What are the symptoms of a hydrocele?

Hydrocele Symptoms

A hydrocele presents primarily as a painless scrotal swelling that may cause discomfort when it grows to a significant size, potentially leading to difficulty in walking and reduced quality of life. 1

Clinical Presentation

Hydrocele is defined as an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testis. The key symptoms and characteristics include:

• Painless scrotal swelling - The most common and primary symptom
• Fluctuant mass - The swelling typically feels like a fluid-filled sac
• Translucent on transillumination - A classic diagnostic finding
• Potential discomfort when the hydrocele grows large
• Difficulty walking with very large hydroceles
• Scrotal heaviness sensation

In some cases, a hydrocele may be reactive to underlying conditions, particularly:

• As a complication of epididymitis 2
• Following varicocelectomy 3
• Rarely, as a reaction to an underlying testicular tumor 4

Types of Hydrocele

Hydroceles can be classified into two main types:

1. Primary (Idiopathic) Hydrocele:

   • Results from an imbalance in fluid production and reabsorption in the tunica vaginalis
   • Most common in adolescents and adults 3
   • Typically non-communicating with the peritoneal cavity

2. Secondary Hydrocele:

   • Associated with underlying pathology such as:
     • Infection (epididymitis/epididymo-orchitis)
     • Post-surgical (especially after varicocelectomy)
     • Trauma
     • Testicular tumors (rare but important consideration)

Diagnostic Considerations

The diagnosis of hydrocele is primarily clinical but should include:

• Physical examination: Identifying a non-tender, fluctuant scrotal mass that transilluminates
• Ultrasound: Essential when:
  • The testicle cannot be properly palpated
  • There is any suspicion of underlying pathology
  • The hydrocele is complex or has septations 4
  • To rule out testicular torsion in cases with acute pain 2

Important Clinical Pearls and Pitfalls

1. Beware of "complex hydrocele" findings on ultrasound, especially in young men, as this may rarely represent an underlying testicular tumor 4

2. Recurrent hydroceles despite drainage may indicate:

   • Communication with the peritoneal cavity
   • Underlying inflammatory process
   • Need for definitive surgical management 5

3. Acute onset of scrotal pain with a hydrocele requires urgent evaluation to rule out testicular torsion, which is a surgical emergency 2

4. Hydroceles in the setting of epididymitis are reactive and typically resolve with treatment of the underlying infection 2

Management Considerations

Treatment depends on symptoms and underlying cause:

• Observation for asymptomatic or small hydroceles
• Aspiration and sclerotherapy with agents like doxycycline (84% success rate with a single treatment) 6
• Surgical hydrocelectomy for:
  • Large symptomatic hydroceles
  • Recurrent hydroceles despite aspiration
  • Hydroceles with suspected underlying pathology

When a hydrocele causes significant discomfort or impacts quality of life, intervention is warranted to prevent ongoing symptoms and potential complications 1.