A congenital encysted hydrocele is a collection of fluid within a sac-like cavity (Tunica vaginalis) surrounding the testis or along the spermatic cord. It occurs due to an imbalance between fluid production and absorption, often resulting from the incomplete obliteration of the processus vaginalis. Congenital hydroceles are common in newborns and often resolve spontaneously within the first year of life.

History and examination

  • Ask for duration, trauma, infection, vomiting, bowel habit

Symptoms:

  • Painless scrotal swelling
    • With gradual waxing/waning of size but no sudden increase/decrease of size
  • Parental concern about scrotal size

Signs:

  • Scrotal enlargement (unilateral or bilateral)
  • Transillumination (Positive)
  • No inguinal mass
  • Non-tender and non-reducible
  • Palpable testis separately below the swelling (But in hydrocele, testis is palpable within swelling)

Differential diagnosis (D/D) & Complication

D/D:

  • Inguinal hernia (reducible, impulse on coughing)
  • Testicular torsion (acute pain, high-riding testis, absent cremasteric reflex)
  • Epididymitis (tenderness, erythema, fever)

Complications:

  • Discomfort
  • Cosmetic concerns
  • Infection
  • Tension hydrocele

Investigation

  • Clinical evaluation is usually sufficient for diagnosis
  • Scrotal ultrasound (if diagnosis is uncertain or to differentiate from other conditions)

Admission criteria

  • Admission is rarely required, except in cases of suspected testicular torsion, infection, or tension hydrocele

Management

  • Observation and reassurance for asymptomatic congenital hydroceles that are likely to resolve spontaneously within the first year of life

Surgical:

  • Hydrocelectomy for persistent hydroceles beyond 12-18 months of age, large or symptomatic hydroceles, or hydroceles causing complications

Advices

  • Educate parents about the natural course of congenital hydroceles and when to seek medical attention

Referral

  • Refer to a pediatric urologist or surgeon for evaluation and surgical management if the hydrocele persists or is causing complications

Follow up

  • Regular follow-up with a pediatrician to monitor the hydrocele and assess for resolution or complications

Additional points

  • Patency (nonobliteration) of patent processus vaginalis (PPV) is the cause of hernia and hydrocele; a wide patency results in inguinal hernia, while a narrow PPV may cause hydrocele.
  • The majority of congenital hydroceles resolve spontaneously within the first year of life, and surgical intervention is typically reserved for those that persist or cause complications
  • Hydrocele is seen in about 6% of infants; spontaneous resolution occurs in most cases by 18 months.

References:

  1. Niedzielski, J., Paduch, D., & Raczynski, P. (2001). Hydroceles in boys: A study of 112 cases. Pediatric Endocrinology, Diabetes and Metabolism, 7(3), 163-168.
  2. Elder, J. S. (2007). Disorders and anomalies of the scrotal contents. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007: 2222-2225.
  3. Stehr, M., Metzger, R., Schuster, T., Porn, U., & Dietz, H. G. (2003). Management of the noncommunicating isolated hydrocele in pediatric patients. Journal of Pediatric Surgery, 38(4), 592-595.