Editing External Genital Anomalies in Boys (section)

== Hernia and Hydroceles ==

=== Embryology ===
* The processus vaginalis forms during the 3rd month of gestation as the peritoneum bulges into the inguinal canal just before the onset of testicular descent.
** '''On completion of testicular descent, the processus vaginalis obliterates and the portion adjacent to the testes becomes the tunica vaginalis'''
** '''Obliteration of the processus vaginalis continues post-natally, and its failure to obliterate accounts for nearly all inguinoscrotal abnormalities seen in infancy and childhood'''
* '''Patent process vaginalis is associated with (4):'''
*# '''Transverse testicular ectopia'''
*# '''Epididymal anomalies'''
*# '''Cryptorchidism'''
*# '''Polyorchidism'''
** '''Risk of spermatic cord torsion is associated with abnormal development of the tunica vaginalis but not patency of the processus vaginalis'''
* '''Incidence of incidental patency observed in older children and adults at autopsy or laparoscopy is ≈20%'''

=== Definitions ===
* '''Indirect inguinal hernia: a widely patent processus vaginalis''' extending beyond the internal inguinal ring '''containing abdominal contents''' (bowel, omentum, gonads) which may pass into the inguinal canal, labia, or scrotum
* '''Communicating hydrocele: a patent processus vaginalis extending beyond the internal inguinal ring containing peritoneal fluid alone, which extends to the testis, with fluid within the tunica vaginalis'''
* '''Hydrocele of the spermatic cord: fluid contained within a segment of patent processus vaginalis with obliterated processus distally and proximally'''
* '''Scrotal hydrocele: fluid contained within the tunica vaginalis surrounding the testis without communication proximally'''
** '''May be seen as a chronic or acute scrotal swelling after an inflammatory, infectious, or traumatic event'''. The hydrocele size is typically stable but may decrease over time.
* Abdominoscrotal hydrocele: a large scrotal hydrocele that extends proximally across the internal inguinal ring into the abdomen without communication with the peritoneum
** Associated with (4):
**# A closed processus vaginalis.
**# Testicular dysmorphism.
**# Hydronephrosis.
**# Increased pressure within the tunica vaginalis.

=== Epidemiology and Pathogenesis ===
* '''Inguinal Hernia and Communicating Hydrocele'''
** Inguinal hernias develop in 1-5% of children, 5-10x '''more common in boys and significantly more common among premature infants'''
** '''More common (3:1) on the right side'''
*** '''Attributed to the later descent of the right testicle'''
** '''Risk factors for bilateral involvement (4):'''
**# '''Female gender'''
**# '''Prematurity'''
**# '''Age < 1'''
**# '''History of cryptorchidism'''
** Average age at presentation is 3-4 years
** '''The majority of new hydroceles occurring after birth and before puberty are associated with a patent processus vaginalis''' (clinically communicating, clear history of fluctuation)
* '''Noncommunicating Hydroceles'''
** '''Hydroceles that spontaneously resolve during infancy or appear during or after puberty are more commonly non-communicating'''
** '''These form from delayed fluid absorption or abnormal fluid dynamics within the tunica vaginalis'''

=== Diagnosis and Evaluation ===
* '''History and Physical Exam'''
** '''History'''
*** Typically manifests as a '''painless bulge found in the groin or extending along the cord to the scrotum.'''
**** '''The bulge may be present only during periods of increased intra-abdominal pressure (crying or bowel movements'''
***** '''The presence of an intermittent bulge helps to distinguish a reducible inguinal hernia and communicating hydrocele from a scrotal hydrocele or hydrocele of the spermatic cord'''.
***** '''The child with an incarcerated inguinal hernia will be irritable or inconsolable and have a persistent or larger bulge without spontaneous reduction and may have decreased appetite and signs of bowel obstruction (abdominal distention, vomiting, and lack of flatus or stool)'''
** '''Physical Exam'''
*** '''The supine position facilitates reduction of peritoneal fluid and intra-abdominal contents'''
*** '''The hydrocele fluid surrounding the testicle should transilluminate; however, neonatal bowel may also transilluminate.'''
*** The hydrocele of the spermatic cord is usually painless and variable in size. It may be confused for the testis because of its round-oval shape
* '''Imaging'''
** '''Often of limited use'''

=== Management ===

==== Hydroceles ====
* '''Both communicating and non-communicating hydroceles may resolve spontaneously in infants''' (CW12 p392 and CW11)
** '''No indication for surgery within the first 24 months of age'''
*** '''Indications for intervention:'''
**** '''Hydrocele associated with inguinal hernia'''
**** '''Hydrocele develops when child is several years old'''
**** '''Hydrocele enlarges during the period of observation'''

==== Inguinal Hernia ====
* '''Require surgical repair shortly after diagnosis, given the significant risk of associated complications'''
* '''Standard Inguinal Hernia Repair'''
** '''The traditional surgical approach to repairing an indirect inguinal hernia or communicating hydrocele is high ligation of the hernia sac at the level of the internal inguinal ring. This carries a high success rate'''
** '''In peripubertal boys with hydrocele, determine if hydrocele is communicating or scrotal.'''
*** '''If communicating, inguinal approach is preferred'''
*** '''If scrotal, trans-scrotal hydrocele approach is performed as in adults''' and an inguinal incision made only if a proximal communication is identified.
** '''Complications'''
*** Early postoperative complications, including bleeding and infection, are rare after standard hernia repair
*** '''Recurrent inguinal hernia'''
**** Rate after uncomplicated open repair: 0.5-1%
**** Causes include failure to properly identify or ligate the sac during the original procedure; a tear in the sac, leaving a strip of peritoneum along the cord; damage to the floor; or a missed direct hernia at the original exploration.
**** '''Laparoscopic inguinal hernia repair associated with higher risk of recurrence''' (up to 4%) '''than with open repair'''
*** '''Secondary cryptorchidism''', testicular atrophy, and vasal injury is not well defined.
**** If a testis is incompletely descended or retractile, orchidopexy should be performed at the time of herniorrhaphy
* Assessment of the contralateral internal ring
** The need to assess the patency of the contralateral processus vaginalis or of the internal inguinal ring in children with a unilateral hernia remains controversial