Inguinal Hernia in Children: My Child Has a Groin Swelling—Hernia or Hydrocele?
A swelling in the groin or scrotum can be worrying for parents, particularly when it appears suddenly or seems to come and go.
In children, one of the common causes is an inguinal hernia, while another is a hydrocele. Although these conditions also occur in adults, their cause, anatomy and treatment in children are quite different from those in adults. Children therefore need a different approach to diagnosis and treatment, and these problems are best evaluated and treated by a pediatric surgeon.
Understanding the difference between a hernia and a hydrocele is important because their treatment and the urgency of treatment are also different.
What is an inguinal hernia?
An inguinal hernia occurs when there is a persistent opening between the abdomen and the groin through which abdominal contents can come into the groin.
In boys, the swelling may extend into the scrotum. In girls, it may appear as a swelling in the groin or genital area.
Parents may notice that the swelling:
Appears when the child cries, coughs or strains
Becomes more prominent when the child is active
Disappears when the child is relaxed or lying down
May come and go over a period of time
The swelling itself may not cause any pain. However, if the contents of the hernia become trapped, the swelling may become painful, firm and difficult to push back. The child may also develop vomiting, abdominal discomfort or significant distress.
If the blood supply to the trapped tissue becomes compromised, the hernia is said to be strangulated. This is an emergency because it can cause damage to the intestine, including gangrene, and in boys can also compromise the blood supply to the testis. In severe cases, it can become life-threatening.
Importantly, this progression can occur over a relatively short period of time.
This is why an inguinal hernia in a child should generally be treated before these complications develop, rather than waiting for symptoms of strangulation.
Is a hernia different from a hydrocele?
Yes.
A hydrocele is a collection of fluid in a sac around the testicle or in the groin.
In a hernia, bowel or other abdominal tissue enters the same sac.
The treatment, therefore, is different. Many hydroceles in young infants can be observed because they may disappear on their own, whereas an inguinal hernia requires surgical repair.
Is sonography mandatory for a child's inguinal hernia?
No, not in every child.
In many children, an inguinal hernia can be diagnosed from the history and clinical examination. If the swelling is typical and the diagnosis is clear, an ultrasound is usually not medically necessary.
However, ultrasound may be useful when the diagnosis is uncertain, the swelling cannot be demonstrated during examination, or another cause of the swelling needs to be considered.
An ultrasound may also be required for insurance or documentation purposes, even when it is not essential for making the clinical diagnosis.
A photograph of the swelling taken by parents when it is visible can also be useful if the swelling has disappeared by the time the child is examined.
When should a hernia be operated on?
A diagnosed inguinal hernia in a child generally requires surgical repair because the underlying opening does not usually close on its own.
The timing depends on the child's age, general health and the nature of the hernia.
A hernia that becomes painful, tense, irreducible or associated with vomiting or significant distress requires urgent assessment, as it may be incarcerated or strangulated.
An uncomplicated hernia should generally be repaired electively rather than waiting for complications to develop.
What is the right age for surgery?
There is no single age that applies to every child.
A hernia in a newborn or young infant may require earlier attention because the risk of complications is higher, while the timing also depends on prematurity and the child's general condition.
In an older child with an uncomplicated hernia, surgery can usually be planned electively.
The important point is that a child should not be made to wait simply to reach a particular age if a hernia requiring repair has already been diagnosed.
Open surgery or laparoscopy?
Both open and laparoscopic techniques are used for childhood inguinal hernia repair.
Open repair
Open inguinal hernia repair is my preferred approach for most children.
It involves a small incision in the groin, usually placed along or close to the natural underwear line. The operation does not enter the abdominal cavity and directly addresses the hernia sac.
It has been used successfully in children for many decades and is a very effective and well-established operation.
Open repair can also often be performed without the routine use of muscle relaxants, depending on the anesthetic technique and the individual child's requirements.
The important point for parents is not simply whether an operation is called "open" or "laparoscopic", but that the child is treated by a surgeon experienced in pediatric surgery and by a team experienced in pediatric anesthesia and perioperative care.
If the hernia is on one side, should both sides be operated on?
Not always.
Sometimes the passage on the opposite side may also remain open. However, an open passage does not necessarily mean that the child has a hernia or will develop one in the future. Only a small proportion of these otherwise open passages will actually go on to develop a hernia requiring surgery.
Therefore, an asymptomatic opposite side does not routinely need to be explored or operated upon in every child.
In boys, surgery is generally limited to the side with the clinically evident hernia, avoiding unnecessary dissection around the vas deferens and testicular blood vessels.
In young girls, particularly those below 2 years of age, there is a lower threshold for exploring the opposite side, as the likelihood of a contralateral hernia is higher in this age group.
The decision is ultimately individualised according to the child's age, sex and clinical circumstances.
Is treatment different in boys and girls?
The basic principle of repairing an inguinal hernia is similar, but there are important differences.
In boys
The hernia sac lies close to the vas deferens and the blood vessels supplying the testis. These structures need to be carefully protected during surgery.
In girls
An inguinal hernia may sometimes contain an ovary or fallopian tube.
Does hernia surgery affect my child’s future fertility or sexual function?
A routine, uncomplicated childhood inguinal hernia repair is not expected to affect future fertility or sexual function.
In boys, particular care is taken to protect the vas deferens and the blood supply to the testis during surgery.
As with any operation, complications are possible, but when the procedure is performed appropriately, parents should not expect a childhood hernia repair to interfere with their child's future sexual development or function.
What should parents do if the swelling suddenly changes?
Parents should seek urgent medical attention if a previously intermittent swelling:
Becomes painful
Becomes hard or tense
Becomes red or discoloured
Is associated with vomiting
Is associated with significant abdominal pain or distress
These may be signs of an incarcerated or strangulated hernia.
The important message for parents
A groin or scrotal swelling in a child should not simply be assumed to be a hydrocele or a harmless swelling.
A hernia and a hydrocele are different conditions, and their treatment in children is different from that in adults.
In many children, a hernia can be diagnosed in the clinic. Once a true inguinal hernia is diagnosed, it is generally better to repair it before incarceration or strangulation occurs.
Children are not simply small adults. Their anatomy, physiology, anesthesia and surgical requirements are different. For this reason, inguinal hernia and hydrocele in children are best managed by a surgeon trained and experienced in pediatric surgery.
Frequently Asked Questions
Can an inguinal hernia disappear on its own?
The swelling may disappear because the contents return to the abdomen, but the underlying opening generally remains. A diagnosed inguinal hernia therefore usually requires surgical repair.
Can girls have inguinal hernias?
Yes. Hernia can occur in both boys and girls.
Can a child develop a hernia on the other side later?
Yes, it is possible, but an asymptomatic patent processus vaginalis does not mean that a clinical hernia will definitely develop.
Can hernia surgery affect my child’s future fertility?
A properly performed, uncomplicated repair is not expected to affect future fertility or sexual function.
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