What is the next step in managing bilateral hydrocele (fluid accumulation in the testicles), left epididymal cyst (abnormal fluid-filled structure near the testis), and left-sided varicocele (enlargement of the veins in the scrotum)?

Management of Bilateral Hydrocele, Left Epididymal Cyst, and Left-sided Varicocele

For patients with bilateral hydrocele (more prominent on the right side), left epididymal cyst, and left-sided varicocele, surgical intervention is recommended for the hydrocele and epididymal cyst, while the varicocele may require treatment only if associated with infertility or pain. 1

Diagnostic Evaluation

Before proceeding with treatment, a proper evaluation should include:

1. Scrotal ultrasound: Already performed to identify the conditions, but should be reviewed to:

   • Confirm the size and characteristics of the hydroceles
   • Evaluate the epididymal cyst dimensions (particularly if >5 cm)
   • Assess the grade of varicocele
   • Rule out any underlying testicular masses 1

2. Pain assessment: Determine if any of these conditions are causing discomfort or pain

3. Fertility concerns: If the patient has fertility concerns, a semen analysis should be performed to assess if the varicocele is affecting sperm parameters 1

Treatment Algorithm

For Bilateral Hydrocele:

• Surgical hydrocelectomy via scrotal approach is the standard treatment for symptomatic hydroceles 2
• Alternative: Sclerotherapy may be considered as a less invasive option with success rates of 76-94% 3, 4
  • Involves aspiration of fluid followed by injection of a sclerosing agent
  • Can be performed as an outpatient procedure
  • May require multiple sessions for complete resolution

For Left Epididymal Cyst:

• Surgical excision if the cyst is symptomatic or >5 cm in diameter
• Percutaneous sclerotherapy is a valid alternative with reported 84% success rate after one or two sessions 5
  • Performed under ultrasound guidance
  • Uses sclerosing agents like 3% Polidocanol
  • Avoids surgical complications
  • Lower cost than surgery

For Left-sided Varicocele:

• Observation is appropriate if:

  • The varicocele is asymptomatic
  • There are no fertility concerns
  • No testicular atrophy is present 1

• Surgical correction should be considered if:

  • The varicocele is painful
  • There is evidence of abnormal semen parameters in an infertile couple
  • There is evidence of testicular atrophy 1

Important Considerations

1. Hydrocele after varicocele repair: Be aware that varicocele repair itself can lead to hydrocele formation in some cases (reported in up to 8% of cases) due to lymphatic obstruction 6

2. Ultrasound limitations: Routine use of ultrasound to identify non-palpable varicoceles is discouraged as treatment of these is not associated with improvement in fertility 1

3. Right-sided varicocele: Although not mentioned in this case, it's worth noting that isolated right varicoceles may warrant abdominal imaging to rule out retroperitoneal pathology, though this is not necessary for left or bilateral varicoceles 1

4. Epididymitis vs. epididymal cyst: Ensure the epididymal cyst is not confused with epididymitis, which would require antibiotic treatment rather than surgical intervention 1

Follow-up

After treatment:

• Follow-up ultrasound at 3-6 months to assess resolution
• If sclerotherapy was performed for either hydrocele or epididymal cyst, consider repeat procedure if there is persistence of the condition 5, 3
• If varicocele was treated and fertility was a concern, repeat semen analysis at 3-6 months post-procedure

By addressing each condition appropriately, both the patient's symptoms and any potential impact on fertility can be effectively managed.