Hydrocele, Hernia, Neonatal Torsion, and Scrotal Masses
Barry A. Kogan
Hydrocele and Hernia
I. DEFINITION
A. Hydrocele: An accumulation of fluid around the testicle.
Types: Communicating and noncommunicating (Fig. 5-1A-B).
1. Communicating: Persistence of a patent processus vaginalis with the same pathophysiology as an indirect hernia (see below) but a smaller opening, preventing bowel from entering. The fluid around the testis is peritoneal fluid. This is a congenital defect.
2. Noncommunicating: No connection to the peritoneum; rarer in children, occurs mostly in adolescents and adults. The fluid comes from the mesothelial lining of the tunica vaginalis and can be the result of inflammation of the testis or epididymis. This is an acquired lesion.
Types: Indirect inguinal, direct inguinal, and femoral.
1. Inguinal, indirect: Persistence of a patent processus vaginalis. This defect is congenital and allows protrusion of peritoneal contents (usually omentum or small intestine) through the internal inguinal ring along the spermatic cord for a variable distance, and in some cases, as far as the scrotum. This may become incarcerated if it cannot be reduced back into the peritoneum. If so, the pressure of the hernia may alter blood flow to the testis, which can be damaged from ischemia. In addition, the blood flow to the bowel may be affected and, in this circumstance, it is called a strangulated hernia.
2. Inguinal, direct: Weakness in the floor of the inguinal canal. This is an acquired condition and is uncommon in children.
3. Femoral: Rare in children.
II. EMBRYOLOGY OF INDIRECT INGUINAL HERNIAS AND HYDROCELES
A. During the third month of gestation, the peritoneal lining of the abdominal cavity protrudes out of the internal inguinal ring following the gubernaculum, which attaches to the base of the scrotum (or, in girls, to the labia major). This is the processus vaginalis. Late in gestation, the testis descends along the same path from the retroperitoneal space through the inguinal canal just posterior to the processus vaginalis and into the scrotum.
B. At approximately the time of birth, the portion of the processus vaginalis between the peritoneum and the scrotum obliterates separating the
residual tunica vaginalis in the scrotum from the peritoneum. If the processus fails to obliterate, it is said to remain patent.
residual tunica vaginalis in the scrotum from the peritoneum. If the processus fails to obliterate, it is said to remain patent.
 FIG. 5-1 Hydroceles. A: Communicating. B: Noncommunicating. |
C. For obvious embryologic reasons, premature infants will have a much higher rate of patency of the processus vaginalis. If the patent processus is large enough to allow bowel to enter, there is an indirect inguinal hernia. If the processus is patent but the connection is small, a communicating hydrocele is likely to result when peritoneal fluid enters the inguinal
canal. If the processus does obliterate, a noncommunicating hydrocele may result by secretion of fluid into the residual tunica vaginalis. This is usually associated with inflammation in the scrotum.
canal. If the processus does obliterate, a noncommunicating hydrocele may result by secretion of fluid into the residual tunica vaginalis. This is usually associated with inflammation in the scrotum.
 FIG. 5-2 Hernia. |
III. INCIDENCE
A. Approximately 1% to 3% of boys have a hernia.
B. In premature babies, the rate is approximately 3 times as high depending on the degree of prematurity.
C. About 10% of children with hernias will have a family history of hernia although there is no known inheritance pattern or gene identified.
D. At least one-third are diagnosed before 6 months of age.
E. The M/F ratio is 8/1. The R/L ratio is 2/1 and about 16% are bilateral, more common in younger patients.
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