What is a hydrocele?

Hydrocele: Definition and Management

A hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testicle, resulting from an imbalance in fluid production and reabsorption. 1

Types and Pathophysiology

Hydroceles can be classified into two main categories:

1. Congenital/Primary Hydrocele

   • Results from incomplete obliteration of the processus vaginalis
   • Common in infants and children
   • Types include:
     • Communicating hydrocele: Connected to the peritoneal cavity through a patent processus vaginalis (PPV)
     • Non-communicating hydrocele: Fluid collection isolated from the peritoneal cavity
     • Cord hydrocele: Located along the spermatic cord above the testicle 2

2. Secondary/Acquired Hydrocele

   • Develops due to inflammation, trauma, or other pathological processes
   • More common in adults
   • Can occur as a complication after procedures like varicocelectomy 1

Pathophysiology

The processus vaginalis normally obliterates and involutes during fetal development, leaving no communication between the peritoneal cavity and the scrotum. This involuted layer becomes the tunica vaginalis. Incomplete involution results in a patent processus vaginalis (PPV), allowing fluid to accumulate as a hydrocele 3.

In congenital hydroceles:

• The prevalence of PPV is highest during infancy (up to 80% in term male infants) and decreases with age
• Congenital hydroceles typically resolve spontaneously within 18-24 months 3

Clinical Presentation

Hydroceles typically present as:

• Painless, fluctuant scrotal swelling
• Translucent mass on transillumination
• May change in size throughout the day (if communicating)
• Usually non-tender unless complicated by infection or torsion

Diagnosis

Diagnosis is primarily clinical but may be supported by:

1. Physical examination:

   • Painless, fluctuant scrotal mass
   • Positive transillumination
   • Ability to get above the swelling (unlike hernias)

2. Ultrasound:

   • First-line imaging modality for scrotal conditions 3
   • Shows anechoic fluid collection surrounding the testicle
   • Can help rule out underlying testicular pathology
   • Essential when testicle is not palpable to exclude underlying masses 1

Management

Management depends on the patient's age and type of hydrocele:

1. Infants and Children:

   • Observation for most congenital hydroceles, as they typically resolve spontaneously by 12-24 months 4
   • Surgical intervention indicated if:
     • Hydrocele persists beyond 2 years of age
     • Associated with inguinal hernia
     • Causes discomfort or cosmetic concerns
     • Shows signs of communication with peritoneal cavity

2. Adults:

   • Hydrocelectomy via scrotal approach is the standard treatment for idiopathic hydroceles 1
   • Aspiration may be considered for temporary relief or in poor surgical candidates, but recurrence is common
   • Treatment of underlying cause for secondary hydroceles (e.g., infection, tumor)

Special Considerations

• Cord hydroceles (located along the spermatic cord) may require specific surgical approaches depending on whether they are encysted (non-communicating) or funicular (communicating) varieties 2
• Post-varicocelectomy hydroceles should initially be managed with observation with or without aspiration; persistent large hydroceles may require hydrocelectomy 1
• Ultrasound is mandatory in cases with non-palpable testicles to rule out underlying testicular masses 1

Complications

• Infection
• Discomfort due to size
• Cosmetic concerns
• Rarely, pressure effects on surrounding structures

Proper diagnosis and appropriate management based on patient age and hydrocele type are essential for optimal outcomes and to prevent unnecessary interventions for self-limiting conditions.