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Inguinal and Femoral Hernias and Hydroceles 359

Note: I.I.R. = internal inguinal ring; E.I.R. = external inguinal ring; O.P.V. = obliterated
processus vaginalis; P.P.V. = patent processus vaginalis.
Figure 58.2: Diagrammatic representation of different types of inguinal hernias and hydroceles in boys
following the descent of the testes into the scrotum.

whole PV and in the presence of a wide neck, an inguinoscrotal (com- History
plete, scrotal) hernia will be the outcome (see Figure 58.2B). A careful and accurate history is taken, followed by meticulous exami-
Congenital hydroceles formed after the failure of fusion of the PV nation of the child. There is usually a history (given by the mother or
may be communicating or noncommunicating (see Figure 58.2D–G). caregiver) of an asymptomatic bulge or mass in the groin or scrotum
Where the opening of the PV that has failed to obliterate completely or labia, which is intermittent and originates from the internal inguinal
is narrow and will not allow intestines to herniate but permits ring. The mass appears on crying in the infant or younger child; in the
peritoneal fluid to trickle into it, a communicating hydrocele will result. older child, it may appear with coughing or walking or playing around
Noncommunicating hydroceles can be of three types: (i.e., on increasing the intraabdominal pressure). Also of note in the
history is that the bulge varies in size; it may periodically disappear
1. vaginal or scrotal hydrocele, formed when the proximal portion of
spontaneously (when the contents completely return to the peritoneal
the PV obliterates completely, leaving the distal tunica vaginalis to fill
cavity) or by application of gentle pressure by the parent. The mass
with fluid;
usually does not cause pain or much discomfort to the child. Often the
2. infantile hydrocele, formed when the proximal portion of the PV caregiver or the older child can point to the exact location of the bulge.
obliterates as far as the inguinal canal so that part of the PV is patent Most hernias are seen in the first year of life, often when the parents are
continuous with the tunica vaginalis; or
changing the diaper of a crying or straining child or bathing the child.
3. encysted hydrocele of the spermatic cord, or simply hydrocele of the Physical examination
cord, formed when there is complete involution of the proximal PV and
the part above the tunica vaginalis, leaving an isolated cystic dilatation. The history of a mass should be confirmed by examining the child in
various positions, upright or supine. It is important to ascertain that the
In the case of females in which the canal of Nuck is patent, a testes are in the scrotum because a retractile testis will mimic an ingui-
hydrocele or a hernia (usually containing intestine or ovary and nal hernia by causing a bulge at the external inguinal ring. One of the
fallopian tube) will form. following procedures will increase the intraabdominal pressure in order
It is important to remember that the mere presence of a PPV does not to augment the demonstration of a groin mass.
automatically mean a hernia or a hydrocele necessarily occurs. The PPV
may take about a year or two in some instances to obliterate completely, 1. Lie the infant supine with the hands held above the head and the
but not all children with a PPV will develop a hernia or a hydrocele. lower limbs held straight down. This can be done by an assistant
Conditions associated with an increased risk of development of or the parent. This makes the child strain or cry, thus increasing the
IH include positive family history, prematurity, low birth weight, intraabdominal pressure and causing the bulge to appear if it is actually
undescended testes, hypospadias, epispadias, exstrophy of the bladder, present. Standing the patient upright may help at times.
ambiguous genitalia, ascites, gastroschisis, omphalocele, and male 2. Ask the older child to jump or bounce up and down, which may
gender, among others (e.g., increased intraabdominal pressure). allow the mass to appear in the inguinal region.
Clinical Presentation 3. Ask the older child (>6 years of age) to cough or blow up a balloon.
Inguinal hernias appear as intermittent, usually reducible, lumps in the This will make the bulge appear. (Often, children <6 years of age just
groin (Figures 58.3 and 58.4) and are painless. refuse to carry out instructions, even though they very well understand
the request to do so.)