Groin Pains
Answer: C
The two main causes of painless groin swelling in the infant are hydrocele and hernia.
The overall incidence of hernia in boys and girls ranges from 1-4%, is five times more common in boys, and occurs on the right side in 60% of cases.
Premature boys have the highest incidence of hernia (up to 30%) and premature girls carry a higher risk (2%) than full-term girls (D).
A brief anatomy review:
The gubernaculum aids in the descent of the gonads in both boys and girls (naturally, the gonads descend further in boys). In boys, it becomes the scrotal ligament; in girls, it becomes the ovarian ligament and the round
ligament of the uterus.
The processus vaginalis is an evagination of the peritoneum into the groin. In boys, it is the path the testis
takes on its descent into the scrotum; it later becomes the visceral and parietal layers of the tunica vaginalis.
In girls, the processus vaginalis is not needed for gonadal descent (they never make it that far) and it normally obliterates. However, when there is a persistent processus vaginalis in the female (called the canal of Nuck), it can be the route of fluid accumulation and the cause of a hydrocele in the labium majorum.
How this explains hydroceles:
A hydrocele may be communicating or non-communicating and reactive or non-reactive. A communicating
hydrocele is caused by a patent processus vaginalis that communicates with the peritoneum; peritoneal fluid slowly accumulates in the scrotum or labium. A non-communicating hydrocele results from accumulation of fluid with subsequent obliteration of the connection. These almost always resolve before the first birthday. A reactive
hydrocele denotes fluid accumulation due to trauma or infection; a non-reactive hydrocele is the aforementioned accumulation of peritoneal fluid.
The connection:
Indirect hernias are often accompanied by hydroceles in this age range.
If-then scenarios in groin swelling in infants:
No mass: the child likely has a communicating hydrocele. Since there is an observed anatomic defect, the development of a hernia is likely. The child needs outpatient referral for an elective repair (C).
Reducible mass: the child has a reducible indirect hernia. He or she may be an outpatient candidate, depending on the child’s history and access to a pediatric surgeon. It should be noted that approximately 10% of reducible hernias will incarcerate while awaiting elective repair. In premature infants, this rate is as high as 30% (D).
Some centers simply admit infants with hernia (by history or physical examination – contrast this with the often non-emergent nature of indirect hernias in adults).
Incarcerated hernia: as in any age, emergent manual or surgical reduction is necessary.
Groin mass in the infant girl: the management of a groin mass in the baby girl differs from that of the boy, as
there is a much higher incidence of gonadal involvement: 80% of these cases include the ovary, with a high incidence of torsion. Ultrasound should be obtained and a more conservative management is indicated (i.e. admission and earlier exploration).
More about the timing of repair:
The overall complication rate is similar between immediate repair (within 72 hours) and delayed repair (1 to 3 months). However, there may be a slightly higher incidence of incarceration with delayed repair (possibly simply due to more exposure time to the risk).
What else should we know about the management of inguinal hernias in infants?
Up to 60% of cases of children with unilateral indirect hernia have a patent processus vaginalis, which theorectically puts them at risk for a metachronous hernia, or a future contralateral hernia. Urologists and pediatric surgeons differ in the approach to the screening for this (e.g. ultrasound, abdominal
insufflation, or direct exploration). As children age, the risk dramatically decreases (A).
References
Lee SL, Gleason JM, Sydorak RM. A critical review of premature infants with inguinal hernias: optimal timing of repair, incarceration risk, and postoperative apnea. J Pediatr Surg. 2011; 46(1):217-20.
Merriman LS, Herrel L, Kirsch AJ. Inguinal and Genital Anomalies. Pediatr Clin N Am. 2012; 59:769–781.
Nataraja RM, Mahomed AA. Metachronous contralateral pediatric inguinal hernia. Open Access Surgery. 2010; 3: 87–90.
Vaos G, Gardikis S, Kambouri K, Sigalas I, Kourakis G, Petoussis G. Optimal timing for repair of an inguinal hernia in premature infants. Pediatr Surg Int. 2010; 26(4):379-85.
The two main causes of painless groin swelling in the infant are hydrocele and hernia.
The overall incidence of hernia in boys and girls ranges from 1-4%, is five times more common in boys, and occurs on the right side in 60% of cases.
Premature boys have the highest incidence of hernia (up to 30%) and premature girls carry a higher risk (2%) than full-term girls (D).
A brief anatomy review:
The gubernaculum aids in the descent of the gonads in both boys and girls (naturally, the gonads descend further in boys). In boys, it becomes the scrotal ligament; in girls, it becomes the ovarian ligament and the round
ligament of the uterus.
The processus vaginalis is an evagination of the peritoneum into the groin. In boys, it is the path the testis
takes on its descent into the scrotum; it later becomes the visceral and parietal layers of the tunica vaginalis.
In girls, the processus vaginalis is not needed for gonadal descent (they never make it that far) and it normally obliterates. However, when there is a persistent processus vaginalis in the female (called the canal of Nuck), it can be the route of fluid accumulation and the cause of a hydrocele in the labium majorum.
How this explains hydroceles:
A hydrocele may be communicating or non-communicating and reactive or non-reactive. A communicating
hydrocele is caused by a patent processus vaginalis that communicates with the peritoneum; peritoneal fluid slowly accumulates in the scrotum or labium. A non-communicating hydrocele results from accumulation of fluid with subsequent obliteration of the connection. These almost always resolve before the first birthday. A reactive
hydrocele denotes fluid accumulation due to trauma or infection; a non-reactive hydrocele is the aforementioned accumulation of peritoneal fluid.
The connection:
Indirect hernias are often accompanied by hydroceles in this age range.
If-then scenarios in groin swelling in infants:
No mass: the child likely has a communicating hydrocele. Since there is an observed anatomic defect, the development of a hernia is likely. The child needs outpatient referral for an elective repair (C).
Reducible mass: the child has a reducible indirect hernia. He or she may be an outpatient candidate, depending on the child’s history and access to a pediatric surgeon. It should be noted that approximately 10% of reducible hernias will incarcerate while awaiting elective repair. In premature infants, this rate is as high as 30% (D).
Some centers simply admit infants with hernia (by history or physical examination – contrast this with the often non-emergent nature of indirect hernias in adults).
Incarcerated hernia: as in any age, emergent manual or surgical reduction is necessary.
Groin mass in the infant girl: the management of a groin mass in the baby girl differs from that of the boy, as
there is a much higher incidence of gonadal involvement: 80% of these cases include the ovary, with a high incidence of torsion. Ultrasound should be obtained and a more conservative management is indicated (i.e. admission and earlier exploration).
More about the timing of repair:
The overall complication rate is similar between immediate repair (within 72 hours) and delayed repair (1 to 3 months). However, there may be a slightly higher incidence of incarceration with delayed repair (possibly simply due to more exposure time to the risk).
What else should we know about the management of inguinal hernias in infants?
Up to 60% of cases of children with unilateral indirect hernia have a patent processus vaginalis, which theorectically puts them at risk for a metachronous hernia, or a future contralateral hernia. Urologists and pediatric surgeons differ in the approach to the screening for this (e.g. ultrasound, abdominal
insufflation, or direct exploration). As children age, the risk dramatically decreases (A).
References
Lee SL, Gleason JM, Sydorak RM. A critical review of premature infants with inguinal hernias: optimal timing of repair, incarceration risk, and postoperative apnea. J Pediatr Surg. 2011; 46(1):217-20.
Merriman LS, Herrel L, Kirsch AJ. Inguinal and Genital Anomalies. Pediatr Clin N Am. 2012; 59:769–781.
Nataraja RM, Mahomed AA. Metachronous contralateral pediatric inguinal hernia. Open Access Surgery. 2010; 3: 87–90.
Vaos G, Gardikis S, Kambouri K, Sigalas I, Kourakis G, Petoussis G. Optimal timing for repair of an inguinal hernia in premature infants. Pediatr Surg Int. 2010; 26(4):379-85.
