What are the management options for hydrocele?

Management of Hydrocele

The most effective management approach for hydrocele depends on the type, size, and symptoms, with surgical repair (hydrocelectomy) being the definitive treatment for symptomatic cases that don't resolve spontaneously.

Types and Pathophysiology

Hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testis. There are two main types:

1. Primary (Idiopathic) Hydrocele:

   • Results from imbalance between fluid secretion and reabsorption in the tunica vaginalis
   • Common in adults and adolescents

2. Secondary Hydrocele:

   • Communicating/Congenital: Due to patent processus vaginalis (PPV)
   • Reactive: Secondary to infection, trauma, or testicular pathology

Diagnostic Evaluation

• Physical examination: Transillumination to distinguish from solid masses
• Ultrasound: Mandatory when:
  • Testicle is not palpable
  • Suspicion of underlying testicular mass
  • Need to differentiate from other scrotal pathologies (hernia, varicocele)

Management Algorithm

1. Congenital Hydrocele in Infants and Children

• Observation for up to 18-24 months as most resolve spontaneously 1
• Surgical repair indicated if:
  • Persists beyond 24 months
  • Associated with inguinal hernia
  • Large or symptomatic

2. Adult/Adolescent Idiopathic Hydrocele

• Small, asymptomatic: Observation

• Symptomatic or enlarging: Treatment options include:

  a) Hydrocelectomy (definitive treatment):

  • Scrotal approach for simple hydrocele
  • Success rate >90%
  • Complications include hematoma, infection, and recurrence

  b) Aspiration and sclerotherapy:

  • Alternative for poor surgical candidates
  • 84% success rate with single treatment using doxycycline 2
  • Less invasive but higher recurrence rate than surgery
  • Contraindicated in communicating hydroceles

3. Secondary Hydrocele

• Treat underlying cause (infection, trauma, tumor)
• For post-varicocelectomy hydrocele:
  • Initial observation with or without aspiration
  • Surgical correction for persistent large hydroceles 3, 4

Special Considerations

Hydrocele in Filariasis

• May be associated with lymphatic filariasis causing hydrocele and lymphedema 1
• Requires treatment of the underlying parasitic infection

Urgent Management Scenarios

• Acute painful hydrocele: Rule out testicular torsion with Doppler ultrasound 1
• Hydrocele with suspected infection: Evaluate for epididymitis or orchitis 1

Surgical Approaches

1. Open Hydrocelectomy: Standard treatment via scrotal incision
2. Laparoscopic Repair: Particularly useful for communicating hydroceles in children 5
3. Lord's Plication: Minimal dissection technique for selected cases

Post-Treatment Follow-up

• Monitor for recurrence
• Evaluate for complications (hematoma, infection)
• For children who undergo varicocele repair, long-term follow-up is recommended as hydrocele may develop months to years after surgery 4

Pitfalls and Caveats

• Always rule out testicular malignancy in adults with new-onset hydrocele
• Avoid aspiration alone without sclerotherapy as recurrence is nearly universal
• In cases of hydrocele with scrotal pain, consider other diagnoses including torsion, epididymitis, or orchitis
• For patients on anticoagulation requiring hydrocele surgery, appropriate perioperative management is necessary 1