Hydrocele in Infants and Children

Background

• A hydrocele is an abnormal, painless accumulation of fluid between the parietal and visceral layers of the tunica vaginalis and/or along the spermatic cord, leading to swelling in the scrotum and/or groin.
• Hydroceles are either congenital or acquired.
  • Congenital types
    • Communicating hydroceles (also called primary hydroceles) are the result of an incomplete closure of the processus vaginalis and account for most hydroceles in infants and children.
    • Spermatic cord hydroceles result from patency of the mid-portion of the processus vaginalis and include 2 subtypes, encysted and funicular.
    • Scrotal (noncommunicating) hydroceles result from obliteration of the processus vaginalis from the internal ring to upper extent of tunica vaginalis causing fluid accumulation around the testicle contained by the tunica vaginalis.
    • A hydrocele of the canal of Nuck is an abnormal open pouch of peritoneum extending into the labia majora. It is extremely rare and only occurs in females.
  • Acquired types include noncommunicating hydroceles and abdominoscrotal hydrocele and are rare in infants and children.
• The reported incidence of communicating hydroceles in male infants is 0.7%-4.7%.
• The causes and pathogenesis of hydrocele vary based on the type.
• The complications of a hydrocele may include testicular damage.
• Most primary congenital communicating hydroceles typically resolve spontaneously by age 12 months.

Evaluation

• Children usually present with painless scrotal swelling and/or inguinal bulge.
  • In males, a communicating hydrocele usually presents as a swollen hemiscrotum, but may be localized to the groin or may extend along the cord structures and include the hemiscrotum.
  • In males, a noncommunicating hydrocele is localized to the hemiscrotum.
  • Rarely, in females, a hydrocele is localized to the groin and may extend into the vulva.
• Make the diagnosis based on the history and physical exam, including a thorough genital exam:
  • classical exam findings are palpation of a painless, smooth, fluid-filled swelling in scrotum or groin that transilluminates
  • with communicating hydrocele, the swelling may be intermittent and may not be present at the time of the exam
• Perform a scrotal ultrasound in males if the diagnosis is uncertain, the swelling is too large and tense for an adequate palpation of teste(s), if there is any doubt about the character of a solid intrascrotal testicular mass, or there is a history of scrotal trauma.
• Ultrasound is used to confirm the diagnosis of a canal of Nuck hydrocele in females.

Management

• A period of watchful waiting should precede surgery in all infants with a communicating hydrocele in the first 12 months of life (Strong recommendation).
• Consider watchful waiting for 6-9 months for a majority of late-onset hydroceles, which are usually noncommunicating.
• Surgery
  • Perform surgery early if there is a suspected concomitant inguinal hernia or underlying testicular pathology (Strong recommendation).
  • Choose surgical treatment approach based on the type of hydrocele:
    • High ligation of the patent processus vaginalis via inguinal incision is indicated for the repair of communicating hydrocele and abdominoscrotal hydrocele.
    • An open repair or hydrocelectomy via the scrotum is indicated for the repair of a noncommunicating hydrocele.
  • The open method of a hydrocele repair is the preferred standard approach, but laparoscopic approaches may be as effective as an open repair for communicating hydroceles.
• Follow-up includes monitoring for postsurgical complications.