History

Fact Explanation
Scrotal swelling Often a unilateral, tense swelling that is present at birth. There are two types of congenital hydrocele; in the funicular variety; the processus vaginalis remains patent, allowing for communication with the peritoneal cavity. In the encysted variety there is no communication with the peritoneum or tunica vaginalis, and is also known as an encysted cord of the cyst. Right sided hydroceles are relatively more common occurring in 60 percent, left sided hydroceles are rarer at 25 percent while bilateral hydroceles are seen in 15 percent. [1],[2],[3]
Pain Is a rare occurrence. Severe pain, irritability and tugging at the scrotum indicate the rare possibility of an infected hydrocele. Other causes for an acute scrotum such as torsion and epididymo-orchitis may coexist. [1],[4]
Prematurity Incidence in new born babies is 5%, but it is encountered more often in premature neonates, born before the gestational age (32 to 38 weeks) at which the processus vaginalis closes. The incidence of congenital hydrocele rises with decreasing age of gestation. [5]
Congenital hydrocele of the female Known as the hydrocele of canal of Nuck and is rarely reported in children. Often presents later in life as it is not obvious at birth, as a lump in the groin. The diagnosis requires radiological investigation. [6]
References
  1. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher JK ed. Bailey and Love's SHort Practice of Surgery. 23rd edition. London. Hodder and Arnold. 2000.
  2. GOEL Krishna M, GUPTA Devendra K ed. Hutchison's Paediatrics. 2nd edition. New Delhi. Jaypee Brothers Medical Publishers (Pvt) Ltd. 2012.
  3. QURESHI Z, AHMED S, HAIDER IZ, KHAN K. Primary hydrocoeles in infants and children. J Ayub Med Coll Abbottabad. [Online] 2011 Oct-Dec;23(4):64-5.[Viewed 21 April 2014]. Available from: PMID: 23472416
  4. OKATAN Eda , KEIJZER Richard. Testicular Torsion in a Hydrocele. N Engl J Med [Online] 2009; 361:698 [Viewed 21 April 2014]. Available from: DOI: 10.1056/NEJMicm0805348
  5. O' NEILL James A ed. Principles of Paediatric Surgery. 2nd edition. New York. Mosby. 2004.
  6. CHANDRASEKHARAN L, RAJAGOPAL A. The Hydrocele Of The Canal Of Nuck: An Ultrasound Diagnosis. The Internet Journal of Radiology. [Online] 2005 Volume 4 Number 2. [Viewed 21 April 2014] Available from: http://ispub.com/IJRA/4/2/12888

Examination

Fact Explanation
Unilateral scrotal swelling On inspection the swelling fills one side of the scrotum. Though rarely hydroceles can be bilateral. Usually hydroceles are of a ovoid shape, containing up to 500 ml of fluid and can grow to a diameter of 10 cm. [1], [2]
Can palpate the spermatic cord It is possible to 'get above' the lump and palpate the spermatic cord, which confirms that the swelling is confined to the scrotum. [1]
Testis cannot be palpated The testis cannot be palpated separately within the scrotum on the affected side. As the fluid of the hydrocele surrounds the body of the testis. [1] In an encysted hydrocele of the cord, the swelling may extend up to the external ring and moves on tugging of the testis.
Smooth, well defined surface The surface of the scrotum is smooth and well defined, rarely it may be possible to palpate a fluctuant lump that is herniation of the hydrocele through its coverings. [1]
Fluctuant The two layers of the tunica vaginalis are filled in with clear, yellowish fluid that is rich in protein. [1],[2]
Transilluminable The fluid contained with the two layers of the tunica vaginalis is transilluminable. [1],[2]
Presence of an associated inguinal hernia [3] Often found in association with a congenital hydrocele, due to the patent processus vaginalis, that allows for herniation. [3],[4]
Undescended testis [3] May co-exist with congenital hydrocele.The patent processus vaginalis generally obliterates upon testicular migration to the scrotum. [3],[4]
References
  1. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG ed. Browse's introduction to the symptoms and signs of surgical disease. 4th edition. London. Hodder and Arnold. 2005.
  2. Inguinal hernias and hydroceles in infancy and childhood: A consensus statement of the Canadian Association of Paediatric Surgeons. Paediatr Child Health. [Online] 2000 Nov-Dec; 5(8): 461–462. [Viewed 21 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819962/#__ffn_sectitle
  3. DUCKETT JW. Treatment of Congenital Inguinal Hernia. Ann Surg. [Online] Jun 1952; 135(6): 879–884.[Viewed 21 April 2014]. Available from: PMCID: PMC1802201
  4. FAVORITO Luciano A, COSTA Waldemar S, SAMPAIO Francisco J. Relationship between the persistence of the processus vaginalis and age in patients with cryptoorchidism. Int Braz J Urol.[Online] 2005; 31: 57-61 [Viewed 21 April 2014]. Available from: http://www.brazjurol.com.br/january_february_2005/Favorito_ing_57_61.htm

Differential Diagnoses

Fact Explanation
Inguinal hernia Congenital inguinal hernias and hydrocele coexist, as both arise due to a persistent processus vaginalis. Differentiation is important as management options are divergent. Inguinal hernia presents as an inguinal lump that extends to the scrotum and becomes more prominent during crying/straining. On examination the lump extends into the inguinal region (not confined to the scrotum) and there may be thickening of the spermatic cord (‘silk glove’ sign). [1]
Testicular tumor Presents as a hard. irregular lump that is confined to the scrotum. In neonates, no signs of metastasis are seen. [2]
Torsion of the testis Presents as an acute scrotum, with the characteristic sign of the affected testis lying in a higher and more horizontal position. [3]
Spermatocele Extremely uncommon among neonates and infants, but is a common differential for hydrocele. Presents as a cystic lump confined to the scrotum, however the testis can be palpated separately. [3]
Varicocele A rare possibility, tortuous swelling will become obvious in the standing position. On palpation the characteristic 'bag of worms' can be felt. Should be identified and treated early to prevent sub fertility in adulthood. [3],[4]
References
  1. Inguinal hernias and hydroceles in infancy and childhood: A consensus statement of the Canadian Association of Paediatric Surgeons. Paediatr Child Health. [Online] 2000 Nov-Dec; 5(8): 461–462. [Viewed 21 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819962/#__ffn_sectitle
  2. ROSS Jonathan H, KAY Robert Kay. Prepubertal Testis Tumors. Rev Urol. [Online] 2004 Winter; 6(1): 11–18.[Viewed 22 April 2014] Available from: PMCID: PMC1472674
  3. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG ed. Browse's introduction to the symptoms and signs of surgical disease. 4th edition. London. Hodder and Arnold. 2005.
  4. GREENFIELD SP, SEVILLE P, WAN J. Experience with varicoceles in children and young adults. J Urol. [Online] 2002 Oct;168(4 Pt 2):1684-8; discussion 1688. [Viewed 22 April 2014] Available from: PMID: 12352334

Investigations - for Diagnosis

Fact Explanation
Ultrasonography Will show a tubular cystic lesion in the corresponding groin. [1] An abnormal collection of fluid seen in tunica vaginalis between the visceral and parietal layers of the . An ultrasound scan will also demonstrate causes for a secondary hydrocele such as trauma or torsion.
Pre natal ultrasound scan [2] At 28 weeks of gestation, the testes begin their descent into the scrotum, posterior to the peritoneum and the processus vaginalis, following the path of the gubernaculum testis. The migration through the inguinal canal takes 2 to 3 days, and the descent from the external ring to the bottom of the scrotum takes an additional 4 weeks. Thus, the process is completed at 32 weeks’ gestation. However, due to the wide variation in this time frame, prenatal scans are only of limited benefit. [2]
References
  1. YANG Dal Mo, KIM Hyun Cheol, LIM Joo Won, JIN Wook et al. Sonographic Findings of Groin Masses. JUM [Online] May 1, 2007 vol. 26 no. 5 605-614.[Viewed 22 April 2014] Available from: http://www.jultrasoundmed.org/content/26/5/605.full
  2. PRETORIUS Dolores H, HALSTED Mark J, ABELS Wendy Abels, CATANZARITE Val A, KAPLAN George. Hydroceles Identified Prenatally: Common Physiologic Phenomenon? J Ultrasound Med [Online] 17:49–52, 1998 [Viewed 21 April 2014]. Available from: http://www.jultrasoundmed.org/content/17/1/49.full.pdf

Investigations - Screening/Staging

Fact Explanation
Neonatal examination Neonatal examination should be performed in all neonates prior to discharge from a healthcare facility or by a public health worker providing domiciliary care. This will enable identification of scrotal/groin lump and early referral to a surgical unit. [1]
References
  1. GOEL Krishna M, GUPTA Devendra K ed. Hutchison's Paediatrics. 2nd edition. New Delhi. Jaypee Brothers Medical Publishers (Pvt) Ltd. 2012.

Management - Specific Treatments

Fact Explanation
Conservative The recommended management of a hydrocele is observation during the first 2 years of a child’s life, unless the diagnosis of a hernia cannot be excluded. Most congenital hydroceles due to a patent processus vaginalis resolve before this age. By adopting a wait and see policy it is possible to reduce unnecessary surgery. [1]
Open surgery Hydroceles that persist or appear beyond the age of 2 years are unlikely to resolve spontaneously and should, therefore, undergo elective surgical repair. At the same time the surgeon should search for a hernial that may not have been clinically evident. [2], [3]
Laparoscopic extra peritoneal repair of hydrocele A two-port laparoscopic technique for treatment of hydrocele in children, which allows a completely extra peritoneal closure of the patent processus vaginalis. [4]
References
  1. HALL NJ, RON O, EATON S, PIERRO A. Surgery for hydrocele in children-an avoidable excess? J Pediatr Surg. [Online} 2011 Dec;46(12):2401-5.[Viewed 21 April 2014]. Available from: doi: 10.1016/j.jpedsurg.2011.07.029.
  2. Inguinal hernias and hydroceles in infancy and childhood: A consensus statement of the Canadian Association of Paediatric Surgeons. Paediatr Child Health. [Online] 2000 Nov-Dec; 5(8): 461–462. [Viewed 21 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819962/#__ffn_sectitle
  3. DUCKETT JW. Treatment of Congenital Inguinal Hernia. Ann Surg. [Online] Jun 1952; 135(6): 879–884.[Viewed 21 April 2014]. Available from: PMCID: PMC1802201
  4. WANG DJ, QIU JG, FANG YQ, SI TJ, LUO JB, GAO X. Laparoscopic extraperitoneal repair of symptomatic hydrocele in children: a single-center experience with 73 surgeries. J Endourol. [Online] 2011 Jul;25(7):1221-5. [Viewed 21 April 2014]. Available from: doi: 10.1089/end.2010.0594.