Hernia, hydrocele, undescended testis and foreskin questions in baby boys

Most worries about a baby boy's genitals turn out to be normal stages of growth. A swollen scrotum is often a harmless hydrocele, and a foreskin that will not pull back is normal for years. A few problems do need surgery or urgent care, though: a hernia, a testis that has not come down, and a twisted testis. Here are the questions parents ask Dr Dutta most, with clear answers.

What is the swelling in my baby boy's groin or scrotum?

It is usually either a hydrocele (fluid around the testis) or an inguinal hernia (a loop of bowel pushing into the groin). Both come from a small channel that should close before birth but stays open.

Before birth, each testis travels down from the tummy into the scrotum through this channel. Normally it seals shut. If a tiny opening remains, fluid can trickle down and collect around the testis. If the opening is wider, a piece of bowel can slip through and make a bulge in the groin.

In one large study, a third of babies with a hydrocele present from birth had been born premature.¹

How can I tell a hernia from a hydrocele?

A hernia is a lump in the groin that comes and goes, often getting bigger with crying or straining. A hydrocele is a soft, smooth swelling around the testis. If it changes size during the day, the channel is still open (a communicating hydrocele), and a surgeon should see it.

• Hernia: bulge in the groin or scrotum, often appears when the baby cries and disappears when calm or asleep.
• Hydrocele: painless swelling of the scrotum. A tense, painful or rapidly changing swelling needs to be seen urgently.
• Both can be present together.

A doctor can usually tell them apart by examining your baby. An ultrasound scan helps if there is doubt. Take a photo on your phone when the swelling is at its biggest, because it may vanish by the time you reach the clinic.

Does a hydrocele go away on its own?

Yes, most hydroceles present at birth go away by themselves, so doctors usually watch and wait rather than operate.

Surgeons from one centre that followed 355 children advised waiting until the child is 1 year old at the least, and ideally 2, before deciding on surgery for a hydrocele present since birth.¹ Even in children over 1 year who were watched without surgery, most hydroceles cleared within 6 months.¹

For hydroceles that appear after birth, the same surgeons listed reasons not to wait, such as a hernia, an undescended testis or a tense hydrocele.¹ In Dr Dutta's practice, a hernia, a tense swelling, or a hydrocele that changes size during the day goes to a surgeon at any age.

Does an inguinal hernia in a baby need an operation?

Yes. A hernia does not close by itself, and it should be repaired soon after diagnosis, because the bowel can get stuck.

A review of 22 studies with nearly 15,000 children found that about 7% of hernias got stuck while children waited for planned surgery, and 11% in premature babies.² A Canadian study of children under 2 found that waiting longer than 14 days doubled the risk of the hernia getting stuck. The authors advised repair within 14 days of diagnosis.³

The operation is common and usually done as a day case. Ask your surgeon about timing if your baby is premature or has other health problems.

What is a stuck (incarcerated) hernia, and why is it an emergency?

A stuck hernia is one that will not go back in. It is an emergency because the trapped bowel, or the testis on that side, can lose its blood supply.

Signs of a stuck hernia:

• a firm, tender lump in the groin that does not go away when the baby calms down
• redness or blue colour over the lump
• non-stop crying, vomiting (especially green vomit) or a swollen tummy
• refusing feeds

Go to hospital straight away. Do not try to push it back in yourself. Babies under 1 year have a higher risk of the hernia getting stuck.³

What is an undescended testis?

It means one or both testes have not reached the scrotum by the time of birth. It is common, especially in premature babies, and often corrects itself in the first few months.

NHS guidance says undescended testes often move down into the scrotum within the first 12 weeks after birth.⁴ American urology guidance calls it the most common genital problem found at birth.⁵

Your doctor will check your son's scrotum at birth and at later visits. If one side of the scrotum looks empty, mention it at the next visit. If both sides look empty in a newborn, ask for a review the same day: American guidance calls for immediate specialist assessment, because it can signal a hormone condition such as congenital adrenal hyperplasia (CAH).⁶

When is surgery done for an undescended testis?

The NHS refers babies to a specialist if one testis has not come down by 4 to 5 months, or after about 8 weeks if both are affected. Surgery is usually done at around 1 year of age.⁴

The American Urological Association advises referral by 6 months (corrected for prematurity), and surgery within the following year.⁶ It found surgery (orchidopexy, bringing the testis down and fixing it in the scrotum) works best, and it does not recommend hormone injections.⁵

Why not wait longer? A testis in the wrong place may not develop well. Surgery may lower, but does not remove, the later risk of fertility problems and testicular cancer.⁵ That is why boys who had this condition should learn to check their testes as teenagers.

What is a retractile testis?

A retractile testis is a normal testis that pulls up into the groin at times, for example in the cold or when touched, but can be brought down into the scrotum easily.

A strong muscle reflex causes this, and it is common in young boys. You may see both testes in the scrotum during a warm bath, and one disappear when your son is cold or upset. This does not need surgery. American guidance still advises checking its position at least once a year, because it can move up and stay up.⁶

Should I pull back my baby's foreskin to clean it?

No. Do not pull back your baby's foreskin. In babies it is normally stuck to the head of the penis and will separate by itself over years.

Forcing it back can tear the skin, cause pain and bleeding, and lead to scarring that makes the foreskin truly tight later. Clean only the outside with plain water during baths. No soap, powder or oil is needed inside.

Grandmothers sometimes advise stretching the foreskin daily to "open" it. Please gently say no. The penis will look after itself.

At what age does the foreskin pull back on its own?

It varies a lot. In some boys it pulls back in early childhood; in many it does not fully retract until the teenage years. Both are normal.

A study of 603 Japanese boys found that none had a fully retractable foreskin at 6 months. By 11 to 15 years, about 63% did. A tight ring at the tip was seen in 84% of the youngest boys and only 9% of the oldest.⁷ The authors concluded that incomplete separation is normal in babies and continues into adolescence.⁷

Once it starts to move easily, teach your son to slide it back gently in the bath, rinse, and always pull it forward again.

My son's foreskin balloons when he pees. Is that a problem?

Usually not. Ballooning happens when urine fills the space under a naturally tight foreskin before it trickles out. It is common and normally harmless.

A UK study measured urine flow and bladder emptying in boys with a non-scarred, tight foreskin, with and without ballooning. Neither group showed signs that the flow of urine was blocked.⁸

See a doctor if your son strains hard to pee, passes only a thin dribble, has pain, or has a urine infection or repeated redness and swelling of the tip.

What is phimosis, and does it need treatment?

Phimosis means a foreskin that cannot be pulled back. In young boys this is normal and needs no treatment. It only needs attention if it causes trouble or the tip becomes white and scarred.

When treatment is needed, a steroid cream rubbed on the tight part of the foreskin is usually tried first. A Cochrane review of 14 trials found that 4 to 8 weeks of steroid cream may increase the chance of the foreskin loosening fully, with few side effects.⁹ The evidence was of low certainty.⁹

Circumcision or a smaller operation to widen the foreskin is kept for boys who do not respond, or who have scarring.

What is balanitis, and how do I treat it?

Balanitis is redness, swelling and soreness of the tip of the penis or foreskin. Mild cases settle with simple care; see a doctor if it does not improve in a day or two or if there is pus.

• Soak in a bath of plain warm water and let him pee in the water if it stings.
• Change nappies often and let the area air dry.
• Avoid soap, bubble bath and wet wipes on the area.
• Do not pull back the foreskin to clean.

In the Japanese study above, a few boys had such inflammation but none had a urine infection.⁷ Repeated bouts are worth discussing with a paediatric surgeon.

Is circumcision medically necessary for my baby?

For most boys, no. Circumcision is an elective choice for families, usually for religious or cultural reasons. It is medically needed only for a few conditions, such as scarred phimosis.

The American Academy of Pediatrics concluded that the health benefits of newborn circumcision outweigh the risks, enough to justify access for families who choose it. It also stressed that the procedure is elective and that parents should weigh it against their own religious, cultural and personal views.¹⁰ Benefits it found include fewer urine infections and lower rates of some sexually transmitted infections later in life.¹⁰

If you choose it, the AAP says it should be done by a trained person with sterile technique and proper pain relief.¹⁰ Untrained providers have more complications.¹⁰

How do I care for my baby's penis after circumcision?

Keep the area clean with plain water, protect it from sticking to the nappy, and watch for bleeding or trouble passing urine.

• Put a dab of petroleum jelly on the tip or on the nappy at each change, unless your surgeon advises otherwise.
• A yellowish film on the healing tip is normal and is not pus.
• Fasten nappies loosely.
• Give paracetamol only if your doctor has advised a dose.

The AAP stresses that parents should be taught how to care for the penis, whether or not their son is circumcised.¹⁰ Call your doctor if bleeding soaks through, if your baby is not passing urine, or if redness spreads or there is fever.

What is testicular torsion, and how fast must it be treated?

Testicular torsion means the testis twists on its cord and cuts off its own blood supply. It is a surgical emergency: the sooner it is untwisted, the better the chance of saving the testis.

A systematic review looked at 1,283 cases where timing was reported in 6-hour blocks. The testis survived in about 97% of cases treated within 6 hours, falling to about 79% at 7 to 12 hours and about 43% at 19 to 24 hours.¹¹ Some testes survived even later, so never assume it is too late.¹¹

Signs are sudden, severe pain in the testis, groin or lower tummy, often with nausea or vomiting. A younger child may just cry and refuse to walk. The NHS advises going to the emergency department immediately.¹² Boys are often embarrassed, so teach your son to tell you about any pain "down there" at once.

When should I take my son to a doctor urgently?

Go to hospital straight away if your son has:

• sudden, severe pain or swelling in the testis or groin¹²
• a groin lump that is hard, tender or will not go back, with crying or vomiting
• green vomiting or a swollen tummy
• a red, swollen, painful scrotum
• both sides of the scrotum empty in a newborn⁶
• a tense or painful scrotal swelling, or one that changes size quickly
• a foreskin pulled back that cannot be brought forward, with swelling of the tip
• not passing urine, or straining with only drops of urine

Book a routine visit for:

• a scrotum that looks empty on one side
• a hydrocele still present after age 1
• ballooning with straining, repeated balanitis, or a white scarred foreskin tip