A 1-day-old boy is undergoing routine evaluation in the nursery. He was born via vaginal delivery to a primigravida at 38 weeks gestation. The mother took a daily prenatal vitamin and had routine prenatal care. Pregnancy was complicated by gestational diabetes, which was controlled by diet. Labor and delivery were unremarkable. Birth weight was 3.7 kg (8 lb 2 oz). The boy is awake and alert with normal tone and a strong sucking reflex. The lungs are clear to auscultation, and the heart has a normal rate and rhythm without murmurs. The abdomen is soft, nontender, and nondistended. The penis is uncircumcised, and the urethral meatus is visualized at the tip of the glans. The scrotum is significantly swollen with no discoloration. Both testicles are palpated within the scrotal sac. A light shone behind the scrotum transilluminates the swelling. Which of the following is the most appropriate next step in management of this patient?
Show Explanatory Sources
A hydrocele is a fluid collection within the tunica vaginalis, a sac surrounding the testis. During fetal development, an outpouching of the peritoneum descends with the testis into the scrotum and forms the processus vaginalis and the tunica vaginalis. Typically, the processus vaginalis then obliterates; however, if it remains open, peritoneal fluid can accumulate and cause a communicating hydrocele. In contrast, a noncommunicating hydrocele is formed if the processus obliterates normally but fluid collected within the tunica vaginalis does not reabsorb.
Hydroceles are common in neonates and present with painless unilateral or bilateral scrotal swelling. The swelling may fluctuate with crying or straining (increased intra-abdominal pressure) in infants with a communicating hydrocele; however, noncommunicating hydroceles are irreducible and remain constant in size.
Transillumination helps differentiate scrotal masses, as hydroceles are cystic and transmit light whereas inguinal hernias contain bowel that does not typically transilluminate. Most hydroceles, both communicating and noncommunicating, should spontaneously resolve by age 1 year and can be safely observed during that period.
(Choice A) Aspiration of the fluid is not recommended due to risks of infection and damage to nearby structures.
(Choice B) Genetics consultation may be indicated for ambiguous genitalia, but it is not necessary for this patient with a normal penis and bilateral descended testes.
(Choice D) Ultrasound imaging is used to identify an inguinal hernia in a patient with a scrotal mass that does not transilluminate.
(Choice E) Surgical intervention is indicated for hydroceles that persist beyond age 1 year, as spontaneous resolution is unlikely in such cases.
Educational objective:
Newborn hydroceles typically present with painless scrotal swelling that transilluminates on examination. Management includes observation and reassurance, as most cases resolve spontaneously by age 1 year.