What are the diagnosis and treatment options for hydrocele and varicocele?

Diagnosis and Management of Hydrocele and Varicocele

Diagnosis

The diagnosis of both hydrocele and varicocele should primarily rely on thorough clinical examination, with ultrasound reserved for specific indications such as non-palpable testicles or when physical examination is difficult.

Varicocele Diagnosis

• Clinical examination:

  • Examine patient in both standing and supine positions
  • Varicoceles typically appear as "bag of worms" in the scrotum
  • Grade 3 (visible through scrotal skin), Grade 2 (palpable without Valsalva), Grade 1 (palpable with Valsalva)
  • 90% are left-sided due to anatomical factors 1

• Imaging:

  • Color Doppler ultrasound indicated when:
    • Physical examination is difficult (e.g., in obese patients)
    • Confirmation needed before repair
    • Post-treatment evaluation 2
  • Routine ultrasound for non-palpable varicoceles is discouraged 2
  • Abdominal imaging for isolated right varicoceles that are large, new-onset, or non-reducible 2

• Red flags requiring urgent evaluation:

  • Acute onset varicocele
  • Isolated right-sided varicocele (especially in men over 40)
  • Non-reducible varicocele
  • These may indicate retroperitoneal malignancy 1

Hydrocele Diagnosis

• Clinical examination:

  • Transillumination of scrotal swelling
  • Assessment for fluctuation in size (suggests patent processus vaginalis)
  • Evaluation of testicle palpability 3

• Imaging:

  • Scrotal ultrasonography mandatory when testicle is non-palpable to rule out underlying testicular mass 3

Treatment

Varicocele Management

Microsurgical varicocelectomy is the recommended treatment for symptomatic varicoceles, those associated with infertility with abnormal semen parameters, or when there is testicular atrophy, particularly for grade 3 varicoceles. 2

• Indications for treatment:

  • Documented infertility with abnormal semen parameters
  • Palpable varicocele with testicular size discrepancy/atrophy
  • Symptomatic pain or discomfort
  • Minimal or no female fertility factors 2

• Treatment options:

  1. Microsurgical varicocelectomy:

     • Improves semen parameters in 60-70% of cases
     • Lower risk of hydrocele formation compared to non-microsurgical approaches 2, 4

  2. Percutaneous embolization:

     • Truly minimally invasive alternative
     • Avoids lymphatic channels, reducing hydrocele risk
     • 91% success rate in resolving varicoceles
     • Excellent for pain resolution 5

  3. Laparoscopic varicocelectomy:

     • Higher risk of hydrocele formation (22.8-29.8%)
     • Lower risk when vessels are ligated but not divided (11.8% vs 31.1%) 4

• Special considerations:

  • Sperm banking before intervention, especially with significant testicular volume loss 2
  • Consider IVF with ICSI alongside or instead of repair for severe oligospermia 2

Hydrocele Management

Open hydrocelectomy via scrotal incision is the standard treatment for idiopathic hydroceles that are symptomatic or cosmetically concerning. 3

• Treatment options:

  1. Observation:

     • Appropriate for small, asymptomatic hydroceles
     • First-line for post-varicocelectomy hydroceles 3

  2. Aspiration with or without sclerotherapy:

     • Consider for post-varicocelectomy hydroceles
     • May be used for temporary relief 3

  3. Open hydrocelectomy:

     • Standard treatment for persistent, symptomatic hydroceles
     • Required for large persistent hydroceles after varicocelectomy 3

Post-Treatment Evaluation

• Varicocele:

  • Ultrasound evaluation 3-6 months after treatment
  • Repeat semen analysis 3-6 months post-treatment 2

• Hydrocele:

  • Clinical follow-up to assess resolution
  • Ultrasound if recurrence is suspected 3

Prevention of Complications

• Hydrocele formation after varicocelectomy:
  • Use microsurgical techniques with lymphatic sparing
  • Consider percutaneous embolization (0% hydrocele risk) 5
  • If using laparoscopic approach, ligate vessels without division 4
  • Hydrocele formation occurs in up to 29.8% of patients after laparoscopic varicocelectomy with longer follow-up 4
  • Hydroceles may develop an average of 18.2 months post-operation 6

Special Considerations

• Most men with left varicocele (approximately 80%) can father children without intervention 2
• Early treatment of grade 3 varicocele with testicular atrophy is recommended to prevent further decline in testicular function 2
• Patients with varicocele and fertility concerns should be referred to a urologist with expertise in fertility 1