Hydrocele is an accumulation of fluid in the tunica vaginalis surrounding the testis. In children, it is commonly due to the persistence of a patent processus vaginalis. Hydroceles are usually benign and often resolve spontaneously within the first year of life. However, they can sometimes cause discomfort and may require surgical intervention if persistent or symptomatic.

History and examination

  • Male infants and young children
  • Risk factors: Family history of hydrocele or inguinal hernia, history of prematurity

Symptoms

  • Painless scrotal enlargement may vary in size during the day or with position changes
  • Discomfort or heaviness in the scrotum (in older children)

Signs

  • Swelling in the scrotum, usually unilateral but can be bilateral
  • Transillumination positive: Light transmission through the scrotal swelling, indicating fluid accumulation

Differential diagnosis (D/D) & Complication

D/D:

  • Inguinal hernia (Bowel sounds in the scrotum, reducible swelling, worsens with crying or straining)
  • Testicular torsion (Sudden onset severe pain, high-riding testis, negative Prehn’s sign)
  • Epididymitis or orchitis (Painful and tender swelling, fever)

Complications:

  • Inguinal hernia
  • Compression of testicular blood supply (rare)

Investigation

  • No investigations are typically needed for diagnosis
  • Ultrasound may be considered if there is uncertainty in the diagnosis or to rule out other pathologies

Admission criteria

  • Usually not required

Management

Medical:

  • Observation and reassurance: Most hydroceles in children resolve spontaneously by 12-18 months of age

Surgical:

  • Indications: Persistent hydrocele beyond 12-18 months, large or symptomatic hydrocele, or suspicion of an inguinal hernia
  • Procedures: Hydrocelectomy or inguinal approach with high ligation of the patent processus vaginalis

Advices

  • Reassure parents about the benign nature of hydroceles in children and the likelihood of spontaneous resolution
  • Educate parents on the signs and symptoms of inguinal hernia and testicular torsion, which require urgent medical attention

Referral

  • Refer to a pediatric surgeon if the hydrocele persists beyond 12-18 months or if surgery is indicated

Follow up

  • Regular follow-up to monitor the size and progression of the hydrocele until resolution

Additional points

  • Encourage parents to report any sudden changes in size, color, or pain associated with the hydrocele

References

  1. Huang, W. Y., & Chen, Y. F. (2017). Pediatric hydrocele and hernia. In Asian Journal of Urology (Vol. 4, No. 4, pp. 230-235). Elsevier.