Patient Presentation
A 54-day-old male came to clinic after his parents noticed a lump in his left groin the prior evening while giving him a bath. They said that it did not appear to bother the patient, had not changed in size nor had any color changes since they had noticed it. He had not been ill. They denied any fevers, rashes, scratches, nausea or emesis. The past medical history showed a term infant without complications. The family history was negative for anatomic genitourinary problems or cancer. The review of systems was negative.

The pertinent physical exam showed a smiling infant with weight in the 50% and normal vital signs. A 1×1.5 centimeter firm mass was noted in the left groin. It was located medially to the inguinal canal. It appeared be aligned with the spermatic cord and move with it. It could not be transilluminated and was not physically pulsatile. Both testes were palpable in the scrotum with normal alignment. Both testes were the same size bilaterally and hydrocoeles were noted in the scrotum bilaterally. There were no diaper rashes, other rashes or skin changes on the legs or groin. The examination was otherwise normal.

The diagnosis of an inguinal mass was made and the resident and attending pediatrician considered that this could be an inguinal hernia or lymph node but the location and mass characteristics didn’t appear to be as consistent. A hydrocoele was also considered but the mass was in the inguinal area and not in the scrotum. A soft tissue tumor was considered but seemed again unlikely because of age. Anatomic variations of the vasculature or vas deferens were considered and seemed more consistent because of the location. The radiologic evaluation of an ultrasound found the diagnosis of a hydrocoele of the spermatic cord. The attending pediatrician was surprised as she had not seen this variation of a hydrocoele in her clinical practice. The patient was referred to pediatric surgery and was being monitored for resolution.

Figure 119 – Longitudinal ultrasound image thorough the inguinal canal (to the left of image) and the scrotum (to the right of image) shows a cystic structure within the inguinal canal consistent with a spermatic cord hydrocoele. Within the scrotum is the normal epididymis and testicle and a small hydrocoele.

Discussion
Hydrocoeles are common anatomic variations caused by the incomplete obliteration of the processus vaginalis. The processus vaginalis is a peritoneal remnant that follows the testis and spermatic cord into the scrotum as the testis descends into the scrotum during development. As the processus vaginalis traverses from the testis back to the peritoneum, a hydrocoele can occur at any point along its length. The obliteration of the processus vaginalis occurs with the closure at the internal inguinal ring, followed by closure just above the testes with atresia of the area in between. The closure of the area around the testes itself is often not complete by the time of birth and hydrocoeles are commonly seen in the scrotum; most resolve by 1 year of age. The hydrocoeles may be uni- or bilateral.

Learning Point
Hydrocoele of the spermatic cord (HSC) is a uncommon variation of hydrocoele. There can be a chronic or acute onset of swelling in the upper groin or inguinal area above the testis and epididymis. HSC is divided into 2 or 3 types depending on the author.

• An encysted HSC occurs when there is obliteration of the processus vaginalis at both ends with solitary cyst formation. This does not change in size.
• A funicular HSC occurs when there is obliteration of the processus vaginalis distally leaving open the proximal processus vaginalis to communicate with the peritoneum. This may change in size because of differing amounts of peritoneal fluid in the cyst.
• A mixed HSC has a proximal opening of the processus vaginalis but has an integrated wall around the cyst that causes it to act like a encysted HSC. It does not change in size because the wall prevents fluid from entering the cyst. These types of cysts can be solitary or multiple.

HSC is usually treated by pediatric surgeons and treatment may be watchful waiting if there is a funicular HSC up to around 1 year of age after which it is repaired. If there is an encysted HSC or there appears to be a related inguinal hernia then surgery is usually recommended earlier. HSC torsion can occur but is very rare. In one study of HSC, 30% of patients had anatomic inguinal defects on the contralateral side.

Hydrocoeles have been known to the medical profession for hundreds of years. In an 1843 article, Dr. Robert Liston describes encysted hydrocoeles:

“I. On the testicle, betwixt the albuginea and tunica vaginalis – at first as transparent cysts, but gradually increasing in size.

II. As presenting by the side of the epididymis, betweixt that body and the reflection of the processus vaginalis from the testis.

III. As appearing in the course of the spermatic chord above the testicle. In this latter situation, no doubt, collections of various kinds are to be met with in the loose filamentous tissue of the chord; in the unobliterated portions of the spermatic process covering that body; or possibly, in more immediate connexion with the vas deferens itself.”

Questions for Further Discussion
1. What is the differential diagnosis of testicular pain? For a review click here
2. What is the differential diagnosis of scrotal swelling? For a review click here
3. What is the differential diagnosis of vulvar masses? For a review click here

Related Cases

Disease: Hydrocoele | Testicular Disorders

Symptom/Presentation: Mass or Swelling

Specialty: Nephrology / Urology | Surgery |
Radiology / Nuclear Medicine / Radiation Oncology

Age: Infant

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Testicular Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Liston R. A few observations on encysted hydrocele. Med Chir Trans. 1843;26:216-22.

Chang YT, Lee JY, Wang JY, Chiou CS, Chang CC. Hydrocele of the spermatic cord in infants and children: its particular characteristics. Urology. 2010 Jul;76(1):82-6.

Senayli A, Senayli Y, Sezer E, Sezer T. Torsion of an encysted fluid collection. Scientific World Journal. 2007 Apr 9;7:822-4.

Rathaus V, Konen O, Shapiro M, Lazar L, Grunebaum M, Werner M. Ultrasound features of spermatic cord hydrocele in children. Br J Radiol. 2001 Sep;74(885):818-20.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital