eMedicine Specialties > Pediatrics: Surgery > Urology

Hydrocele and Hernia in Children: Differential Diagnoses & Workup

Author: Joseph Ortenberg, MD, Clinical Professor of Urology and Pediatrics, Louisiana State University School of Medicine, New Orleans; Director of Urologic Education, Children's Hospital, New Orleans;
Coauthor(s): Sean Collins, MD, Assistant Professor or Urology, Department of Urology, Louisiana State University Health Sciences Center - New Orleans; Christopher C Roth, MD, Fellow, Department of Pediatric Urology, Children's Hospital of Oklahoma, University of Oklahoma Health Sciences Center
Contributor Information and Disclosures

Updated: Sep 21, 2009

Differential Diagnoses

Abdominal Trauma
Cryptorchidism
Testicular Torsion
Varicocele in Adolescents

Other Problems to Be Considered

Retractile testis
Epididymitis or orchitis
Scrotal trauma (eg, scrotal hematoma, hematocele, testicular rupture)
Inguinal lymphadenitis
Tumors of the testis (benign or malignant)
Tumors of the spermatic cord (eg, rhabdomyosarcoma)

Workup

Laboratory Studies

  • Laboratory evaluation is generally not essential to the evaluation of hydroceles and hernias.
  • Leukocytosis may be a sign of a strangulated hernia.
  • Leukocytosis with a higher percentage of neutrophils suggests an infectious and/or inflammatory process (eg, epididymo-orchitis).

Imaging Studies

  • Indications for scrotal or inguinal ultrasound
    • Suggestion of torsion of a testicle or ovary (use duplex ultrasonography to evaluate blood flow)
    • Suggestion of tumor of the spermatic cord
    • Suggestion of tumor of the testicle
    • Trauma and concern about testicular rupture
  • Role of ultrasonography in the evaluation of asymptomatic patent processus vaginalis (PPV)
    • As noted above, PPV can be difficult to diagnose with physical examination.
    • When a unilateral inguinal hernia is discovered on physical examination, the chance of PPV on the contralateral side can be as high as 63% in children younger than 2 months. This prevalence decreases with age. Up to 20% of patients develop an inguinal hernia on the contralateral side, but it is controversial whether to proceed with any type of imaging preoperatively or exploration at the time of surgery. This has encouraged interest in ultrasonography to assess a contralateral PPV in the preoperative period.
    • Research studies have shown a positive correlation between ultrasonography findings of PPV and intraoperative findings of PPV. The false-negative rate (ie, ultrasonography findings are normal, even when a proven PPV exists) is unknown. Further research with this modality may clarify the risk of developing a contralateral hernia later, but, at present, ultrasonography is not considered to be routine in the evaluation of any type of PPV.
  • Abdominal plane films are used to rule out bowel obstruction due to an incarcerated or strangulated hernia.

Procedures

  • Manual reduction of incarcerated hernias: Necrotic bowel is usually so swollen that it cannot be reduced manually. An incarcerated hernia can progress to perforation in as few as 2 hours. For these two reasons, parents and primary care physicians are encouraged to reduce hernias. Surgical consultation is critical even if the hernia is reduced successfully. In the emergency department, manual reduction of incarcerated hernias incorporates the following procedure:
    • Administer sedation to the child.
    • Elevate the child's buttocks and apply a padded ice pack to the inguinal area to reduce swelling.
    • Slowly compress the hernia at its most distal aspect while holding 2 fingers of the opposite hand at the neck of the hernia sac, at the level of the internal inguinal ring. This technique prevents the hernia from being pushed alongside the inguinal canal.
    • Maintain pressure continuously. Ten or more minutes of slow continuous pressure is often required.
    • The hernia should slide slowly back into the abdomen.
    • A child who has undergone incarcerated hernia reduction should be observed closely after this procedure. Rarely, necrotic bowel can be reduced back into the abdomen. This bowel may then perforate and result in peritonitis, which requires emergency exploration with resection of the necrotic bowel to avoid sepsis.

More on Hydrocele and Hernia in Children

Overview: Hydrocele and Hernia in Children
Differential Diagnoses & Workup: Hydrocele and Hernia in Children
Treatment & Medication: Hydrocele and Hernia in Children
Follow-up: Hydrocele and Hernia in Children
References
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References

  1. Esposito C, Valla JS, Najmaldin A, et al. Incidence and management of hydrocele following varicocele surgery in children. J Urol. Mar 2004;171(3):1271-3. [Medline].

  2. Kaya M, Huckstedt T, Schier F. Laparoscopic approach to incarcerated inguinal hernia in children. J Pediatr Surg. Mar 2006;41(3):567-9. [Medline].

  3. Boocock GR, Todd PJ. Inguinal hernias are common in preterm infants. Arch Dis Child. Jul 1985;60(7):669-70. [Medline].

  4. Hata S, Takahashi Y, Nakamura T, et al. Preoperative sonographic evaluation is a useful method of detecting contralateral patent processus vaginalis in pediatric patients with unilateral inguinal hernia. J Pediatr Surg. Sep 2004;39(9):1396-9. [Medline].

  5. Hosgor M, Karaca I, Ozer E, et al. The role of smooth muscle cell differentiation in the mechanism of obliteration of processus vaginalis. J Pediatr Surg. Jul 2004;39(7):1018-23. [Medline].

  6. Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am. Aug 1998;45(4):773-89. [Medline].

  7. Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in children: a three-center experience with 933 repairs. J Pediatr Surg. Mar 2002;37(3):395-7. [Medline].

  8. Shirvani AR, Ortenberg J. Communicating hematocele in children following splenic rupture: diagnosis and management. Urology. Apr 2000;55(4):590. [Medline].

  9. Skoog SJ, Conlin MJ. Pediatric hernias and hydroceles. The urologist's perspective. Urol Clin North Am. Feb 1995;22(1):119-30. [Medline].

  10. Weber T, Tracy T. Groin hernias and hydroceles. In: Pediatric Surgery. 2nd ed. WB Saunders Co; 1993:562.

  11. Wiener ES, Touloukian RJ, Rodgers BM, et al. Hernia survey of the Section on Surgery of the American Academy of Pediatrics. J Pediatr Surg. Aug 1996;31(8):1166-9. [Medline].

  12. Yerkes EB, Brock JW, Holcomb GW, Morgan WM 3rd. Laparoscopic evaluation for a contralateral patent processus vaginalis: part III. Urology. Mar 1998;51(3):480-3. [Medline].

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Further Reading

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Keywords

hydrocele, hernia, process vaginalis, PV, inguinal hernia, inguinal canal, scrotum

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Contributor Information and Disclosures

Author

Joseph Ortenberg, MD, Clinical Professor of Urology and Pediatrics, Louisiana State University School of Medicine, New Orleans; Director of Urologic Education, Children's Hospital, New Orleans;
Joseph Ortenberg, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, and Society of University Urologists
Disclosure: Nothing to disclose.

Coauthor(s)

Sean Collins, MD, Assistant Professor or Urology, Department of Urology, Louisiana State University Health Sciences Center - New Orleans
Sean Collins, MD is a member of the following medical societies: American Urological Association and Louisiana State Medical Society
Disclosure: Nothing to disclose.

Christopher C Roth, MD, Fellow, Department of Pediatric Urology, Children's Hospital of Oklahoma, University of Oklahoma Health Sciences Center
Christopher C Roth, MD is a member of the following medical societies: Alpha Omega Alpha and American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Howard M Snyder III, MD, Professor, Department of Surgery, Division of Pediatric Urology, University of Pennsylvania School of Medicine
Howard M Snyder III, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, and National Kidney Foundation
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Harry P Koo, MD, Chairman of Urology Division and Director of Pediatric Urology, Virginia Commonwealth University; Professor of Surgery, VCU School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond
Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Marc Cendron, MD, Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston
Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, European Society for Paediatric Urology, Johns Hopkins Medical and Surgical Association, New Hampshire Medical Society, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

 
 
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