Inguinal Hernia/Hydrocele

Condition: Inguinal Hernia/Hydrocele

Overview ("What is it?")

  • Before birth, a boy’s testicles are located within the abdomen. Under the influence of a number of different hormones, the testicles migrate down the abdomen, through a canal in the groin (called the processus vaginalis) and finally into the scrotum (See Figure 1).  In most males, the canal closes. However, in some children (including females), the canal fails to close leading to an inguinal (groin) hernia or hydrocele.

Figure 1

  • An inguinal hernia is a bulge in the groin created by tissue or organs that are located within the belly (also known as the abdomen). In boys, this bulge is often found in the scrotum. The hernia typically contains either fat from within the abdomen or even intestines. If bowel gets trapped outside of the belly, then its blood supply can be cut off which is dangerous and requires immediate surgery. In girls, the ovary is the most common organ that is found within the hernia.
  • A hydrocele is fluid filled sac in the groin or scrotum. Hydroceles have similar physical exam findings as an inguinal hernia but no bowel or tissue is found within the sac. (See Figure 2). The hydrocele may connect to the abdominal cavity (thus called a communicating hydrocele) or have no connection (non-communicating hydrocele).
  • Inguinal hernias and hydroceles will develop in up to five percent of all children.
  • Inguinal hernias are also much more common in premature infants and in boys. 
  • A chronic cough and excessive straining while going to the bathroom may induce the hernia or hydrocele to occur.

Signs and Symptoms ("What symptoms will my child have?")

  • The most common initial sign of an inguinal hernia is a bulge in the groin or scrotum. The bulge will typically come and go; it is often present when the child is straining or crying. When the child relaxes, the bulge may go away. 
  • If the bulge becomes trapped (incarcerated), it may mean that organs from inside the belly are trapped inside the hernia. The hernia is a small space and blood flow to the trapped organs may be decreased. The child will likely experience pain or tenderness. The bulge may also become much more firm or even red when this happens.
  • Symptoms of a strangulated hernia (where the blood supply of the contents of the hernia is cut off) include severe pain, vomiting, lack of appetite, redness or bruising around the bulge, and sometimes, fevers and  bloody stools.
  • Hydroceles can present in a similar fashion with a bulge in the groin or scrotum. Fluid is made in the inside of the abdomen so if there is a communication between the hydrocele and the inside of the belly, the fluid can move back and forth from the scrotum into the belly, leading to change in size of the scrotum. Acute swelling of the hydrocele may lead to pain and tenderness to that area.

Diagnosis (“What tests are done to find out what my child has?”)

  • Typically, the diagnosis of an inguinal hernia or a hydrocele is made solely on physical exam. Therefore, if you notice a groin bulge in your child or any of the symptoms listed above, take them to your doctor or visit the emergency room as soon as possible.
  • Inguinal hernias or hydroceles that are not associated with severe pain, redness, vomiting or abdominal distention do not require emergent consultation. A routine visit to your pediatrician can be scheduled for further evaluation.
  • Other conditions that can present with symptoms similar to an inguinal hernia or hydrocele are enlarged lymph nodes, testicular torsion (twisting of the testicle), varicocele, undescended or retractile testes. Your doctor will be able to distinguish between these conditions based on physical exam or order appropriate tests if necessary.
    • If the diagnosis is not clear, especially if problems with the testicle are being considered, an ultrasound of the groin may be required. An ultrasound uses sound waves to create an image or picture of the internal structures. It is useful in looking at blood flow. It does not use radiation.

Treatment (“What will be done to make my child better?”)

  • Medical treatment:  There is no medicine that would make hernias get better.
  • Surgery is required to fix the inguinal hernia or communicating hydrocele. It is generally recommended that these be fixed immediately, especially in infants, due to the risk of the hernia becoming trapped outside the abdomen and becoming a medical emergency.
    • Typically, a small incision is made near the bulge and the contents of the hernia are pushed back into the abdomen. The hole where the organs are exiting from the belly (hernia) is closed. Unlike adult hernia repairs, mesh is typically not used.
      • A laparoscopic approach may also be used. In this case, small cuts are made on the belly allowing a scope and instruments to be inserted to visualize and repair the hernias.
    • If the hernia was trapped outside the abdomen, the surgeon will first ensure that the blood supply to the bowel has not been cut off for too long. If it has, a small piece of bowel may need to be removed, and the bowel sewn back together.
    • A non-communicating hydrocele does not require immediate treatment unless it causes significant pain. Most can be observed until 12 to 18 months of age. If the hydrocele is still large at that age, some will recommend surgery since it may affect the growth of the testicle and that there may actually be an associated hernia.  
    • Preoperative preparation:  Your child will be advised to bathe or shower the night before or the morning of surgery to decrease the risks of wound infection. S/he should not have any solid food for eight hours before surgery and stop liquids by 2-4 hrs prior to surgery (ask your doctor’s office for specific times).
    • Postoperative care:  Most of these procedures are done on a day surgery basis, allowing discharge of the child after surgery. Same day discharge would depend on the condition of the patient and is your surgeon’s choice.
  • Risks/benefits:
    • Risks:  Bleeding, infection, damage to surrounding organs. In males, the blood vessels that supply the testicle and the vas deferens (tube that connects the testicle to the penis) may be injured. Recurrence of hernia is less than 12% in the child’s lifetime.
    • Benefits:  Benefits include repair of hernia and decreasing danger of trapping intestine and other organs in the hernia.

Home Care (“What do I need to do once my child goes home?”)

  • Instructions after discharge can vary based on the institution or the surgeon, age of the child, and complexity of the surgery. However some general principles remain the same. 
  • Diet:  Most patients are able to eat a general diet.
  • Activity:  If the patient had the procedure with small incisions (laparoscopic), he or she can return to normal activity in 1-2 weeks. If the surgery is done through a big incision, then he or she can be back to normal activities in 2-4 weeks, with a weight restriction of 10 pounds up until that time.
  • Wound care:  The patient can shower after three days but may want to wait 5-7 days after surgery before soaking the wound.
  • Medicines:  Medication for pain such as acetaminophen (Tylenol®) or ibuprofen (Motrin® or Advil®) or something stronger like a narcotic may be needed to help with pain for a few days after surgery. Stool softeners and laxatives are needed to help regular stooling after surgery, especially if narcotics are still needed for pain.
  • What to call the doctor for:  After discharge from surgery, problems that may indicate infection such as fevers, wound redness and discharge should be addressed.
  • Follow-up care:  The patient should be seen by a surgeon or pediatrician/family practice doctor at least once to check the surgical wound.

Long-Term Outcomes (“Are there future conditions to worry about?”)

  • In general, the risk of the hernia returning in children is less than 1%. However, there are a few exceptions including those children who may have connective tissue disorders.
  • Other risks of surgery include bleeding, infection (1-3%), pain, damage to surrounding structures, recurrent hernia (<1%) and side effects of anesthesia. These are rare and the procedure is generally well tolerated.

References:

  1. Ashcraft, K. (2010). Ashcraft's pediatric surgery (5th ed.). Philadelphia: Saunders/Elsevier.
  2. Ramskook, C. et. al. (2014, October 20). Overview of Inguinal Hernia in Children UpToDate.
  3. Figure 1: http://www.adhb.govt.nz/newborn/Guidelines/Anomalies/InguinalScrotalGenitalProblems.htm.

Updated: 11/2016
Authors: Romeo C. Ignacio, Jr., MD: J. Prieto, MD
Editors: Patricia Lange, MD; Marjorie J. Arca, MD