What is the recommended treatment for a testicular hernia?

Treatment for Testicular Hernia (Inguinal Hernia with Testicular Involvement)

Surgical repair should be performed urgently to prevent testicular ischemia and atrophy, particularly in infants and children with incarcerated inguinal hernias where the risk of testicular complications is highest. 1, 2

Immediate Management Based on Clinical Presentation

For Incarcerated Inguinal Hernia with Testicular Involvement

Urgent surgical intervention is mandatory because the duration of ischemia directly determines testicular viability. 2 In infants with irreducible incarcerated hernias, testicular ischemia occurs in 56.2% of cases, making this a surgical emergency rather than an elective procedure. 2

• Perform immediate inguinal hernia repair through an inguinal approach with early spermatic cord control at the internal inguinal ring before any testicular manipulation. 1, 3
• Assess testicular viability intraoperatively using visual inspection and Doppler assessment if available. 2
• Consider orchidopexy rather than orchiectomy for ischemic testicles, as conservative management with orchidopexy can preserve testicular function in 77.8% of cases when followed appropriately. 2
• Reserve orchiectomy only for clearly non-salvageable testicles with documented necrosis or complete loss of viability, as the orchiectomy rate during hernia repair should be limited to specific testicular abnormalities. 4

For Reducible Inguinal Hernia

Elective surgical repair should be performed promptly to prevent incarceration, which carries a 22-times increased risk of requiring orchiectomy compared to primary reducible hernias. 4

• Schedule repair without unnecessary delay in infants, as the risk of incarceration drives the preference for surgical intervention. 1
• Use either open or laparoscopic approach, as both have comparable recurrence rates, though laparoscopic repair in children older than 3 months requires fewer pain medications postoperatively. 1
• Avoid scrotal violation for biopsy or surgery; always use an inguinal approach with early cord control. 1, 3

Surgical Technique Considerations

Standard Approach

• Perform high ligation of the hernia sac at the internal inguinal ring through an inguinal incision. 1
• Carefully dissect and preserve the spermatic cord structures to minimize risk of testicular atrophy, which can occur from iatrogenic injury. 1, 5
• Inspect the testicle for viability if there was any concern for incarceration or prolonged symptoms. 2

Contralateral Exploration Decision

The decision regarding contralateral exploration remains controversial, with practice patterns varying widely. 1

• Consider contralateral exploration in high-risk groups: former preterm infants and children younger than 2 years, where the incidence of bilateral patent processus vaginalis is highest. 1
• Weigh the risk of spermatic cord injury (from unnecessary exploration) against the benefit of preventing future contralateral incarceration. 1
• In male patients, 15% of surgeons never explore the contralateral side, 12% always do, and 73% use an age cutoff for decision-making. 1

Postoperative Monitoring Protocol

For Cases with Testicular Ischemia

Implement serial Color Doppler ultrasonography to monitor testicular recovery and detect atrophy early. 2

• Perform ultrasound at 3 days, 7 days, then at 1,3, and 6 months postoperatively, documenting testicular size, volume, and arterial flow patterns at each visit. 2
• Continue monitoring for at least 6 months as testicular atrophy can develop in 22.2% of cases despite initial preservation attempts. 2
• Measure testosterone, LH, and FSH levels if bilateral involvement or testicular atrophy develops to assess endocrine function. 1, 6

For Uncomplicated Repairs

• Teach testicular self-examination to all patients due to the increased risk of testicular cancer in patients with a history of inguinal hernias and testicular complications. 6
• Monitor for ascending testicle, a rare but documented complication that may require orchidopexy even years after initial repair. 7

Special Populations

Preterm Infants

Balance the risk of incarceration against postoperative respiratory complications when timing repair. 1

• Most surgeons wait until 38-60 weeks corrected gestational age (mean 53.1 weeks) before elective repair. 1
• Perform urgent repair regardless of gestational age if incarceration occurs. 2

Patients with Testicular Atrophy

Consider the increased malignancy risk in atrophic testicles, particularly those with volumes <12 mL. 1, 6

• Perform testicular ultrasound and tumor markers (AFP, β-HCG, LDH) to rule out underlying malignancy. 6, 8
• Discuss orchiectomy versus surveillance based on contralateral testicular function and patient age. 6

Critical Pitfalls to Avoid

• Never delay repair in incarcerated hernias attempting prolonged manual reduction, as each hour of ischemia decreases testicular salvage rates. 2
• Never perform scrotal incision for hernia repair, as this violates lymphatic drainage patterns and increases complication risks. 1, 3
• Never fail to document the specific indication if orchiectomy is performed, as vague documentation suggests potentially avoidable procedures. 4
• Never dismiss testicular swelling or pain post-hernia repair as routine postoperative changes without Doppler assessment, as focal testicular infarction can occur even after laparoscopic repairs. 5
• Never forget to discuss fertility preservation (sperm banking) before any intervention that might affect testicular function, even in prepubertal patients. 1, 6, 3