> Table of Contents > Hydrocele
Hydrocele
Jared M. Patton, MD, MS
John E. Laird, MD, FAAFP
image BASICS
DESCRIPTION
A collection of fluid between the parietal and visceral layers of the tunical vaginalis within the scrotum
  • Communicating hydrocele (patent processus vaginalis)
    • Direct communication with the peritoneal cavity
    • Contains peritoneal fluid
    • Almost always with associated indirect inguinal hernia
    • Decreases in size with recumbent position
  • Noncommunicating hydrocele (the processus vaginalis is not patent)
    • No direct connection to the peritoneal cavity
    • Fluid contained is from the mesothelial lining.
    • Can be isolated to the cord with the distal and proximal portions of the processus vaginalis closed
  • Acute hydrocele: fluid collection resulting from an acute process within the tunica vaginalis, typically involving only the scrotum
  • System(s) affected: Urogenital
Pediatric Considerations
In a communicating hydrocele, consider contralateral inguinal exploration to rule out an occult indirect hernia.
EPIDEMIOLOGY
Predominant age: childhood (1)
Incidence
Estimated at 0.7-4.7% of male infants
Prevalence
  • 1,000/100,000
  • Estimated at 1% of adult men
ETIOLOGY AND PATHOPHYSIOLOGY
  • Incomplete closure of the processus vaginalis trapping peritoneal fluid anywhere along the length of the tunica vaginalis
  • Failure of closure of the processus vaginalis maintaining a communication to the peritoneal cavity
  • Imbalance of the secretion and reabsorption of fluid from the lining of the tunica vaginalis
  • Infection
  • Tumors
  • Trauma
  • Ipsilateral renal transplantation
RISK FACTORS
  • Ventriculoperitoneal shunt
  • Exstrophy of the bladder
  • Cloacal exstrophy
  • Ehlers-Danlos syndrome
  • Peritoneal dialysis
COMMONLY ASSOCIATED CONDITIONS
  • Testicular tumors
  • Scrotal trauma
  • Ventriculoperitoneal shunt
  • Nephrotic syndrome
  • Renal failure with peritoneal dialysis
image DIAGNOSIS
PHYSICAL EXAM
  • Swelling in the scrotum or inguinal canal
  • Scrotal mass, usually fluctuant
  • Fluctuation in size with change of position (communicating hydrocele)
  • Scrotal mass that transilluminates
DIFFERENTIAL DIAGNOSIS
  • Indirect inguinal hernia
  • Orchitis
  • Epididymitis
  • Varicocele
  • Traumatic testicular injury
  • Testicular torsion or torsion of appendix testes
  • Testicular neoplasm
DIAGNOSTIC TESTS & INTERPRETATION
  • Inguinoscrotal ultrasound (US): can demonstrate the presence of bowel (e.g., distinguish incarcerated hernia from a hydrocele of the cord) as well as the presence of testicular torsion
  • Testicular MRI when US is unable to distinguish etiology
  • Doppler US or testicular nuclear scan can distinguish testicular torsion.
Diagnostic Procedures/Other
Test Interpretation
Patent processus vaginalis on imaging in communicating hydroceles
image TREATMENT
ISSUES FOR REFERRAL
  • Urology referral for symptomatic adults or if underlying diagnosis is unclear
  • Pediatric urology/surgery referral for children with symptomatic noncommunicating hydrocele
  • Children with communicating hydroceles can be expectantly managed until at least 2 years of age to allow time for spontaneous resolution unless there is a concern for inguinal hernia (1)[C].
  • New-onset hydrocele in late childhood and preadolescent patients typically resembles the adult type hydrocele pathology (2)[B].
SURGERY/OTHER PROCEDURES
  • Children: Surgical treatment is generally deferred until 2 years of age as many hydroceles will spontaneously resolve. Some evidence shows that delaying longer than 2 years may be appropriate and decrease unnecessary surgery (1)[C].
    • When surgery is indicated, children with communicating hydroceles may undergo either open or laparoscopic approach.
      • Open inguinal approach involves ligation of the processus vaginalis and excision, distal splitting, or drainage of hydrocele sac (in a hydrocele of cord, the sac can be completely removed) (3)[B]
      • Open scrotal approach involves ligation and removal of the processus vaginalis. The benefit of this approach is improved cosmesis and decreased operative time (4)[B].
      • Laparoscopic repair offers the benefit of contralateral exploration and repair with low long-term recurrence rates and similar operative times as open procedures (5)[B].
  • P.499

  • Adults: No therapy is needed unless the hydrocele causes discomfort or unless there is a significant underlying cause such as a tumor (6).
    • If resection is indicated, a scrotal approach with resection of hydrocele sac has the highest complication rate but lowest recurrence rate (7)[C].
    • Jaboulay-Winkelmann procedure (for a thick hydrocele sac): The hydrocele sac is wrapped posteriorly around cord structures (7)[C],(8)[A].
    • Lord procedure (for a thin hydrocele sac): Radial sutures are used to gather the hydrocele sac posterior to testis and epididymis (7)[C],(8)[A].
    • Aspiration of the hydrocele with instillation of a sclerosing agent has been successfully used in adults.
      • Aspiration with instillation of 1 to 4 mg of polidocanol has demonstrated a cure rate of 56% after the first treatment and 89% after the second treatment (9)[A].
      • The benefit of aspiration versus surgery is a decrease in cost and operative complications. (9)[A].
    • Hydrocelectomy may be performed endoscopically via a transscrotal approach; it involves cauterization of the entire parietal surface of the tunical vaginalis (10)[A].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Open inguinal or scrotal approach is typically performed as an outpatient.
  • Laparoscopic approach may require 24-hour admission for postoperative monitoring.
  • Sclerotherapy is a same-day office procedure.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Depending on method of treatment, initial follow-up is generally in the first 4 to 6 weeks.
  • With sclerotherapy follow-up for confirmation of resolution or to proceed with retreatment
  • Postoperative follow-up at 2 to 4 weeks and subsequent 2- to 3-month intervals until resolution of any postoperative complications
REFERENCES
1. Hall NJ, Ron O, Eaton S, et al. Surgery for hydrocele in children—an avoidable excess? J Pediatr Surg. 2011;46(12):2401-2405.
2. Koutsoumis G, Patoulias I, Kaselas C. Primary new-onset hydroceles presenting in late childhood and pre-adolescent patients resemble the adult type hydrocele pathology. J Pediatr Surg. 2014;49(11):1656-1658.
3. Gahukamble DB, Khamage AS. Prospective randomized controlled study of excision versus distal splitting of hernial sac and processus vaginalis in the repair of inguinal hernias and communicating hydroceles. J Pediatr Surg. 1995;30(4):624-625.
4. Alp BF, Irkilata HC, Kibar Y, et al. Comparison of the inguinal and scrotal approaches for the treatment of communicating hydrocele in children. Kaohsiung J Med Sci. 2014;30(4):200-205.
5. Yang XD, Wu Y, Xiang B, et al. Ten year experience of laparoscopic repair of pediatric hydrocele and the long-term follow-up results [published online ahead of print July 14, 2015]. J Pediatr Surg.
6. Swartz MA, Morgan TM, Krieger JN. Complications of scrotal surgery for benign conditions. Urology. 2007;69(4):616-619.
7. Ku JH, Kim ME, Lee NK, et al. The excisional, plication and internal drainage techniques: a comparison of the results for idiopathic hydrocele. BJU Int. 2001;87(1):82-84.
8. Miroglu C, Tokuc R, Saporta L. Comparison of an extrusion procedure and eversion procedures in the treatment of hydrocele. Int Urol Nephrol. 1994;26(6):673-679.
9. Lund L, Kloster A, Cao T. The long-term efficacy of hydrocele treatment with aspiration and sclerotherapy with polidocanol compared to placebo: a prospective, double-blind, randomized study. J Urol. 2014;191(5):1347-1350.
10. Emir L, Sunay M, Dadali M, et al. Endoscopic versus open hydrocelectomy for the treatment of adult hydroceles: a randomized controlled clinical trial. Int Urol Nephrol. 2011;43(1):55-59.
Codes
&NA;
ICD10
  • N43.3 Hydrocele, unspecified
  • N43.2 Other hydrocele
  • P83.5 Congenital hydrocele
Clinical Pearls
&NA;
  • A hydrocele can usually be diagnosed by physical exam and transillumination. If there is any concern for other underlying process, a formal US is recommended.
  • Aspirating a hydrocele is not indicated as the primary treatment due to high recurrence rate.
  • Attempted aspiration of an unconfirmed hydrocele could lead to bowel injury in an undiagnosed inguinal hernia.
  • Laparoscopic repair in children offers the benefit of contralateral exploration and repair.
  • Expectant management of children with hydrocele until >2 years of age is acceptable to allow sufficient time for spontaneous resolution.