Excessive sac pressures: the pathogenesis and innocence of hydroceles in children

Comparison of the size of bilateral testis in children with unilateral non-communicating hydrocele and its correlation with age

BACKGROUND

Opinions on the optimal age for surgical management of hydroceles in young boys are not uniform. Scrotal ultrasonography can be used to diagnose hydroceles and measure testicular size. A comparison of bilateral testicular size with hydrocele and the change in trend with age has not been reported. We therefore aimed to analyze the bilateral testicular size of children with unilateral non-communicating hydroceles and examine the correlation between age and testicular volume.

METHODS

Non-communicating hydrocele cases in children were included. Ultrasound results, age, and diagnose time were retrospectively recorded. The bilateral testicular size was compared, and the correlation between age and testicular volume was analyzed.

RESULTS

There were 138 cases of non-communicating hydrocele, ranging in age from 11 to 72 months. The diagnose time ranged from 3 days to 54 months. The volume of the testis on the side of the hydrocele was larger than that on the normal side (P < 0.001). Testicular length was not different bilaterally. Testicular width and height were greater on the hydrocele side than on the normal testicular side (P<0.001). Age was positively correlated with testicular volume on the normal side (P = 0.004) but not on the hydrocele side.

CONCLUSIONS

An important finding was that when the contralateral normal testicular volume increases with age, the testicular volume does not increase on the hydrocele side. This finding confirms the adverse effects of hydrocele on testicular growth and provides a basis for early treatment.

The outcomes of conservative management and the natural history of asymptomatic hydroceles in children

PURPOSE

To elucidate the natural history of asymptomatic hydroceles (AHs) in children with conservative management and to discuss management strategies for AHs in children.

METHODS

We retrospectively reviewed 113 children with AHs who were followed without immediate surgery. Patients were divided into four groups according to age at presentation; group 1: ≤ 1 month, group 2: 1-12 months, group 3: 12-24 months, and group 4: > 24 months. Ages at spontaneous resolution or surgery were reviewed. To assess the effect of AH on the testis, testicular size before and after conservative management was compared in 11 cases.

RESULTS

In groups 1, 2, 3, and 4, spontaneous resolution occurred in 94.3%, 75.0%, 65.0%, and 33.3%, and the average time to resolution from presentation was 5, 5, 17, and 9 months, respectively. 41 patients underwent surgery at a mean age of 4.2 years. The testicular size did not differ significantly between before and after conservative management (14.4 vs. 14.5 mm, p = 0.483).

CONCLUSION

About one-third of children over 2 years of age achieve spontaneous resolution. Hydroceles with conservative management may not affect the testicular size. Thus, initial conservative management before surgery is recommend for AHs in children, even over 2 years of age.

Shear wave elastography evaluation of testes with non-communicating hydrocele in infants and toddlers: A preliminary study

INTRODUCTION

Shear wave elastography (SWE) is a new technology and non-invasive ultrasound device that can measure tissue rigidity and elasticity.

OBJECTIVE

This controlled prospective study aimed to demonstrate using SWE whether there was a difference between the elasticity of testes with non-communicating (NC) hydrocele in infants and toddlers and elasticity of controls' testes without hydrocele, and to reveal quantitative values of elasticity reflecting histological findings.

MATERIAL AND METHODS

Testes of 37 cases at an average age of 6.32 months and diagnosed with NC hydrocele between December 2016 and April 2017 were evaluated for hydrocele and testicular volumes, and testes elasticity through ultrasonography and SWE.

RESULTS

Of all cases, 15 had bilateral hydroceles, while 22 were diagnosed with unilateral hydrocele. Testes with NC hydrocele (n = 52) in infants and toddlers were compared with testes without hydrocele (n = 36) in controls. Median hydrocele volume of 52 testes with NC hydrocele was 5.0 cm³ (0.2-37). Median volume of testes with hydrocele was 0.6 cm³ (0.2-1.5) in the study group, and 0.5 cm³ (0.3-1) in controls (P = 0.577). Although median elastography values were measured as 1.67 m/s (1.29-2.59) and 10.0 kPa (2.1-23) in patients, those of controls were found to be 1.61 m/s (1.27-2.34) and 8.25 kPa (5.1-18.9) (P = 0.03, P = 0.005, respectively). While there was no between-group difference in testes volumes, a statistically significant difference was observed in SWE-derived quantitative data (Summary Table).

DISCUSSION

As a novel elastographic method, SWE is used to track shear waves passing through tissues by quantifying the elasticity of structures and nodules, such as liver fibrosis, and to improve the characterization of breast and thyroid nodules. Shear wave elastography was assessed to be a beneficial ultrasonography tool to predict the histologic features of undescended testicles, which might replace testicular biopsy in the modern management of undescended testes. This study also quantitatively measured whether there was a change in testicular tissues with NC hydrocele through SWE, and found that SWE values of testes with NC hydrocele were significantly higher compared with those of controls, despite the absence of a significant difference in testes volumes.

CONCLUSIONS

The present study confirmed that quantitative changes in testes elasticity can reliably be evaluated through SWE. Non-communicating hydrocele may be damaging to testicular tissues. More definitive results will be achieved with further comprehensive studies including larger patient populations. It is believed that the operation age of children with NC hydrocele can be re-evaluated in the future.

Decision making in the management of hydroceles in infants and children

The aim of this article was to establish a ground for evidence-based decision making in dealing with hydroceles, according to the age of the child and the presenting signs and symptoms. This prospective cohort study was conducted at Al-Kademyia Teaching Hospital in Baghdad, Iraq, during the period from December 2001 to December 2005. There were two groups of patients: group 1 involved 121 patients that presented with hydroceles at less than 1 year of age that were followed up to their first birthday to monitor the fate of hydroceles. Group 2 involved 140 patients, 1-12 years of age, who presented with hydroceles and had surgery. Their age, the affected side, diurnal changes in size, and the findings at surgery were recorded. In group 1, 89% of patients with hydroceles had spontaneous resolution or showed marked improvement during the first year of life and only 11% required an operation. The indications for surgery were the presence of an associated inguinal hernia (7%) and development of a huge hydrocele (3%). In group 2, 83% of patients with hydroceles presented within the first 5 years of age. Diurnal changes in the size of hydroceles were encountered in 92% of cases.

CONCLUSION

89% of patients with infantile hydrocele will have a spontaneous resolution owing to the ongoing changes in the patent processus vaginalis. Surgical intervention in the first year of life is only required for those who have an associated inguinal hernia and for those with hydroceles that become huge in size.

Effect of hydrocele on appendix testis in children

The purpose of this study was to investigate the effects of an elevated hydrostatic pressure of hydrocele on the structural integrity and steroid receptor expression pattern of the appendix testis in children. Twenty-six testicular appendages were obtained from boys (aged between 13 and 79 months, mean 40 months) who underwent surgical exploration because of hydrocele or congenital inguinal hernia. The tissue sections of testicular appendages were stained with hematoxylin-eosin. Immunohistochemistry and immunofluorescence laser microscopy were performed using monoclonal mouse anti-human receptors against androgen and estrogen receptors. Patients were divided into three groups: group A (n = 8) represented patients with groin hernia without hydrocele, who served as control group; group B (n = 7) represented patients with communicating hydrocele; and group C (n = 11) represented patients with noncommunicating hydrocele. The tissue sections of appendix testis expressed both androgen and estrogen receptors in all patients in groups A and B, and epithelial destruction was not present. The presence of androgen receptor (two of 11, P < 0.001) and estrogen receptor (four of 11, P = 0.006) was lower and the number of appendix testes with epithelial destruction was higher (eight of 11, P = 0.001) in group C. We demonstrated that groin hernia and communicating hydrocele did not influence the receptor expression pattern and the anatomic structure of testicular appendages, whereas noncommunicating hydrocele caused damage as indicated by the absence of steroid receptors and destruction of the epithelial surface. A better understanding of the physiological role of testicular appendages may change the indications of surgical treatment in patients with noncommunicating hydrocele.

Congenital hydrocele: prevalence and outcome among male children who underwent neonatal circumcision in Benin City, Nigeria

OBJECTIVE

To determine the prevalence and spontaneous resolution of congenital hydrocele diagnosed in male neonates who underwent circumcision at our centre.

PATIENTS AND METHODS

All male neonates presented for circumcision at the University of Benin Teaching Hospital, Benin City, Nigeria between January 2002 and December 2006 were examined for the presence of hydrocele. Those diagnosed with this condition were recruited and followed up in a surgical outpatient clinic for 2 years. The number of cases of spontaneous resolution and age at which this occurred were documented on a structured pro forma.

RESULTS

A total of 2715 neonates were circumcised and 128 (4.7%) were diagnosed with 163 cases of hydrocele, while 27 cases in 25 (0.9%) children failed to resolve at the age of 2 years. Neonatal hydrocele was bilateral in 112 (68.7%), and there were 20 (12.3%) right and 31 (19.0%) left. Among those with hydrocele, 28.1% were delivered preterm and resolution was spontaneous in many of them, with no observed significant statistical difference to those delivered full term (P=0.4740). Of the 163 hydrocele cases, 136 (83.4%) resolved spontaneously by age 18 months with peak resolution at 4-6 months. No spontaneous resolution occurred after 18 months and no hydrocele-related complication occurred during follow up.

CONCLUSION

Neonates with congenital hydrocele should be observed for spontaneous resolution for at least 18 months before being subjected to surgery.

Testicular volume before and after hydrocelectomy in children

OBJECTIVE

The purpose of this study was to investigate whether there is an association between communicating congenital hydroceles and testicular volume in children.

METHODS

Seventeen children with unilateral communicating congenital hydroceles who underwent hydrocelectomies were included in the study. Testicular volumes were measured before and after hydrocelectomy on both the affected and unaffected sides.

RESULTS

We found statistically significant differences in testicular volumes between the normal sides (mean +/- SD, 0.62 +/- 0.24 mL) and the sides with hydroceles (0.72 +/- 0.26 mL) before surgery (P < .001) and in testicular volumes of the sides with hydroceles before (0.72 +/- 0.26 mL) and after (0.60 +/- 0.19 mL) surgery (P < .001). There was no significant difference in testicular volumes before (0.62 +/- 0.24 mL) and after (0.62 +/- 0.21) surgery on the normal sides (P = .978). The mean decrease in volume of the testes with hydroceles after hydrocelectomy was approximately 15%.

CONCLUSIONS

This study shows that there is an association between congenital communicating hydroceles and testicular volume in children. Clinicians should be aware that there is a decrease in testicular volume after hydrocelectomy so they do not misdiagnose this change as postoperative trauma or atrophy.