What is the recommended treatment for a testicular hernia?

Treatment of Testicular Hernia

Surgical repair is the recommended treatment for testicular hernia, with the approach determined by patient age, hernia characteristics, and testicular involvement. 1

Diagnosis and Assessment

• Testicular ultrasound should be performed to confirm the diagnosis, assess the contralateral testis, and rule out underlying pathology 2
• Blood tests including tumor markers (AFP, β-HCG, LDH) should be considered if malignancy is suspected 2
• Color Doppler ultrasonography is essential to evaluate testicular blood flow, particularly in cases of incarceration 3

Treatment Algorithm

For Infants and Children

• Urgent surgical intervention is recommended for incarcerated inguinal hernias to prevent testicular ischemia and potential atrophy 3
• Surgical options include:
  • Open repair through inguinal approach - standard technique with high success rate 1
  • Laparoscopic repair - comparable recurrence rates to open repair with potentially less post-operative pain in children older than 3 months 1

For Adults

• Radical orchiectomy through an inguinal incision is indicated when testicular cancer is suspected 1, 4
• Organ-preserving surgery/partial orchiectomy may be considered in specific situations:
  • Bilateral testicular involvement
  • Tumor in a solitary testis
  • Contralateral atrophic testis 2, 4

Special Considerations

Incarcerated Hernias

• Require emergency surgical intervention to prevent testicular ischemia 3
• Conservative management with close monitoring may be attempted for testicular ischemia resulting from incarcerated inguinal hernia in infants 3
• Follow-up with color Doppler ultrasound for at least 6 months is recommended to monitor for testicular atrophy 3

Contralateral Exploration

• The utility of contralateral inguinal exploration in children remains controversial 1
• According to the American Academy of Pediatrics survey:
  • 15% of surgeons never explore the contralateral side in male patients
  • 12% always explore
  • 73% have an age cutoff beyond which they would not explore 1

Risk of Testicular Atrophy

• Testicular atrophy is an uncommon but recognized complication of inguinal hernia repair 5
• Risk factors include:
  • Previous groin or scrotal surgery
  • Overzealous dissection of distal hernia sac
  • Dislocation of the testis from the scrotum into the wound
  • Concomitant scrotal surgery 5

Common Pitfalls and How to Avoid Them

• Failing to recognize crossed testicular ectopia, which may present as an irreducible inguinal hernia requiring urgent surgery 6, 7
• Inadequate assessment of testicular blood flow before and after hernia repair, particularly in incarcerated hernias 3
• Overzealous dissection during repair, which can lead to testicular atrophy 5
• Failure to consider fertility preservation before definitive treatment in cases requiring orchiectomy 2

Follow-up

• Regular monitoring of testicular volume and blood flow with ultrasound is recommended after repair, especially in cases of incarceration 3
• Self-examination should be taught to patients with a history of testicular issues due to increased risk of testicular cancer 2
• Long-term follow-up is necessary to monitor for late complications including hypogonadism and malignancy 2