Pediatric hernias and undescended testis in Jordan: A retrospective study

Abstract

BACKGROUND

Pediatric hernias and undescended testis (UDT) are common surgical conditions in children, with distribution varying by age, sex, and anatomical site. Although data from Western studies are abundant, limited data are available regarding their epidemiology in the Middle East, especially in Jordan.

AIM

To evaluate the demographic distribution of pediatric hernias and UDT by age, sex, and anatomical site, and to compare findings with Western populations.

METHODS

A retrospective observational study was conducted at Al-Hussain New Salt Hospital, including pediatric patients (≤ 18 years) who underwent surgical intervention for hernia and/or UDT between 2019 and 2025. Patients who had been diagnosed but were treated at different facilities were not included. Data were extracted from medical records, including age (broken down into set age categories), sex, and diagnosis. Associations between categorical variables were assessed using χ² or Fisher’s exact tests, with Cramér’s V used as a measure of effect size.

RESULTS

A total of 1647 pediatric patients were enrolled, with 77.5% being males. The most common diagnoses were right inguinal hernia (32.8%) and left inguinal hernia (22.5%). UDT diagnoses accounted for 29.8% of cases overall. Among male patients (n = 1276), UDT was observed in 40.3% of cases and was significantly associated with age [χ²(4) = 147, P < 0.001], occurring more frequently in older children. The distribution of diagnoses varied significantly by age [χ²(32) = 215, P < 0.001] and sex [χ²(8) = 282, P < 0.001]. Inguinal hernias were more prevalent in younger age groups, whereas UDT was more frequently observed in older patients.

CONCLUSION

Pediatric hernias and UDT in this cohort exhibited distinct age- and sex-specific patterns, with UDT predominantly detected in older children, indicating a delayed presentation relative to findings from Western populations.

Key Words: Pediatric hernia; Inguinal hernia; Umbilical hernia; Undescended testis; Orchiopexy; Epidemiology; Jordan

Core Tip: This single-center study provides new epidemiological data on undescended testis and pediatric hernias in Jordan, which is an area with limited research publications about this topic across 2019-2025. We found that the prevalence of right-sided inguinal hernia coincides with Western studies; however, undescended testis diagnosis is confined to an older age demographic, which is opposite to the global studies. So, accordingly, these results demonstrate the importance of region-specific data.

INTRODUCTION

Pediatric inguinal hernia and undescended testis (UDT) are among the most common pediatric surgical conditions. An inguinal hernia occurs more frequently in males and premature infants than in females. Although right-sided predominance has been reported in many studies, pediatric inguinal hernias can occur on either side and in both sexes. UDT is also among the most common congenital genital anomalies in the male population. Factors that affect normal testicular descent include genetics, hormones, and anatomy[1,2].

Epidemiologically, pediatric inguinal hernia and UDT have been well established in the Western world, whereas there are limited data available regarding their prevalence in the Middle East, specifically in Jordan. The lack of studies in the region may mask important population and clinical characteristics related to ethnicity, environmental influences, genetics, and access to medical care.

This study aims to better understand the demographics associated with pediatric hernia and UDT at the Al-Hussain New Salt Hospital, including anatomic site distribution, age, and gender, and to compare these findings with those of Western studies to examine regional differences and thus contribute to the pediatric surgical epidemiological literature.

MATERIALS AND METHODS

Study design, setting, and study period

This is a retrospective observational study performed in Al-Hussain New Salt Hospital from 2019 to 2025. This study was conducted and reported in accordance with the STROBE.

Study population (eligibility criteria)

Patients aged 18 years or younger who had surgery for a hernia or an UDT at Al-Hussain New Salt Hospital during the study period were included. 1647 patients met the inclusion criteria, which were: (1) Age ≤ 18 years at the time of surgery; (2) Diagnosis of hernia and/or UDT; and (3) Surgery conducted at Al-Hussain New Salt Hospital. Patients diagnosed at the hospital but who underwent surgery at a different facility were excluded.

Ethics and human subjects issues

Ethical approval for this study was given by the Institutional Review Boards of Al-Balqa’ Applied University, Faculty of Medicine, and Al-Hussain New Salt Hospital, No. 32/2/2025/2026.

Data collection methods and variables

Data were extracted from electronic medical records, including age, sex, and diagnosis, and all the data were cleaned before analysis to minimize entry errors and inconsistencies. One record per patient was the unit of analysis. To avoid including the same operation twice, only the first (index) operation was included for patients who had more than one eligible operation during the study period.

Diagnoses were classified into hernia only, UDT only, or combined hernia + UDT when both conditions were documented in the same record. UDT laterality was recorded as right, left, or bilateral based on operative documentation. This classification was used because both conditions represent common pediatric surgical pathologies managed within the same clinical setting. While UDT occurs exclusively in males, female patients were included in the analysis of hernia cases to reflect the overall surgical cohort. Age was categorized into five predefined groups: Newborn (0-28 days), infant (1-12 months), toddler (1-3 years), child (4-12 years), and adolescent (13-18 years)[3].

Missing data

Missing data were examined for each variable. For each study, records lacking the necessary variables for the comparison were omitted (complete-case analysis).

Statistical analysis

Analyses were conducted utilizing Jamovi (version 2.3.28). Categorical variables were summarized using frequencies and percentages. The χ² test or Fisher’s exact test was used to find relationships between categorical variables when the predicted cell counts were low. Cramér’s V was employed as an effect size metric due to its suitability for connections between nominal categorical variables. We employed binary logistic regression to look into UDT status in male patients. Unadjusted models were utilized because of the restricted availability of covariates in retrospective records. A P value < 0.05 was considered statistically significant. Benjamini-Hochberg false discovery rate correction was applied across χ² tests.

RESULTS

This study consisted of 1647 patients who had undergone surgery for inguinal, umbilical, or other hernia types and/or UDT at Al-Hussain New Salt Hospital in Jordan. Diagnoses were distributed by age group and sex, as well as the outcomes of χ² tests evaluating associations between these variables, are displayed in the following tables along with the sample’s descriptive statistics. The population in this study included both male and female patients with hernias, while UDT diagnoses were restricted to male patients.

Descriptive statistics

There were 1647 pediatric patients in the study. 77.5% of the cohort were males and 22.5% females. The greatest portion of patients were children aged 4 to 12 years (39.4%), followed by infants (27.4%) and toddlers (26.1%). Fewer subjects were adolescents (1.0%), and the rest of the group consisted of newborns (6.1%). Overall demographic characteristics are shown in Table 1. Among 1276 male patients, a significant proportion had UDT. Left-sided UDT was seen in 204 patients (16.0%), whereas right-sided UDT was observed in 198 patients (15.5%). Bilateral UDT comprised 89 cases (7.0%).

Table 1 Overall demographic characteristics of the surgical cohort (n = 1647).

Variable	Category	n (%)
Age group	Newborn	101 (6.1)
	Infant	451 (27.4)
	Toddler	430 (26.1)
	Child	649 (39.4)
	Adolescent	16 (1.0)
Sex	Male	1276 (77.5)
	Female	371 (22.5)

The study population included all surgically treated children with hernia and/or undescended testis. Undescended testis occurred exclusively in male patients.

Additionally, 23 individuals (1.8%) had concurrent inguinal hernia and UDT. Distribution of UDT among male patients is shown in Table 2. UDT was more frequently observed in older age groups in male patients (n = 1276). The diagnosis was less likely to be observed in infants (20.0%) and newborns (7.1%). On the other hand, it was highly observed in toddlers (47.3%) and children (53.3%). Despite being the small number in the adolescents’ age group, they had the highest percentage (85.7%). A significant association was seen between age and UDT [χ²(4) = 147, P < 0.001], with a moderate effect size (Cramér’s V = 0.339). Distribution of UDT by age group among male patients is shown in Table 3.

Table 2 Distribution of undescended testis among male patients (n = 1276).

Diagnosis		n (%)
UDT	Left	204 (16.0)
	Right	198 (15.5)
	Bilateral	89 (7.0)
Inguinal hernia	Left	261 (20.5)
	Right	388 (30.4)
	Bilateral	36 (2.8)
Combined hernia and UDT		23 (1.8)
Umbilical hernia		53 (4.2)
Other hernias		24 (1.9)

Undescended testis diagnoses are restricted to male patients. Percentages are calculated using the total number of male patients (n = 1276). UDT: Undescended testis.

Table 3 Distribution of undescended testis by age group among male patients (n = 1276), n (%).

Age group	UDT present		Total
	Absent	Present
Adolescent	2 (14.3)	12 (85.7)	14
Child	235 (46.7)	268 (53.3)	503
Infant	284 (80.0)	71 (20.0)	355
Newborn	65 (92.9)	5 (7.1)	70
Toddler	176 (52.7)	158 (47.3)	334
Total	762 (59.7)	514 (40.3)	1276

Percentages are calculated within each age group. UDT: Undescended testis.

The most common diagnosis was right inguinal hernia (32.8%) followed by left inguinal hernia (22.5%). UDT diagnoses accounted for 12.4% (left), 12.0% (right), and 5.4% (bilateral) of the cohort. Umbilical hernia was 7.9% of the cohort, and less than 5% were bilateral forms. The distribution of diagnoses is shown in Table 4.

Table 4 Diagnosis distribution (n = 1647), n (%).

Diagnosis		n (%)
UDT	Left	204 (12.4)
	Right	198 (12.0)
	Bilateral	89 (5.4)
Inguinal hernia	Left	370 (22.5)
	Right	540 (32.8)
	Bilateral	61 (3.7)
Combined hernia and UDT		23 (1.4)
Umbilical hernia		130 (7.9)
Other hernias		32 (1.9)

Sliding hernias were classified under inguinal hernia. UDT: Undescended testis.

The distribution of diagnoses showed significant differences between age groups [χ²(32) = 215, P < 0.001], with a small-to-moderate effect size (Cramér’s V = 0.181). Inguinal hernias were particularly common in younger age groups, particularly in infants and newborns. The right inguinal hernia was more common than the left among all age groups, with 43.5% of cases in infants and 41.6% in newborns, vs 29.0% and 37.6% for the left inguinal hernia, respectively. On the other hand, UDT was more common in older age groups. Right-sided UDT was more common than left-sided UDT, notably in adolescents (43.8% vs 25.0%) and children (17.1% vs 14.5%). Diagnosis distribution by age group is shown in Table 5.

Table 5 Diagnosis distribution by age group (n = 1647), n (%).

Diagnosis		Adolescent	Child	Infant	Newborn	Toddler	Total
UDT	Left	4 (25.0)	94 (14.5)	32 (7.1)	0 (0.0)	74 (17.2)	204 (12.4)
	Right	7 (43.8)	111 (17.1)	28 (6.2)	2 (2.0)	50 (11.6)	198 (12.0)
	Bilateral	1 (6.3)	53 (8.2)	4 (0.9)	2 (2.0)	29 (6.7)	89 (5.4)
Inguinal hernia	Right	2 (12.5)	162 (25.0)	196 (43.5)	42 (41.6)	138 (32.1)	540 (32.8)
	Bilateral	0 (0.0)	16 (2.5)	26 (5.8)	10 (9.9)	9 (2.1)	61 (3.7)
	Left	2 (12.5)	118 (18.2)	131 (29.0)	38 (37.6)	81 (18.8)	370 (22.5)
Combined hernia and UDT		0 (0.0)	10 (1.5)	7 (1.6)	1 (1.0)	5 (1.2)	23 (1.4)
Umbilical hernia		0 (0.0)	65 (10.0)	22 (4.9)	5 (5.0)	38 (8.8)	130 (7.9)
Other hernias		0 (0.0)	20 (3.1)	5 (1.1)	1 (1.0)	6 (1.4)	32 (1.9)
Total		16	649	451	101	430	1647

Percentages are calculated within each age group. UDT: Undescended testis.

The diagnosis distribution among males and females represented an important difference [χ²(8) = 282, P < 0.001], with a moderate-to-strong effect size (Cramér’s V = 0.414). UDT was observed only in males, as expected. On the other hand, inguinal hernias were present in both genders. However, the prevalence within the females was greater for both right (41.0% vs 30.4%) and left inguinal hernias (29.4% vs 20.5%). Umbilical hernia showed a significant female predominance, constituting 20.8% of diagnoses in females against 4.2% in males. Diagnosis distribution by sex is shown in Table 6.

Table 6 Diagnosis distribution by sex (n = 1647), n (%).

Diagnosis		Female	Male	Total
UDT	Left	0 (0.0)	204 (16.0)	204 (12.4)
	Right	0 (0.0)	198 (15.5)	198 (12.0)
	Bilateral	0 (0.0)	89 (7.0)	89 (5.4)
Inguinal hernia	Left	109 (29.4)	261 (20.5)	370 (22.5)
	Right	152 (41.0)	388 (30.4)	540 (32.8)
	Bilateral	25 (6.7)	36 (2.8)	61 (3.7)
Combined hernia and UDT		0 (0.0)	23 (1.8)	23 (1.4)
Umbilical hernia		77 (20.8)	53 (4.2)	130 (7.9)
Other hernias		8 (2.2)	24 (1.9)	32 (1.9)
Total		371	1276	1647

Percentages are calculated within sex. UDT: Undescended testis.

Binary logistic regression indicated that increasing age group was a significant predictor of UDT in males (B = 0.760, SE = 0.068, P < 0.001). Every increase in age group correlated with a greater than twofold rise in the probability of UDT (odds ratio = 2.14, 95% confidence interval: 1.87-2.44). Binomial logistic regression of age group predicting UDT presence among males is shown in Table 7.

Table 7 Binomial logistic regression of age group predicting undescended testis presence among males.

Predictor	Estimate	SE	Z	P value	Odds ratio	95% confidence interval
Age group	0.760	0.0681	11.2	< 0.001	2.1374	1.8704-2.4425

Estimates represent the log-odds of undescended testis presence (1) relative to absence (0).

There was a strong link between diagnosis and age group for male patients [χ²(32) = 214, P < 0.001], with a small-to-moderate effect size (Cramér’s V = 0.21). UDT (all types) was primarily noted in toddlers and children, whereas inguinal hernias were more prevalent in infants and newborns. Diagnosis distribution by age group among males (n = 1276) is shown in Supplementary Table 1. In patients without concurrent UDT, hernia type exhibited a significant variation by sex [χ²(4) = 51.2, P < 0.001], with a small-to-moderate effect size (Cramér’s V = 0.21). Right-sided inguinal hernia was the most common diagnosis in both sexes, while umbilical hernia was relatively more frequent in females. Hernia type by sex among patients without concomitant UDT (n = 1133) is shown in Supplementary Table 2. In patients without concurrent UDT, hernia type exhibited considerable variation across age groups [χ²(16) = 55.6, P < 0.001], with a minimal effect size (Cramér’s V = 0.11). The most common diagnosis for all age groups was a right-sided inguinal hernia, especially in infants and toddlers. An umbilical hernia was more common in children. Hernia type by age group among patients without concomitant UDT (n = 1133) is shown in Supplementary Table 3. All χ² associations remained statistically significant after false discovery rate correction.

DISCUSSION

This study identified several important findings regarding pediatric hernias and UDT among children and adolescents in Jordan. Right inguinal hernia was the most common hernia subtype in both males and females, followed by left inguinal hernia, which is consistent with findings reported in previous studies[4-6]. In contrast, UDT has a nearly equal right- and left-sided involvement (12% and 12.4%, respectively, among all patients vs 15.5% and 16%, respectively, among male patients), differing from the right-sided predominance commonly described in the literature. One of the most striking findings in our study was the delayed age at diagnosis of UDT. More than half of the cases (53.3%) were diagnosed during childhood rather than infancy, suggesting delayed referral and delayed surgical intervention compared with current international recommendations[7-13].

Our results are consistent with other regional and global studies to a limited degree. Inguinal hernia is right-sided due to delayed obliteration of the right processus vaginalis[14], as previously reported in Western and regional populations. Between males and females, there has been a previously reported significantly higher ratio of males diagnosed with hernia in children, with a reported ratio between 3-6:1[6,15,16]. However, there is a lower male-to-female ratio (2.5:1) compared to Western reports (3-6:1), indicating a relatively higher proportion of females in this cohort.

Several factors may explain these differences in findings from Western populations. There may be limited access to specialized pediatric surgical services in some areas, leading to delays in referrals and the management of UDT. There may also be reduced awareness among parents of the need for early evaluation of the UDT condition, leading to delays in seeking care at a medical facility. There may also be suboptimal screening available for neonates and postnatal infants to identify UDTs during the early months of life, resulting in many children presenting later during a well-child visit for a school-age examination. Variability in the referral process for children with UDTs, along with varying levels of healthcare resources for Jordan and those countries with better resources, could also contribute to delays in diagnosis and treatment at the time of diagnosis by a surgeon.

The results from this study have significant importance for healthcare and public health. For example, if we delay the diagnosis and treatment of UDT, we may increase the risk of decreased fertility, potential for testicular cancer, and psychosocial consequences later in life[13,17]. Consequently, our findings emphasize the need for improved neonatal screening, increased physician and parent awareness about UDT, and improved referral processes to ensure timely evaluation/treatment of UDT. The observed epidemiological differences also support the need to collect region-specific data on pediatric surgical cases to inform better practices and policies for healthcare planning in Jordan and throughout the greater Middle East.

There are several limitations to consider. First, because this study was conducted at a single tertiary referral center, it reduces its generalizability. It introduces bias because individuals who were referred for delicate or long-standing problems were more likely to be referred there for treatment. Second, the study examined only surgically treated patients, which does not reflect the true incidence of hernias or UDT in Jordan, as no information on patients who may have been treated with conservative measures or at other centers was collected. Third, due to the retrospective nature of the study, missing records or incomplete information led to missing data, and there was also a relative lack of data on the number of adolescents in this cohort; thus, it is difficult to make age-specific comparisons in the older groups.

Although this study has limitations, it offers important insights into the epidemiology of pediatric hernias and UDT in Jordan, particularly in the Al-Salt area. As this collection is the largest of its kind and spans multiple years, the findings can be relied upon with confidence. This research represents one of the earliest attempts to assess the epidemiology of pediatric surgical procedures in Jordan and will provide baseline data for ongoing national studies on this topic. Future studies should establish multicenter registries and examine the country’s referral practices for pediatric patients to ensure adherence to international guidelines on the optimal timing of orchidopexy[7-13].

CONCLUSION

This retrospective study from Al-Hussain New Salt Hospital demonstrated distinct age- and sex-dependent distributions of pediatric hernias and UDT and revealed that the most common diagnosis was right-sided inguinal hernia. UDT was more common in older age groups, especially adolescents and children, which may reflect delayed diagnosis compared with Western populations. There are strong links between age group and diagnosis, as well as between sex and diagnosis. These links show that disease presentation follows a similar pattern. These results highlight the necessity of enhancing early detection and refining referral mechanisms within the local healthcare system. This study illustrates surgical presentation rather than population incidence.