominal pressure resulting in a high incidence ofinguinal hernias in affected infants. They are also associated with greater risk for surgicalcomplications. It is recommended that prophylactic antibiotic therapy with ampicillin andgentamicin be given perioperatively to children with ventriculoperitoneal shunts. This isalso the recommendation for children with congenital heart disease. Other conditionsassociated with an increased incidence of inguinal hernias include congenital dislocationof the hip, ascites, congenital abdominal wall defects, meconium peritonitis, connectivetissue disorders (Ehlers-Danlos syndrome), mucopolysaccharidosis (Hunter-Hurlersyndrome), ambiguous genitalia, hypospadias/epispadias, cryptorchid testes, and cysticfibrosis. Cystic fibrosis is also associated with agenesis of the vas deferens. Thus, if

bilateral absence of the vas deferens is noted incidentally during herniorrhaphy in a childwithout a prior diagnosis of cystic fibrosis, an evaluation for cystic fibrosis should bedone including a sweat chloride test and/or DNA testing. However, agenesis of the vasdeferens can also be an isolated finding. If a child has cryptorchid testes and an inguinalhernia, elective orchiopexy should be done along with herniorrhaphy to reduce the riskfor ischemia and infarction or the testis (2,4).Most hydroceles resolve by 12-24 months of age following reabsorption of the hydrocelefluid. However, if the hydrocele persists beyond this time frame, if it is large and tense, orif the hydrocele is communicating, it is unlikely to resolve spontaneously and can bedifficult to distinguish from a hernia. In these cases, as with hernias, surgery can becurative. However, there can be complications of surgery including damage to intestine,testis and vas deferens or to ovary and fallopian tube. Rarely, the bladder may bedamaged with resultant urinary ascites. A surgeon should be able to recognize andappropriately manage such injuries (6). Post-operative complications including woundinfection and hernia recurrence are uncommon. In fact, the hernia recurrence rate is lessthan 1% (2). More commonly, a recurrent swelling is due to reaccumulation within thetunica vaginalis and/or enlargement of retained tunica vaginalis tissue due to edema.These will often resolve spontaneously without the need for reoperation (6). However,there is an increased risk for hernia recurrence after repair of incarcerated or strangulatedhernias as compared to elective surgical repair (4). Children with connective tissuedisorders, chronic respiratory disease, and chronic illnesses associated with increasedintra-abdominal pressure are also at higher risk for hernia recurrence (2).

Questions1. True /False: Bilateral inguinal hernias are common in premature infants.2. Which of the following statements is false?. . . . . a. Each testis descends through the inguinal canal into the scrotum within theprocessus vaginalis .. . . . . b. A hydrocele can result from incomplete fusion of the processus vaginalis.. . . . . c. A scrotal hydrocele, or simple hydrocele, is a type of non-communicating


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hydrocele.. . . . . d. A communicating hydrocele can develop into an inguinal-scrotal hernia. Someuse the terms interchangeably.. . . . . e. A hernia sac can contain intestine, omentum, testis/ovary or fallopian tube.3. What is the classic clinical presentation of an inguinal hernia?

Intermittent inguinal, scrotal or labial swelling that spontaneously resolves. 4. True /False: The risk of incarceration and strangulation of an inguinal hernia is highestin the first 12 months of life.5. Which of the following is not part of the differential diagnosis of an inguinal-scrotalswelling in children?. . . . . a. Varicocele. . . . . b. Undescended or retracted testis. . . . . c. Volvulus. . . . . d. Testicular torsion. . . . . e. Testicular cancer6. True /False: All inguinal hernias will eventually require surgery.

7. Which of the following is not a risk factor for development of an inguinal hernia?. . . . . a. Presence of a ventriculoperitoneal shunt. . . . . b. Congenital heart disease. . . . . c. Prematurity. . . . . d. Cystic fibrosis. . . . . e. Family history of inguinal hernias8. True /False: After herniorrhaphy, hernia recurrence is rare.Answers to questions1. True2. a3. Intermittent inguinal, scrotal or labial swelling that spontaneously resolves.4. True5. c6. True7. b8. True

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Inguinal Hernias and Hydroceles