Pediatr Surg Int (2006) 22:1025–1027
DOI 10.1007/s00383-006-1708-6
CASE REPORT
Torsion of an indirect hernia sac within a hydrocele causing acute
scrotum: case report and review of the literature
John W. Tillett Æ James Elmore Æ Edwin A. Smith
Accepted: 8 May 2006 / Published online: 30 September 2006
Ó Springer-Verlag 2006
Abstract We report a case of acute scrotum in a 2-
year-old child caused by torsion of an indirect hernia
sac within a hydrocele. This is an extremely rare cause
of acute scrotal swelling and pain in the pediatric
population, with this case representing only the eighth
instance reported in the literature. Despite the scarcity
with which this diagnosis has been encountered, clini-
cians should include torsion of an indirect hernia sac on
the differential diagnosis for acute scrotum in a child.
Keywords Torsion
Hydrocele
Scrotum
Indirect
hernia sac
Ultrasound
Case report
A 2-year-old white male presented to an outside
emergency department with a 10 h history of right-si-
ded scrotal swelling and irritability. There were no
fevers, abdominal pain, nausea, or vomiting. He had no
significant past medical, past surgical, or family history.
The child was transferred to our institution for scrotal
ultrasound based upon concerns for testicular torsion.
Upon physical exam, he was noted to have a very
swollen and tender right hemiscrotum without fluctu-
ance, with a palpably normal left testis and an indis-
tinguishable right testis (Fig. 1). Laboratory
examination was remarkable for a negative urinalysis,
a white blood cell count of 12,400, and normal testic-
ular tumor makers.
J. W. Tillett (&)
J. Elmore
E. A. Smith
Department of Urology, Children’s Hospital of Atlanta,
Atlanta, GA, USA
e-mail: jtillett@emory.edu
Scrotal Doppler ultrasound was performed, but the
exam was limited secondary to patient movement. This
exam did demonstrate a normal left testis, and a cystic
structure in the region of the right testis with adjacent
fluid, but no normal testicular architecture could be
identified on the right side (Fig. 2). The decision was
made to undergo surgical exploration, as testicular
torsion or tumor could not be ruled out.
The patient underwent a right inguinal exploration.
The right spermatic cord was identified and a normal
appearing right testis was delivered through the
inguinal incision. A large hydrocele sac filled with clear
fluid was identified, which was opened, revealing a
small, pedunculated, necrotic cystic structure arising
from the sac (Fig. 3). This was sharply excised and sent
for frozen section. Intraoperative pathology revealed
no evidence of malignancy. Further up the spermatic
cord, a patent processus vaginalis was encountered
which was suture ligated at its neck and a formal Lord
hydrocele repair was performed.
Final pathology was consistent with a mesothelial-
lined cyst with focal hemorrhagic infarction. The child
was discharged home following an uncomplicated
hospital stay on the first post-operative day.
Discussion
Acute scrotum is often a diagnostic dilemma in the
pediatric population, frequently requiring exploratory
surgery despite sonographic imaging findings. Etiology
of acute scrotum has been reported to involve testic-
ular torsion in 39.5%, torsion of an appendage in 29%,
and epididymoorchitis in 15.5% [1]. A more recent
review of 100 consecutive patients by McAndrew et al.
123
1026 Pediatr Surg Int (2006) 22:1025–1027

Fig. 3 Torsed hernia sac within hydrocele

Fig. 1 Physical examination

testis on the affected side. Because of this uncertainty,

Fig. 2 Sonographic appearance of right testis
scrotal exploration was undertaken, and the finding of
a twisted indirect hernia sac within a hydrocele was
made. This diagnosis is uncommon, with only seven
total cases having been reported previously [4–8].
Table 1 summarizes salient clinical features of these
reported cases. Of note, cases have occurred in boys
from age 2 to 10, with a mean age at presentation of 5.6
years. Seventy-five percent of reported cases have in-
volved the right side.
The etiology of this condition is unclear. Matsumoto
et al. [8] in 2004 postulated that a thin, membranous
hernia sac somehow may become invaginated within a
hydrocele, and then subsequently twist to cause
swelling and pain. As yet, there have been no reported
cases where scrotal trauma has precipitated presenta-
tion of this condition. Unfortunately, the relative
scarcity of this diagnosis has hindered our ability to
fully elucidate the pathophysiology behind it.
Though rare, torsion of an indirect hernia sac is a
possible cause of acute scrotal pain and swelling young
boys that cannot be reliably diagnosed by ultrasound

[2] revealed a different breakdown, with 70% of cases

due to torsion of the appendix testis, 12% with torsion
Table 1 Previously reported cases of torsion of hernia sac within
of the spermatic cord, and 11% with epididymoorchi- a scrotal hydrocele
tis. Despite improved technology in ultrasound, surgi-
Case Age Laterality Past history
cal exploration continues to have much higher (years)
sensitivity than imaging for the diagnosis of torsion,
especially in younger children who have difficulty Esho et al. [4] 10 Left L hydrocele
remaining still for imaging [1, 3]. It is accepted that Motta et al. [5] 2 Right Unremarkable
Motta et al. [5] 3 Right Unremarkable
scrotal exploration is indicated for patients in whom Motta et al. [5] 4 Right Unknown
imaging cannot rule out the possibility of spermatic Perez et al. [6] 8 Right R hydrocele
cord torsion [1]. Matsumoto et al. [8] 10 Right Unremarkable
In the above case, Doppler ultrasound was nondi- Myers et al. [7] 6 Left Unremarkable
Present case 2 Right Unremarkable
agnostic, with the exam failing to demonstrate a viable

123
Pediatr Surg Int (2006) 22:1025–1027
but can be cured by surgical intervention. Pediatric
surgeons, urologists, pediatricians, and emergency
physicians should be aware of this entity and include it
on their differential diagnosis for acute scrotum.
References
1. Watkin NA, Reiger NA, Moisey CU (1996) Is the conserva-
tive management of the acute scrotum justified on clinical
grounds? Br J Urol 78:623–627
2. McAndrew HF, Pemberton R, Kikiros CS et al (2002) The
incidence and investigation of acute scrotal problems in
children. Ped Surg Int 18:435–437
3. Bickerstaff KI, Sethia K, Murie JA (1988) Doppler ultraso-
nography in diagnosis of acute scrotal pain. Br J Surg 75:238–
239
1027
4. Esho JO, Vitko RJ, Cass A (1974) Protrusion and torsion of
an inguinal hernia sac inside a hydrocele of the scrotum. J Ped
Surg 9:423
5. Motta J, Bagli DJ, Savage JV et al (1997) Torsion of an
indirect hernia sac: an unusual cause of acute scrotal swelling
in children. Urology 50:432–435
6. Perez LM, Manibo JF, Netto JMB, Joseph DB (1999) Torsion
of an indirect inguinal hernia sac within a long-standing
ipsilateral hydrocele in an 8-year-old boy. BJU Int 84:731–732
7. Myers JB, Lovell MA, Lee RS, Furness PD, Koyle M (2004)
Torsion of an indirect hernia sac causing acute scrotum. J Ped
Surg 39:122–123
8. Matsumoto A, Nagatomi Y, Sakai M, Oshi M (2004) Torsion
of the hernia sac within a hydrocele of the scrotum of a child.
Int J Urol 11:789–791
123
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.