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Hernias + Hydroceles

• Persistent processus vaginalis allows either fluid (hydrocele) or abdominal contents (hernia) to enter inguinal canal and scrotum
• Intermittent bulge: reducible inguinal hernia or communicating hydrocele, vs scrotal/cord hydrocele
• Incarcerated hernia: persistent/large bulge without spontaneous reduction, evidence bowel obstruction
• Diagnosis: made clinically (parental history and exam), can bring in photos if not seen on exam, no imaging required to plan surgery
• Hydrocele and neonatal bowel will transilluminate
• Hernias require elective require unless nonreducible
• Repair hydrocele if persistent beyone 1yo or enlarging/fluctuating
• Contralateral hernia: seen in up to 60%, perform inguinal laparoscopy at time of repair and fix contralateral side if hernia confirmed
• For surgical technique, see separate section
• Abdominoscrotal hydrocele: scrotal component extends through inguinal canal and can compress structures, can cause lower extremity edema and hydronephrosis, best treated by scrotal approach (per Xu et al JPU 2020)

Special hernia circumstances

• cAIS: 2-3% female inguinal hernias will have testes present at time of repair, current recommendation is to maintain in inguinal region (do not remove) to allow for natural hormone production and self-exams
• Increased intraabdominal pressure: hydrocele/hernia less likely to resolve if child is on peritoneal dialysis or VP shunt, contralateral repair warranted
• Hernia Uteri Inguinale: persistent Mullerian duct structures may herniate into scrotum, can consider removal at time of repair
• Connective tissue disorders: hernias may be more common in these patients, hernia diagnosis may precede diagnosis of syndrome

Varicocele

• Grading: 0 (subclinical, US only), 1 (palpable with Valsalva), 2 (palpable but not visible), 3 (visible)
• Consider CT/US if varicocele does not decompress in supine position
• Surgical indications: testicular asymmetry, left/bilateral hypotrophy, pain, abnormal semenalysis or intratesticular varicocele (1-2% cases)

Other anomalies

• Penoscrotal transposition: usually seen with other GU abnormalities, can repair with skin flaps
• Bifid scrotum: no median raphe, seen with proximal hypospadias, can perform Z-plasty
• Ectopic scrotum: rare, obtain renal US, can perform scrotoplasty and/or orchiopexy
• Scrotal agenesis: rare (7 cases)
• Scrotoschisis: meconium peritonitis causes scrotal rupture and testicular extrusion, treat with orchiopexy and scrotal closure
• Polyorchidism: supernumerary testis, more common on left side, often associated with cryptorchidism
• Splenogonadal fusion: continuous union of spleen and gonad, associated with cryptorchidism