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Hydroceles/Hernias

By Philip E. Gleason, MD

I would like to provide some introductory information regarding hydroceles and hernias. Hydroceles and hernias typically represent a bulging of the groin or scrotum. They can occur anywhere from birth throughout the boy's or man's life. They represent a persistent opening of a passage called the processes vaginalis which is an outpouching of the peritoneum during development. This runs from the abdomen down along the groin into the scrotum. Typically it closes at the opening into the abdomen during development and at birth. However, in approximately 6% of boys and men this will stay open. It therefore can allow passage of fluid or the contents of the abdomen into the groin and down into the scrotum. If the sac is filled with fluid, it is typically called a hydrocele. If it has a piece of bowel or fat from the abdomen called omentum, or solid tissue, it is called a hernia. In many respects, they are tow different names for the exact same process.

I should mention that there can be alternative forms of hydroceles or hernias. Occasionally young boys will have a fluid hydrocele collection around the testicle which does not communicate through the groin area to the abdomen. This oftentimes can be present after birth but usually resolves within the first several months of life or perhaps during the first year or two of life. In addition, sometimes older men can have what is referred to as a direct hernia. This does not represent a communication through the groin but rather a weakness of the lining of the abdomen call the fascia. This allows an outpouching of the abdomen through the groin into the scrotum directly from the abdomen but does no involve the processes vaginalis tract from the abdomen through the groin to the scrotum.

If there is a patent processes vaginalis and communicating hydrocele or indirect inguinal hernia, we oftentimes do consider correction. If the tract is left open for a prolonged period of time, it will tend to accumulate more and more fluid and the hydrocele will get bigger and bigger, ultimately possibly causing some discomfort or risk of herniation. If bowel, omentum, or solid structures get down through the tract into the scrotum, they will sometimes get trapped in place referred to as an incarcerated hernia. That can become quite severe and essentially an emergency in which the scrotum gets very red and painful and if left untreated, the bowel, omentum, or abdominal contents can be damaged to the point of serious medical emergency.

Therefore, we usually go ahead and try to correct the tract before it allows future problems. This involves an out patient surgery in which the children come to the hospital. They have a general anesthetic. A small incision is made in the groin which allows the patent processes vaginalis tract to be identified. If there is any bowel or solid tissue in the tract, this is replaced back within the abdomen. Any remaining fluid is also drained. Care is taken to avoid injury to the vas deferens which transports sperm from the testicle to the body. In addition, the blood supply including the artery and vein to the testicle run through the inguinal canal and care is taken to avoid injury to these blood vessels. The skin is closed with a suture which will dissolve in a week or two. The procedure takes anywhere form 1-1 1/2 hours. The children typically go home on an out patient basis. They can oftentimes be somewhat tender and cranky for a day or two, although after two to three days they have bounced back, recovered, and oftentimes a family will remark that they cannot tell the child had anything done at all. We will usually use some Tylenol with Codeine syrup for pain relief after the procedure. Alternatively, many families just use Tylenol or Advil and that seems to work just as well. We typically try to see the children back two weeks after the surgery to make sure they have recovered from the surgery and have gotten a good result. Risks of the procedure are very minimal. Anesthetic risks can be minimized by trying, if possible, to wait until the child is at least three to six months of age before surgery. The risk is then approximately 1 in 10,000 chances of any anesthetic problem and usually involves wheezing or asthma. This is actually the same risk as any adult and will remain minimal throughout the child's life until old age. Other complications such as bleeding, infection, or damage to the testicular vessels or vas deferens occur less than 1% of the time and the procedure itself is typically very effective without complication. Once performed, it should prevent any future problems, hopefully for life.

We should mention one further point of discussion. If the boy is less than two years of age and presents with a hydrocele/hernia in one groin, there is approximately a 50% chance of having a patient processes vaginalis in the other groin as well, even if there has not been any swelling or previous abnormality. Approximately 20% of those boys will ultimately have a hydrocele or hernia on the opposite side. Therefore, approximately 10% of the population will ultimately have problems on both sides. If the children are under age two and unable to really describe any problems they night have, we oftentimes recommend performing surgery on groins at the time of the anesthetic to identify the communication and, if it is present, go ahead and close it at that time with just one anesthetic and second operation if, down the road, a hydrocele or hernia develops on the opposite side. If the children are older than age two, they can typically tell you if they have had any problems or you have had some test of time to see if there is going to be any problems on the opposite side. As long as there have not been any problems or history, we would typically not pursue surgery but just follow conservatively. If there were future problems down the road, we could certainly correct it at that time but hopefully that would avoid unnecessary surgery in up to 90% of the boys.

I hope this provides some background information on hydroceles and hernias. If we can provide any further information or answer any questions, please let us know.