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 or inflammatory process (eg, epididymo-orchitis).
Imaging Studies
Indications for scrotal or inguinal ultrasonography (US) include the following:
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Suggestion of torsion of a testicle or ovary (duplex US should be used to evaluate blood flow)
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Suggestion of tumor of the spermatic cord
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Suggestion of tumor of the testicle
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Trauma and concern about testicular rupture
US may have a role to play in the evaluation of asymptomatic patent processus vaginalis (PPV). As noted (see Presentation), PPV can be difficult to diagnose on the basis of 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 figure decreases with age. As many as 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 US to assess a contralateral PPV in the preoperative period.
Research studies have shown a positive correlation between US findings of PPV and intraoperative findings of PPV. The rate of false-negative results (ie, US findings that 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, US is not considered to be routine in the evaluation of any type of PPV.
Abdominal plain films are used to rule out bowel obstruction due to an incarcerated or strangulated hernia.
Procedures
Manual reduction of incarcerated hernias is advised when feasible. Necrotic bowel is usually so swollen that it cannot be reduced manually. An incarcerated hernia can progress to perforation in as little 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 steps:
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Administer sedation to the child
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Elevate the child's buttocks, and apply a padded ice pack to the inguinal area to reduce swelling
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Slowly compress the hernia at its most distal aspect while holding two 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
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Maintain pressure continuously; 10 or more minutes of slow continuous pressure is often required
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The hernia should slide slowly back into the abdomen
A child who has undergone incarcerated hernia reduction should be observed closely after the procedure. In rare instances, necrotic bowel can be reduced back into the abdomen. This bowel may then perforate and result in peritonitis, which necessitates emergency exploration with resection of the necrotic bowel to prevent sepsis.
