Inguinal hernia and hydrocele
An inguinal hernia occurs when, during fetal development, a sac surrounding
an infant's normally descending sexual organs (for boys, the testicles into the
scrotum and for girl's, the uterine ligament into the groin area) does not close
as tightly as it should, allowing a portion of the intestine to bulge through
the sac's channel-like opening. Normally the sac closes completely during the
ninth month of intrauterine life or soon after birth.
When fluid collects in a baby boy's scrotum due to the
same inadequate closure of the sac from the abdominal cavity, the condition in
known as a hydrocele. Hydroceles are generally not harmful to the testicles and
do not cause pain to the baby.
Incidence
Hernias and hydroceles are among
the most common of all pediatric surgical problems. Premature infants,
especially, have a higher incidence than full-term babies, and boys more than
girls.
The cause of the problem
Some hernias and
hydroceles seem to run in families, but true hereditary factors have not been
identified.
Signs and symptoms
- A bulge (swelling) in the groin, which at times may extend into the
scrotum, is by far the most frequent sign. The bulge may appear and then
disappear with some regularity especially during straining, crying, or
coughing.
- Although sharp pain is usually not associated with herniation, discomfort
that occurs in some babies is easily overlooked.
- Occasionally constipation, "colicky-baby" syndrome, and even regurgitation
are present.
In the very young baby, the initial presentation may represent more severe
problems. The baby's bulge is firm and tender to touch, the groin and scrotum
may be reddened, and the infant may be vomiting or feeding poorly. A history of
recurring groin swelling that the parents or the pediatrician can reduce (gently
pushing the organs back into place) is a strong indication that a hernia is
present.
Diagnosis
Fetal hydrocele can be diagnosed by ultrasound
(sonogram) examination prior to birth. Evaluation of the urinary system is part
of the routine ultrasound examination done by many obstetricians as part of
their routine prenatal care. Hydroceles are most commonly identified in the
third trimester and occur in approximately 15 percent of all male fetuses.
After the baby is born,the physical examination in many is so characteristic that only observation
is necessary to make the diagnosis. Diagnostic confirmation is made when the
contents of the hernia can be reduced (gently pushed back into place).
Hydroceles are difficult to reduce though many reduce spontaneously when the
child is kept lying on his back for several hours.
If during the examination, the hernia is not clearly evident but the parents
have observed it, repeated examination in two to three weeks is recommended. The
parents should continue observation, be taught how to reduce the hernia and, at
times, even resort to photographing the hernia so that a definite diagnosis can
be established.
If the hernia cannot be reduced, it is known as an incarcerated (or
irreducible). Plain abdominal x-rays are helpful in demonstrating this
situation. Plain films are also useful to distinguish between an acute
hydrocele, for which an operation can be delayed, and incarceration, which
requires immediate attention.
Treatment
The reason for repairing an
inguinal hernia is to prevent incarceration. Since the incidence of
incarceration is inversely related to age, the younger the patient-the sooner
the repair. Premature babies should have their hernias repaired just prior to
discharge from the hospital. Asymptomatic school age children can be repaired
when school is in recess.
The timing of repair is less clear with hydroceles. In most centers, hydroceles
are not repaired until the baby is 12 to 18 months or older. Approximately
90 to 95 percent of all hydroceles resolve spontaneously in the first few
months of life. If a hydrocele becomes very large and tense, earlier repair can
be considered. If a hydrocele cannot be differentiated from a hernia, operation
is indicated.
Typically, the operation is an outpatient procedure performed under general
anesthesia. But premature infants and children with medical conditions such as
cystic fibrosis, or hemophilia, usually need admission for 24 hours of
observation.
Postoperative care
Postoperative care is
straightforward. Since absorbable sutures are used for wound closure, most of
the children can be bathed within 24 to 48 hours. No restriction on diet or
activities is given. Tylenol for analgesia is all that is required. In older
children, sometimes ibuprofen or codeine may be necessary.
Outcomes
Recurrent herniation is rare and is
seen in less than one percent of cases. More often, residual or post-traumatic hydroceles
may be noted. If they do not resolve after several months, aspiration of their
contents may be helpful. See information on
this same topic as written by physicians in Urology.