Background

A hydrocele is a collection of fluid within the processus vaginalis (PV) that produces swelling in the inguinal region or scrotum. An inguinal hernia occurs when abdominal organs protrude into the inguinal canal or scrotum. Inguinal hernia and hydrocele share a similar etiology and pathophysiology and may coexist. In the healthy male neonate, the testicle is surrounded by a closed cavity the tunica vaginalis (!V) of the scrotum. In postnatal life, this is a potential space that should not communicate with the peritoneal cavity of the abdomen.

Pathophysiology
"uring fetal development, the testicle is located below the #idney, within the peritoneal cavity. As the testicle descends through the inguinal canal and into the scrotum, it is accompanied by a sacli#e extension of peritoneum, otherwise #nown as the PV. After the testicle descends, the PV obliterates in the healthy infant and becomes a fibrous cord with no lumen. !he distal tip of the PV remains as a membrane around the testicle the tunica vaginalis. $ormally, the inguinal region and scrotum should not connect with the abdomen. $either abdominal organs nor peritoneal fluid should be able to pass into the scrotum or inguinal canal. If the PV does not close, it is referred to as a patent processus vaginalis (PPV). If the PPV is small in caliber and only large enough to allow fluid to pass, the condition is referred to as a communicating hydrocele. If the PPV is larger, allowing ovary, intestine, omentum, or other abdominal contents to protrude, the condition is referred to as a hernia. %ultiple theories exist regarding the failure of PV closure. &mooth muscle has been identified in PPV tissue but not in normal peritoneum. !he amount of smooth muscle present may correlate with the degree of patency. 'or example, higher amounts of smooth muscle have been found in hernia sacs than in the PPV of hydroceles. Investigation continues to determine the role of smooth muscle in the pathogenesis of this condition.

Epidemiology
Frequency
United States !he incidence of hernias is ()*+) per ())) live births and is much more common following premature birth. ,hile hernia location is more common on the right side, as many as ()- are bilateral.

Mortality/Morbidity
!he greatest ris# associated with a hernia involves an intra*abdominal organ becoming trapped within the hernia sac. !his condition is referred to as incarceration of the organ. If bowel becomes incarcerated, it may become edematous. !he increased pressure may impair venous drainage, leading to more edema, which may impair arterial inflow of the bowel. !his can ultimately cause bowel ischemia and possible rupture. In a male, pressure on the spermatic cord by an incarcerated hernia may affect blood flow to the testis. ,hen perfusion of the bowel is affected, a strangulated hernia exists. A strangulated hernia can lead to perforation of the entrapped bowel, peritonitis, sepsis, and even death. As such, an incarcerated or strangulated hernia is a surgical emergency. If a strangulated bowel is reduced surgically at an early stage, viability may be preserved, and bowel resection may be avoided. In children with a painful nonreducible hernia, incarceration should be suspected, necessitating emergency evaluation. !he omentum may become entrapped in a hernia, causing chronic abdominal pain with a persistent inguinal mass. In females, the ovary or fallopian tube can enter hernia sacs and become incarcerated or strangulated. An incarcerated ovary is an urgent problem that may result in inguinal pain and infarction of the ovary. An incarcerated ovary does not carry the same ris# of sepsis as is seen with bowel incarceration and perforation.

Sex

.ernias are / times more common in boys than in girls. 0owel incarceration is more common in females than in males. In females, an ovary or fallopian tube incarcerates more fre1uently than bowel. !herefore, the overall incidence of bowel strangulation is lower in females than in males.

Age
!he incidence of PPV decreases with age. In newborns, 2)-*34- have a PPV. .ernias are +) times more common in premature infants who weigh less than (5)) g than in babies born at term. As many as 6)- of adults are discovered to have a PPV at autopsy. ,hy all PPVs do not develop into a hernia or hydrocele is not understood.

istory
A bulge in the groin or scrotal enlargement is the classic presentation of hernia or communicating hydrocele. Pain is generally not a prominent feature but may occur if a hydrocele expands 1uic#ly7 tension in the wall may cause milder pain. &evere pain raises concern about a strangulated hernia. Very rarely, a hydrocele may become infected and cause pain. 're1uently, parents report an intermittent bulge. !he bulge may reduce at night in the supine position. A history of vomiting, colic#y abdominal pain, or obstipation suggests bowel obstruction, which may occur with an incarcerated or strangulated hernia.

Physical
8xamine the child in the supine and standing positions. If a bulge is apparent in the standing position, lay the child in the supine position. 9esolution of the bulge in the supine position suggests a hernia or a hydrocele with a patent processus vaginalis (PPV). If the bulge is not readily apparent, perform a maneuver to increase intraabdominal pressure. 'or example, have the child simulate blowing up a balloon, cough, or press firmly on the abdomen. 9estraining a baby:s hands above his or her head causes the baby to struggle, potentially revealing an occult bulge that is not visible otherwise. !ransillumination of the scrotum displays fluid in the tunica vaginalis, suggesting a hydrocele. .owever, this test does not fully exclude a hernia, as the bowel may also transilluminate. 0owel sounds in the scrotum are strongly suggestive of a hernia. A bulge below the inguinal ligament is suggestive of lymphadenopathy. 8xaminers may try to elicit the ;sil# glove; sign. <ently passing the fingers over the pubic tubercle may reveal a PPV. !he thic#ened cord of a hernia or hydrocele sac within the spermatic cord provides the feel of + fingers of a sil# glove rubbing together. =nless a PPV results in hernia or hydrocele, it often goes undetected during physical examination.

!auses
%ost hernias and hydroceles in children are due to idiopathic failure of the PV to close. Any condition that increases intraabdominal pressure can delay or inhibit this closure. o o o o o o o o o o o o !he following is a list of conditions associated with a higher incidence of hernia or hydrocele> ?ryptorchid testis .ypospadias Ambiguous genitalia 8pispadias and exstrophy of the bladder Ventriculoperitoneal shunt @iver disease with ascites Abdominal wall defects ?ontinuous ambulatory peritoneal dialysis Prematurity @ow birth weight 'amily history of hernia or hydrocele .ydrops

o o o o o o o o o o

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%econium peritonitis ?hylous ascites ?ystic fibrosis ?onnective tissue disease %ucopolysaccharidosis 9eactive hydroceles result from inflammation and fluid accumulation in the tunica vaginalis around the testicle, even though the PV is closed. A reactive hydrocele can result from the following factors> !rauma !orsion Infection (eg, epididymo*orchitis) Abdominal or retroperitoneal operations that impair lymphatic drainage .ernia classification Indirect hernias protrude through the internal inguinal ring, lateral to the inferior epigastric vessels. !hey are caused by failure of the PV to obliterate. %ost inguinal hernias in children are the indirect type. !he hernia may extend down the inguinal canal toward the labia or scrotum. ?omplete inguinal hernias are indirect hernias that extend into the scrotum. !he anatomic defect is similar to the defect of a communicating hydrocele, although the PPV is more widely patent in hernias. "irect hernias protrude directly through the floor of the inguinal canal and are medial to the inferior epigastric vessels. In children, these hernias are rare and are usually observed only after prior inguinal surgery. .ydrocele classification ?ommunicating hydroceles involve a PPV that extends all the way into the scrotum. In this case, the PPV is continuous with the tunica vaginalis, which surrounds the testicle. !he anatomic defect is identical to the defect with an indirect hernia7 however, the communication is smaller, so only fluid can pass into the PPV. $oncommunicating hydroceles contain fluid confined to the scrotum within the tunica vaginalis. !he PV is obliterated so the fluid does not communicate with the abdominal cavity. &uch hydroceles are common in infants, and the hydrocele fluid is usually reabsorbed before the infant is aged ( year. 9eactive hydroceles are noncommunicating hydroceles that develop from some inflammatory condition in the scrotum, such as trauma or infection. .ydrocele of the cord occurs when the PV obliterates above the testicle. A small communication with the peritoneum persists, and the PV may be open as far down as the top of the scrotum. A sacli#e area within the inguinal canal fills with fluid. !he fluid does not extend into the scrotum. .ydrocele of the canal of $uc# occurs in girls when fluid accumulates within the PV in the inguinal canal. Abdominoscrotal hydrocele results from a miniscule opening in the PV. 'luid enters the hydrocele and becomes trapped. !he hydrocele continues to enlarge and eventually bulges upward into the abdomen, causing a fluid*filled mass in the abdomen. Abdominal !rauma ?ryptorchidism !esticular !orsion Varicocele in Adolescents $o medical therapy is effective for a hernia or a communicating hydrocele. Aspiration and inAection of sclerosing agents have been recommended for noncommunicating hydroceles in adults, but this therapy is relatively contraindicated in children. 0ecause most hernias and hydroceles in children are associated with a patent processus vaginalis (PPV), sclerosing agents may damage intraabdominal contents and are not li#ely to correct the underlying pathology. Anti*inflammatory agents may be used in the setting of a reactive hydrocele. Antibiotic therapy is often prescribed for infectious epididymo*orchitis with a reactive hydrocele.

"i##erential "iagnoses

.ydroceles following varicocelectomy> A recent study found that hydroceles can develop in up to (+- of children undergoing surgery for varicocele, and the incidence varies with the type of procedure performed. Preservation of the lymphatic vessels at the time of surgery reduces the ris# of later hydrocele. ?onservative management (observation or aspiration) results in resolution of 2)- of these hydroceles. &urgical correction was re1uired in only one third of these hydroceles that occurred following varicocelectomy. B(C

http://emedicine.medscape.com/article/1015147-followup

Background
A hydrocele is a fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord. These fluid collections may represent persistent developmental connections along the spermatic cord or an imbalance of fluid production versus absorption. In rare cases, similar fluid collections can develop along the canal of Nuck in females. See the image below.

Young girl with groin bulge, which, at surgery, was a hydrocele of along the canal of Nuck.

y themselves, hydroceles pose little risk of clinical conse!uence. "owever, the potential for more than fluid to appear within developmental connections between the abdominal cavity and the scrotum or the association with underlying scrotal pathology re!uires that hydroceles be evaluated with due prudence. See the image below.

"ydrocele that e#tended retrograde into the abdominal compartment.

$or additional information on hydroceles, see the articles "ydrocele and "ernia in e%edicine&s 'ediatrics( Surgery volume and "ydrocele, $ilarial in the )rology volume.

istory o# the Procedure

The description of the abdominal cavity parietes to the tunica vaginales is attributed to *alen in +,- A.. "owever, the clear description of the inguinal anatomy and its relationship to groin hernias and hydroceles was not recorded until the +/th century.

Problem
The presence of fluid within the hemiscrotum imparts little clinical impact on the testis. "owever, determining the cause for the increased fluid, specifically any associated clinically significant pathology, remains the primary concern with regard to hydroceles. 0nce pathology that is more ominous has been e#cluded, persistence of the hydrocele or the association of discomfort may indicate the need for surgical intervention. 'atients who have undergone varicocelectomy may be an important e#ception in which a hydrocele may be of clinical importance. This procedure, usually performed when dilated vessels around the testes are believed to increase intratesticular temperatures, thereby leading or contributing to male infertility, may damage nearby lymphatic vessels. This, in turn, may cause the formation of postvaricocelectomy hydroceles in appro#imately ,1 of patients,

potentiating the insulation of the testicle and leading to persistent problems with sperm production. The use of microscopes during this procedure has significantly decreased the incidence of lymphatic obliteration and, therefore, hydrocele formation.

Epidemiology
Frequency
'atent processus vaginalis are found in 234/31 of term male infants at birth. This fre!uency rate steadily decreases until age 5 years, when it appears to plateau at appro#imately 564731. Indeed, autopsy series of men have identified a fre!uency rate of 531 of the processus vaginalis remaining patent until late in life. "owever, clinically apparent scrotal hydroceles are evident in only -1 of term males beyond the newborn period. 8ertain conditions, such as breech presentation, gestational progestin use, and low birth weight, have been associated with an increased risk of hydroceles. The incidence of hydroceles in men is less well known. See the image below.

"ydrocele. Small patent processus vaginalis 9indicated by the bubbles: as viewed laparoscopically.

Etiology
The causes of hydroceles are legion. In children, most hydroceles are of the communicating type, in which patency of the processus vaginalis allows peritoneal fluid to flow into the scrotum, particularly during ;alsalva. In the adult population, filariasis, a parasitic infection caused by Wuchereria bancrofti, accounts for most causes of hydroceles worldwide, affecting more than +53 million people in more than ,< countries 9see "ydrocele, $ilarial:. "owever, this condition is virtually none#istent in the )nited States, where iatrogenic causes of hydroceles predominate. $ollowing laparoscopic or transplant surgery in males, inade!uate irrigation fluid aspiration may cause hydroceles in patients with a patent processus vaginalis or a small hernia. 8areful aspiration of fluid at the end of laparoscopic procedures helps prevent this complication. In noncommunicating hydroceles, for both children and adults, the balance between fluid production within the tunica and the fluid absorption is altered. A few studies have attempted to show a link between certain molecular derangements and an increased incidence of patent processus vaginales 9and therefore hydroceles and indirect hernias:. Two such e#amples include increases in maternal estrogen concentrations during pregnancy and abnormalities in the calcitonin gene4related peptide 98*=': released by the genitofemoral nerve.>+?

Pathophysiology
The pathophysiology of hydroceles re!uires an imbalance of scrotal fluid production and absorption. This imbalance can be divided further into e#ogenous fluid sources or intrinsic fluid production.

Alternatively, hydroceles can be divided into those that represent a persistent communication with the abdominal cavity and those that do not. $luid e#cesses are from e#ogenous sources 9the abdomen: in communicating hydroceles, whereas noncommunicating hydroceles develop increased scrotal fluid from abnormal intrinsic scrotal fluid shifts.

!ommunicating hydroceles
@ith communicating hydroceles, simple ;alsalva probably accounts for the classic variation in siAe during day4sleep cycles. Nonetheless, with the incidence of patent processus so great, why children with clinically apparent hydroceles are relatively few remains somewhat ine#plicable. 8hronically increased intra4abdominal pressure 9eg, as in chronic lung disease: or increased abdominal fluid production 9eg, children with ventriculoperitoneal shunts: probably warrants early surgical intervention.

$oncommunicating hydroceles
In noncommunicating hydroceles, the pathophysiology may occur as a result of increased fluid production or as a conse!uence of impaired absorption. A sudden onset of scrotal hydrocele in older children has been noted after viral illnesses. In such cases, viral4mediated serositis may account for the net increased fluid production. 'osttraumatic hydroceles likely occur secondary to increased serosal fluid production due to underlying inflammation. Although rare in the )nited States, filarial infestations are a classic cause of the decreased lymphatic fluid absorption resulting in hydroceles.

Presentation
"ydroceles typically manifest as a soft nontender fullness within the hemiscrotum. The testis is generally palpable along the posterior aspect of the fluid collection. @hen the scrotum is investigated with a focused beam of light, the scrotum transilluminates, revealing a homogenous glow, without internal shadows. The inability to clearly delineate or palpate the testicular structuresB the presence of tenderness, fever, or any gastrointestinal symptoms 9eg, vomiting, constipation, diarrhea:B or the appearance of internal shadows on transillumination should raise the suggestion of a different diagnosis or some additional underlying pathology. Scrotal ultrasonography is the ne#t logical step.

%ndications
Indications for intervention in hydroceles include the following(

Inability to distinguish from an inguinal hernia $ailure of the hydrocele to resolve spontaneously after an appropriate interval of observation Inability to clearly e#amine testis Association of hydroceles with suggestive pathology 9eg, torsion, tumor: 'ain or discomfort %ale infertility 'atient desire

&ele'ant Anatomy
The developmental anatomy of the inguinal canal is responsible for the genesis of pediatric communicating hydroceles. As the testis descends from the posterolateral genitourinary ridge at the beginning of the third trimester of fetal gestation, a saclike e#tension of peritoneum

descends in concert with the testis. As descent progresses, the sac envelops the testis and epididymis. The result is a serosal4lined tubular communication between the abdomen and the tunica vaginalis of the scrotum. The peritoneum4derived serosal communication is the processus vaginalis, and the serosa of the hemiscrotum becomes the tunica vaginalis. At term, or within the first +45 years of life, the processus vaginalis of the spermatic cord fuses, obliterating the communication between the abdomen and the scrotum. The processus fuses distally as far as the lower epididymal pole and anteriorly to the upper epididymal pole. $ailure of complete fusion may result in communicating hydroceles, indirect inguinal hernias, and the bell4clapper deformity of abnormal testicular fi#ation in the scrotum.>5?

!ontraindications
&eemingly, no true absolute contraindications exist for repair of hydroceles. .owever, given the minimal clinical conse1uence of the hydrocele itself, patients deemed as poor surgical or anesthetic ris# may preclude safe surgical repair. Additionally, while a slight maAority of pediatric surgeons across $orth America would repair any communicating hydrocele (somewhat irrespective of age) if it were clearly communicating, waiting until the child is aged (*+ years is certainly reasonable. Additionally, small atrophic testes, or solitary testes, should be approached with great caution to minimiDe the ris# of anorchia.

http://emedicine.medscape.com/article/438724-overview showall
!he tunica vaginalis is a structure within the testicles. It consists of two layers of serous membranes which cover the tunica vaginalis albuginea, a layer of fibrous material which wraps around the testes. &everal layers of tissue are involved in the structure of the scrotum to support and protect the contents, and the tunica vaginalis is one of them. $umerous detailed drawings of scrotal anatomy are available for people who are interested in learning more about the development and structure of the testes. !his layer of tissue arises from the vaginal process during fetal development. It starts as a pouch in the peritoneum which gradually moves downward and shifts to accommodate the development of the testes. !his occurs in response to hormone levels during development which also predicate the formation of the genitalia. In women, sometimes the vaginal process fails to develop normally during fetal development, and as a result they may develop a structure #nown as the ?anal of $uc#, and they can be prone to cysts and other problems.

http://www.wise!ee".com/what-is-the-tunica-va!inalis.htm http://www.em#r$olo!$.ch/an!lais/u!enital/diffmorpho04.html
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