Hemiscrotal Bulge in an Otherwise Normal Neonate
This full-term male infant is the product of an unremarkable pregnancy and a normal spontaneous vaginal delivery. His physical exam is otherwise normal. The right-sided groin swelling shown below is soft and compressible. It is unclear whether the testicle is contained within the affected hemiscrotum.
Answer: D. Inguinal hernia
Inguinal hernia is found in 3-5% of term infants with a 60% occurrence on the right side. Ninety percent of pediatric inguinal hernias are diagnosed in males. Testicular torsion (option A) presents rarely in the newborn period with an inflamed hemiscrotum without ipsilateral inguinal canal swelling. Testicular tumors (option B) in the neonatal period are exceedingly rare and are found contained in the scrotal sac, though occasionally associated with a concomitant hydrocele in the same hemiscrotum. Hydroceles (option C), which share a common embryologic cause with inguinal hernias, can be soft and compressible as well. However, they can be tense and bluish in color, contain clear fluid, and do not extend above the scrotal sac. Hernias, which contain loops of intestine, can produce swelling that extends above the upper border of the scrotal sac. Ultrasound can help distinguish between the latter two entities, and on occasion they can coexist.
Controversy surrounds the optimal timing for hernia repair (both for term and preterm infants), the need for contralateral exploration, and the risk for incarceration, though laparoscopic repair seems equivalent to open approaches.
Wang KS, Committee on Fetus and Newborn, American Academy of Pediatrics, Section on Surgery, American Academy of Pediatrics. Assessment and management of inguinal hernia in infants. Pediatrics. 2012;130:768-73.
Inguinal hernias and hydroceles in infancy and childhood: A consensus statement of the Canadian Association of Paediatric Surgeons. Paediatr Child Health. 2000;5:461-2.