Hydrocele and indirect inguinal hernia, what is their relationship?

• Hydrocele is the accumulation of fluid between the two layers that form the scrotal sac in men.
• An inguinal hernia is an opening caused by weakness of the abdominal wall through which internal tissue leaks.
• To solve the problems associated with a hydrocele and an inguinal hernia in the same patient, surgery is required.

Hydrocele is an accumulation of fluid between two of the layers that envelop the testicles within the scrotal sac. This accumulation of fluid can have various origins and can be agglutinated in different quantities, reaching up to one litre in the most severe cases.

The scrotal sac, which contains the two testicles and all the tubules that connect them to the rest of the male sex organs, is made up of a series of different layers of tissue. 

Anatomically, we can divide the layers that form the scrotal sac from the outside in to the testicle as follows: scrotum, the dartos muscle, a layer of serous tissue, a muscle called the cremaster muscle, another thin layer of serous tissue, and finally the tunica vaginalis of the testicle.

Of all the layers mentioned above, it is the tunica vaginalis that will form the main part of the development of hydrocele and indirect inguinal hernia as a secondary relationship. The tunica vaginalis or innermost layer of the scrotal sac is made up of two types of subtissue or thinner layers called the parietal layer and the visceral layer. 

This conformation of the innermost layer of tissue of the scrotal sac, which is most in contact with the testicles, allows the movement of the testicles inside the scrotal sac.

The hydrocele is formed by the accumulation of fluid between the parietal and visceral layers.

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The formation of a hydrocele and indirect inguinal hernias do not necessarily share a common origin in a systematic way but they do present a statistically significant relationship favouring the joint presence of hydrocele and indirect inguinal hernia.

The formation of a hydrocele depends to a large extent on the conformation of the tunica vaginalis anatomy. If the tunica vaginalis is constituted in the usual way, i.e. without any alterations, fluid will accumulate between both parietal and visceral layers of the scrotal sac. 

This accumulation is mainly due to an imbalance between the formation and absorption of a clear, transparent fluid that is naturally generated to allow proper sliding of the various layers of the scrotal sac. 

This natural fluid acts as a natural lubricant. In acquired or normally formed hydroceles (not as a result of varicocele surgery) the balance is broken in favour of secretion and proliferation by factors not yet fully understood.

When hydrocele occurs in children, it is mainly due to the persistence of an orifice or duct (medically called the peritoneo-vaginal duct) that connects these layers that make up the tunica vaginalis with the interior of the abdomen, allowing fluid to flow between them and the peritoneum.

The peritoneovaginal duct is central to understanding the relationship and formation of hydrocele and inguinal hernias. The peritoneovaginal duct is patent at birth, but then usually obliterates before the first year of life. Obliteration may be complete, leading to normal conformation of the scrotal sac and tunica vaginalis, or it may be incomplete.

Incomplete closure of the peritoneovaginal canal can lead to 3 different situations in the formation of hydrocele and its relation to inguinal hernias:

• If the most proximal segment, i.e. the one closest to the deep orifice of the inguinal canal, is left open, an indirect inguinal hernia may occur if part of the abdominal contents is able to pass through the deep orifice and penetrate into the inguinal region.
• If both the proximal and distal or more distal ends are obliterated and the segment of the duct in between is kept open, a chordal cyst will form.
• Finally, when the peritoneovaginal duct is not occluded at any point, a communicating hydrocele is formed, i.e. a direct communication between the vaginal and peritoneal cavities.

The answer is yes. To solve the problems caused by a hydrocele associated with an inguinal hernia, the only definitive option is surgery.

However, the operation must be performed in two stages, as the hydrocele surgery is performed by a surgeon specialising in urology while the inguinal hernia operation must be performed by a general surgeon. 

To decide which of the two medical problems is to be solved first, the process is as simple as determining which is the more serious problem and which is causing the most discomfort to the patient.

Once this has been decided, the operations are carried out. These are normally carried out in two different surgical sessions, due to the need for two different surgeons, although in some cases it may be decided to carry out the intervention in the same surgical act with both specialists in the operating theatre, thus avoiding the need for the patient to undergo surgery twice.

If you have an inguinal hernia associated with a hydrocele and are looking for a solution, please contact us by clicking on the image below:

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