Diagnosis: Hydrocele
The most likely diagnosis is a bilateral hydrocele, given the chronic bilateral scrotal edema present since birth, absence of inflammatory signs, and the patient's overall well-being. 1
Clinical Reasoning
Key Distinguishing Features Present
- Bilateral scrotal edema since birth strongly suggests a congenital hydrocele rather than an acute infectious or vascular process 2
- Absence of warmth, erythema, or tenderness effectively rules out epididymitis and orchitis, which characteristically present with increased vascularity, pain, and inflammatory signs 3, 1
- No distress and normal behavior excludes testicular torsion, which presents with severe acute pain and systemic symptoms requiring surgical intervention within 6-8 hours 1, 4
- Well-healed circumcision site indicates the recent surgery is unrelated to the chronic scrotal swelling 1
Why Other Diagnoses Are Excluded
Epididymitis/Orchitis: These conditions present with gradual onset of pain, increased blood flow on Doppler ultrasound, and inflammatory signs including warmth and tenderness—none of which are present in this patient 3, 1
Testicular Torsion: This surgical emergency presents with sudden severe pain, negative Prehn sign, and requires immediate intervention—completely inconsistent with a chronic, painless condition present since birth 1, 4
Phimosis: This diagnosis is anatomically impossible in a circumcised patient, as the foreskin has been removed 1
Varicocele: This condition is exceedingly rare in infants, typically presents in adolescence, and would not cause bilateral scrotal edema extending to the mons pubis 1
Clinical Characteristics of Infantile Hydrocele
- Congenital hydroceles result from patent processus vaginalis allowing peritoneal fluid to accumulate in the scrotum, presenting as translucent swelling that may extend into the inguinal canal 2
- Bilateral presentation can occur and may extend through the mons pubis, as described in this case 2, 5
- Testicular palpation difficulty is expected due to surrounding fluid collection, but testes should be present and normal 2, 6
Immediate Management Approach
- Ultrasound with Doppler is mandatory to confirm the diagnosis, assess testicular position and viability, rule out underlying testicular pathology, and evaluate for patent processus vaginalis 1, 6
- Reassure the mother that the circumcision healing is appropriate and unrelated to the chronic scrotal swelling 1
- Monitor for complications: Tense hydroceles can cause testicular dysmorphism and vascular compromise, though this is rare and typically presents with pain or distress 7, 5
Critical Clinical Pitfall
- Do not delay imaging: While the clinical presentation strongly suggests benign hydrocele, ultrasound is essential to exclude rare but serious conditions such as tension hydrocele (which can compromise testicular perfusion) or underlying testicular masses that may present as "complex hydrocele" 7, 8
- Testicular dysmorphism risk: Infantile abdominoscrotal hydroceles are associated with testicular dysmorphism in up to 78% of cases (18 of 23 testes), though most recover postoperatively with early intervention 5
Definitive Treatment Considerations
- Observation is appropriate for most congenital hydroceles in infants, as many resolve spontaneously by 12-18 months of age 2, 6
- Surgical intervention is indicated if the hydrocele persists beyond 12-18 months, increases in size, or causes complications such as testicular compression 6, 5
- Transscrotal plication represents an effective procedure with decreased postoperative complications compared to inguinal approaches for simple hydroceles 5