What is the management for hydrocele?

Management of Hydrocele

Hydrocele should be managed surgically through hydrocelectomy for definitive treatment in symptomatic cases, while aspiration and sclerotherapy can be considered as a non-surgical alternative with an 84% success rate for simple, non-septated hydroceles.

Types and Etiology

Hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testis. Hydroceles can be classified into:

1. Primary (Idiopathic) Hydrocele: Results from an imbalance between secretion and reabsorption of fluid from the tunica vaginalis

2. Secondary Hydrocele: Associated with underlying conditions such as:

   • Infection (epididymitis, orchitis)
   • Trauma
   • Testicular tumor
   • Lymphatic obstruction
   • Filariasis (in endemic regions) 1

Diagnosis

The diagnosis of hydrocele is based on:

• Clinical presentation: Painless scrotal swelling that transilluminates
• Ultrasound: Confirms the diagnosis and rules out underlying pathology such as testicular masses

Management Approach

Conservative Management

• Appropriate for:
  • Asymptomatic small hydroceles
  • Congenital hydroceles in infants (typically resolve spontaneously within 18-24 months) 1

Aspiration and Sclerotherapy

• Success rate: 84% with a single treatment using doxycycline as sclerosing agent 2
• Indications:
  • Simple, non-septated hydroceles
  • Patients who are poor surgical candidates
  • Patients who prefer non-surgical treatment
• Technique: Aspiration of fluid followed by injection of a sclerosing agent (doxycycline)
• Advantages: Avoids surgical complications, can be performed under local anesthesia
• Limitations: Risk of recurrence, infection, pain

Surgical Management

Surgical intervention is indicated for:

• Symptomatic hydroceles (discomfort, cosmetic concerns)
• Large hydroceles
• Suspected underlying pathology
• Failed sclerotherapy

Surgical Techniques:

1. Lord's Repair:

   • Lowest overall complication rate (particularly hematoma)
   • Suitable for large hydroceles (up to 2.4L reported)
   • Involves plication of the sac without excision 3

2. Hydrocelectomy (Excision technique):

   • Complete excision of the hydrocele sac
   • Most commonly performed technique (46% of cases in comparative studies) 3

3. Jaboulay's Procedure (Bottleneck repair):

   • Eversion and suturing of the sac behind the testicle
   • Used in 26% of cases in comparative studies 3

4. Pull-through Technique:

   • Newer technique allowing removal of large hydrocele sacs through small incision
   • Minimal dissection under direct vision
   • Early recovery with minimal complications 4

Recurrence and Complications:

• Recurrence rate: Approximately 6% across all techniques 3
• Complications:
  • Hematoma (lowest with Lord's repair)
  • Infection (3-4%)
  • Persistent scrotal edema
  • Chronic pain
  • Decreased fertility (rare)

Anesthesia Considerations

Most hydrocele repairs can be performed under:

• Local anesthesia with sedation (93% good tolerance reported) 5
• Spinal anesthesia
• General anesthesia (typically reserved for complex cases or patient preference)

Special Considerations

• Filariasis-associated hydrocele: In endemic regions, treatment of the underlying infection with antiparasitic medication is necessary before addressing the hydrocele 1

• Hydrocele in children: Most congenital hydroceles resolve spontaneously by 18-24 months of age. Surgical intervention is indicated if the hydrocele persists beyond 2 years or if there is a communicating hydrocele with risk of hernia 1

Follow-up

• Post-surgical patients should be followed for at least 6 months to monitor for recurrence
• Mild scrotal edema typically resolves within days after surgery
• Patients can usually resume normal activities within 3-21 days (average 6 days) after surgery 4