What is the treatment for a hydrocele?

Treatment of Hydrocele

The standard treatment for persistent or symptomatic hydroceles is surgical hydrocelectomy, which is considered the gold standard approach, typically performed via scrotal incision. 1

Diagnosis and Assessment

• Proper diagnosis is essential before treatment:
  • Ultrasound is mandatory for non-palpable testicles to rule out underlying testicular masses 1, 2
  • Differential diagnosis should distinguish hydroceles from testicular torsion, epididymitis, or tumors 1
  • Transillumination test can help confirm the diagnosis 3

Treatment Algorithm

1. Asymptomatic Small Hydroceles

• Observation and reassurance are recommended 1
• No intervention required unless the patient develops symptoms

2. Symptomatic or Large Hydroceles

Surgical Options (First-line for persistent cases)

• Open hydrocelectomy via scrotal incision is the standard approach 1, 2
  • Highest success rate
  • Lowest recurrence rate
  • Potential complications: hematoma, infection, chronic pain, injury to scrotal contents 1

Non-Surgical Alternatives

• Aspiration and sclerotherapy for appropriate candidates 1
  • Success rate of up to 84% with a single treatment using doxycycline 4
  • Advantages: avoids hospital expense and surgical complications 4
  • Sclerosing agents include:
    • Doxycycline (most evidence for success) 4
    • Polidocanol (shown effective in case reports) 3
    • Fibrin sealants (Tissucol) 5
  • Potential complications: moderate pain, infection, recurrence 1

3. Special Considerations

• Post-varicocelectomy hydroceles:

  • Initial management should include observation with or without aspiration
  • Large persistent hydroceles may require open hydrocelectomy 2

• Patient selection factors:

  • Age and comorbidities influence choice between surgical and non-surgical approaches 1
  • Patients with high surgical risk may benefit more from sclerotherapy

Clinical Pearls and Pitfalls

• Always perform ultrasound before any intervention to rule out underlying pathology 1
• Simple aspiration without sclerotherapy has high recurrence rates and is not recommended as definitive treatment 3
• Follow-up is essential after any treatment to assess for recurrence and complications 1
• For recurrent hydroceles after sclerotherapy, a second attempt may be successful, but surgical correction should be considered after multiple failures 4

Treatment Decision Framework

1. Assess symptoms and size of hydrocele
2. Rule out underlying pathology with ultrasound
3. Consider patient factors (age, comorbidities, surgical risk)
4. For symptomatic cases:
   • Low surgical risk: Consider hydrocelectomy (gold standard)
   • Higher surgical risk or patient preference for less invasive approach: Consider aspiration and sclerotherapy with doxycycline