What is the treatment for congenital hydrocele in children?

Management of Congenital Hydrocele in Children

Primary Recommendation

Congenital hydroceles in children should be managed with observation for spontaneous resolution until 18-24 months of age, with surgical intervention reserved only for those with associated inguinal hernia or development of a large/tense hydrocele. 1

Understanding Congenital Hydrocele

• Congenital hydrocele results from incomplete obliteration of the processus vaginalis during fetal development, allowing peritoneal fluid to accumulate in the scrotum 1
• The vast majority (89%) of congenital hydroceles resolve spontaneously during the first year of life due to ongoing changes in the patent processus vaginalis 2
• Spontaneous resolution typically occurs within 18-24 months of age 1

Treatment Algorithm

Initial Management: Observation (First-Line)

For infants <18-24 months of age:

• Observe without surgical intervention, as 62-89% will resolve spontaneously 2, 3
• The median time to resolution is approximately 3 months, with a range of 1 day to 24 months 4
• Even communicating hydroceles (those that fluctuate in size or have reducible fluid) can resolve without surgery in 62.7% of cases 3
• Spontaneous resolution can occur even in children >2 years of age, though the rate decreases with age 5

Indications for Immediate Surgical Intervention

Surgery is indicated only in the following circumstances:

• Associated inguinal hernia (accounts for 7% of cases requiring surgery in the first year) - this is the most critical indication as it requires prompt intervention 1, 2
• Development of a huge or tense hydrocele (accounts for 3% of cases requiring surgery) 2
• Abdominoscrotal hydrocele with testicular dysmorphism - these require early intervention to prevent testicular damage 6

Timing of Surgical Intervention

• For persistent hydroceles without the above complications, surgery should be delayed until at least 12-18 months of age 2, 5
• An observation period of 6-12 months is appropriate even for new-onset non-communicating hydroceles in older children before considering repair 4
• The median age for surgical correction when needed is approximately 14 months 3

Critical Distinction: Hydrocele vs. Inguinal Hernia

Do not confuse hydrocele with inguinal hernia, which requires more prompt surgical intervention. 1

• Communicating hydroceles may progress to hernia during observation (6% risk), but incarceration is rare 3
• If hernia develops during observation, surgical repair should be performed without delay 1

Surgical Approach When Indicated

• For standard hydroceles: high ligation of the processus vaginalis with complete excision of the abdominal component 6
• For abdominoscrotal hydroceles: transscrotal plication of the tunica vaginalis is effective with decreased postoperative complications 6
• Surgery is effective and safe when performed, with resolution rates of 97% for communicating hydroceles 4

Common Pitfalls to Avoid

• Premature surgical intervention: Most hydroceles will resolve spontaneously; avoid unnecessary surgery in the first 18-24 months 1, 2
• Missing an associated hernia: Always assess for inguinal hernia, which changes management from observation to prompt surgery 1, 2
• Inadequate observation period: Even communicating hydroceles deserve observation, as 62.7% resolve without surgery 3
• Overlooking abdominoscrotal hydrocele: These tense lesions are associated with high rates of testicular dysmorphism and require earlier intervention 6