From the Guidelines
The primary management of a hydrocele in pediatric patients is typically observation, as most cases resolve spontaneously by age 1-2 years. This approach is supported by the fact that congenital hydroceles, which are essentially clinically apparent patent processus vaginalis (PPV), usually resolve spontaneously within 18 to 24 months 1. No immediate treatment is necessary for asymptomatic hydroceles in infants and young children.
If the hydrocele persists beyond age 2 or becomes symptomatic, surgical intervention may be recommended. The standard procedure is a hydrocelectomy, which involves making a small incision in the scrotum, draining the fluid, and closing the connection between the peritoneal cavity and the tunica vaginalis. For infants, the procedure may be combined with hernia repair if an associated inguinal hernia is present, as the risk of incarceration of bowel and gonadal infarction and atrophy is a concern 1.
Some key points to consider in the management of hydroceles in pediatric patients include:
- The reported prevalence of PPV is as high as 80% in term male infants, but this prevalence declines with age 1
- The estimated childhood risk of developing an inguinal hernia if there is a PPV is between 25% and 50% 1
- Surgery is typically performed as an outpatient procedure under general anesthesia
- Post-operative care includes pain management with acetaminophen or ibuprofen as needed, scrotal support for comfort, and avoiding strenuous activity for 1-2 weeks
- Antibiotics are not routinely prescribed unless there are signs of infection
The conservative approach for young children is based on the fact that patent processus vaginalis, which causes communicating hydroceles, often closes naturally during early childhood 1. Surgery is reserved for persistent cases to prevent potential complications such as testicular torsion or herniation.
From the Research
Management of Hydrocele in Pediatric Patients
The management of hydrocele in pediatric patients can be divided into several approaches, including:
- Observation: This is the primary approach for infants under the age of one year, as most hydroceles resolve spontaneously within the first year of life 2, 3.
- Surgical intervention: This is typically reserved for older children or those with large hydroceles, and can be performed using various techniques, including open surgery or laparoscopic repair 2, 3, 4.
- Scrotal puncture: This is a non-invasive procedure that can be used to treat hydroceles, especially those that develop after varicocele surgery 5.
Indications for Surgery
The indications for surgery in pediatric hydrocele patients include:
- Presence of an associated inguinal hernia 3
- Development of a huge hydrocele 3
- Failure of spontaneous resolution after the age of one year 2
- Symptomatic hydroceles in older children 4
Surgical Techniques
Various surgical techniques can be used to repair hydroceles in pediatric patients, including:
- Open surgery: This is a traditional approach that involves making an incision in the groin to repair the hydrocele 3, 5.
- Laparoscopic repair: This is a minimally invasive approach that involves using a laparoscope to repair the hydrocele 4.
- Two-port laparoscopic technique: This is a novel approach that allows for completely extraperitoneal closure of the patent processus vaginalis without requiring laparoscopic suturing skills 4.
Follow-up and Complications
Follow-up is essential to monitor the resolution of hydroceles and to detect any potential complications, such as recurrence or development of a new hydrocele 2, 5, 4. Complications can be minimized by using appropriate surgical techniques and by providing adequate post-operative care.