Treatment of Hydrocele
Hydrocele treatment should be tailored based on type, size, and symptoms, with surgical hydrocelectomy being the standard treatment for symptomatic or persistent hydroceles, while aspiration and sclerotherapy can be considered as a non-surgical alternative for appropriate candidates.
Definition and Classification
A hydrocele is defined as an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testis 1. Hydroceles can be classified as:
- Primary (idiopathic): Most common in adults, affecting approximately 1% of men 2
- Secondary: Due to underlying conditions such as infection, trauma, or post-surgical complications
Diagnosis
Diagnosis is primarily clinical, but should include:
- Physical examination: Transillumination test is typically positive 2
- Ultrasound: Mandatory in cases with non-palpable testicles to rule out underlying testicular masses 1, 3
- Differential diagnosis: Important to distinguish from testicular torsion, epididymitis, or testicular tumors 4
Treatment Options
1. Conservative Management
- Appropriate for small, asymptomatic hydroceles
- Observation without intervention
- Indicated when hydrocele is not causing discomfort or cosmetic concerns
2. Aspiration and Sclerotherapy
This is an effective non-surgical option with several advantages:
- Success rate: 84% resolution with a single treatment using doxycycline as the sclerosing agent 5
- Procedure: Involves needle aspiration of fluid followed by injection of a sclerosing agent
- Sclerosing agents:
- Benefits: Procedure simplicity, low cost, rapid recovery, minimal side effects 2
- Anesthesia: Can be performed under local anesthesia, including EMLA cream (lidocaine and prilocaine) 6
- Best candidates: Patients with simple, non-septated hydroceles 5
3. Surgical Management (Hydrocelectomy)
- Gold standard treatment for persistent or symptomatic hydroceles 1, 3
- Technique: Open hydrocelectomy via scrotal incision is the standard approach 1
- Indications:
- Large or symptomatic hydroceles
- Failed sclerotherapy
- Hydroceles with suspected underlying pathology
- Hydroceles causing significant discomfort or cosmetic concerns
4. Management of Post-Varicocelectomy Hydrocele
- Initial management should include observation with or without aspiration
- Large persistent hydroceles may require open hydrocelectomy 1
Treatment Algorithm
Asymptomatic, small hydrocele:
- Observation and reassurance
Symptomatic hydrocele:
- First consideration: Patient preference, age, and comorbidities
- Non-surgical candidate or preference for non-surgical approach: Aspiration and sclerotherapy
- Surgical candidate with preference for definitive treatment: Hydrocelectomy
Failed sclerotherapy:
- Consider repeat sclerotherapy (success in some cases) 5
- Proceed to hydrocelectomy if second sclerotherapy fails
Important Considerations
- Ultrasound is essential before any intervention to rule out underlying testicular pathology 1, 3
- Recurrence is possible after both sclerotherapy and surgery
- Pain management should be addressed, particularly after surgical intervention
- Follow-up is recommended to assess for recurrence and complications
Complications to Monitor
- Sclerotherapy: Moderate pain (typically resolves in 2-3 days), infection, recurrence 5
- Surgery: Hematoma, infection, chronic pain, injury to scrotal contents, recurrence
Hydrocelectomy remains the definitive treatment with the lowest recurrence rate, but aspiration and sclerotherapy offer a reasonable alternative for patients seeking to avoid surgery, with success rates approaching surgical outcomes while avoiding hospital expenses and surgical complications 5.