What are the treatment options for hydrocele?

Treatment Options for Hydrocele

The gold standard treatment for hydrocele is open hydrocelectomy via scrotal incision, which provides definitive treatment with the lowest recurrence rate and allows direct visualization and treatment of any underlying pathology. 1

Initial Management Approach

Conservative Management

• Congenital hydroceles in children typically resolve spontaneously within 18-24 months
• Surgical repair is indicated for hydroceles that persist beyond 2 years of age, communicating hydroceles, or large symptomatic hydroceles 1

Treatment Options for Adults

1. Surgical Management (First-line for most patients)

   • Open hydrocelectomy via scrotal incision is the standard approach
   • Benefits:
     • Definitive treatment with lowest recurrence rate
     • Allows direct visualization and treatment of underlying pathology 1
   • Newer minimally invasive techniques:
     • Individualized minimally invasive treatment with smaller incisions (2-cm)
     • Quantitative approach based on hydrocele size (resection extent determined by maximum diameter of effusion)
     • Reduced complications (7.7% minor complications) with no recurrence or chronic pain reported 2

2. Aspiration and Sclerotherapy (Alternative to surgery)

   • Indicated for:
     • Poor surgical candidates
     • Patients who prefer to avoid surgery 1
     • Simple, nonseptated hydroceles 3
   • Success rates:
     • 84% success with a single treatment using doxycycline as sclerosant 3
   • Sclerosing agents options:
     • Doxycycline 3
     • Polidocanol (reported in case studies) 4
     • Fibrin sealant (Tissucol) 5

Special Considerations

Secondary Hydroceles

• Require treatment of underlying cause:
  • Infection (epididymo-orchitis)
  • Trauma
  • Testicular tumor
  • Post-varicocelectomy
  • Filariasis (in endemic regions) 1

Post-Varicocelectomy Hydrocele

• Initial management should include observation with or without aspiration
• Large persistent hydroceles require open hydrocelectomy 6

Diagnostic Evaluation

• Ultrasound with Doppler is essential to:
  • Confirm diagnosis
  • Rule out underlying pathology (especially testicular tumors)
  • Differentiate from other scrotal conditions 1

Potential Complications

Surgical Complications

• Hematoma
• Infection
• Persistent swelling
• Hydrocele recurrence
• Chronic pain 2
• Testicular atrophy (rates ranging from 9.1% to 47.5%) 1

Sclerotherapy Complications

• Moderate pain (typically resolves in 2-3 days)
• Recurrence (approximately 16% with single treatment) 3

Follow-up Care

• Regular monitoring to assess for recurrence
• Specific follow-up schedules recommended based on treatment approach:
  • Conservative management
  • Aspiration and sclerotherapy
  • Surgical repair 1

Clinical Pearls

• Always rule out underlying pathology before treating presumed idiopathic hydrocele
• Transillumination test helps differentiate hydrocele from solid masses
• For patients with scrotal pain after treatment, consider supportive measures:
  • Scrotal support/elevation
  • NSAIDs for anti-inflammatory effects
  • Application of heat or cold over the perineum 1