What is the treatment for a hydrocele?

Hydrocele Treatment

The standard treatment for symptomatic hydroceles is surgical hydrocelectomy, while observation is recommended for asymptomatic small hydroceles, and sclerotherapy is an effective alternative for patients who are poor surgical candidates or prefer non-surgical approaches. 1

Diagnosis and Evaluation

Before initiating any treatment, proper diagnosis is essential:

• Ultrasound is mandatory to:
  • Confirm the diagnosis of hydrocele
  • Rule out underlying testicular masses or pathology
  • Assess size and characteristics of the hydrocele 1
  • Differentiate from other scrotal conditions like testicular torsion or epididymitis 2

Treatment Algorithm

1. Congenital Hydroceles

• Observation is recommended for congenital hydroceles in children as most resolve spontaneously within 18-24 months 1
• Surgical intervention is indicated if:
  • Persistence beyond 2 years of age
  • Associated with inguinal hernia
  • Communicating hydrocele with risk of incarceration 1

2. Asymptomatic Hydroceles in Adults

• Observation and reassurance are appropriate for small, asymptomatic hydroceles 1
• Regular follow-up to monitor for changes in size or development of symptoms

3. Symptomatic or Large Hydroceles

• Surgical hydrocelectomy (first-line treatment) is indicated for:

  • Symptomatic hydroceles causing discomfort
  • Large hydroceles affecting daily activities
  • Cosmetic concerns 1
  • Failed sclerotherapy

• Sclerotherapy (alternative treatment) is appropriate for:

  • Elderly patients
  • High surgical risk patients
  • Patients who prefer non-surgical approaches
  • Non-septated simple hydroceles 1, 3

Treatment Details

Surgical Management

• Open hydrocelectomy via scrotal incision is the gold standard with the lowest recurrence rate 1, 4
• Surgical approach provides definitive treatment with approximately 16% recurrence rate after a single procedure 1
• Possible complications include hematoma, infection, chronic pain, injury to scrotal contents, and recurrence 1

Sclerotherapy

• Success rate of 84% with a single treatment 1, 3
• Procedure involves:
  • Local anesthesia (can use EMLA cream for painless needle insertion) 5
  • Aspiration of fluid
  • Injection of sclerosing agent (e.g., doxycycline) 3
• Advantages include:
  • Avoids hospital expenses
  • Fewer complications compared to surgery
  • Outpatient procedure 3
• Possible complications include moderate pain, infection, and recurrence 1

Special Considerations

Post-Varicocelectomy Hydroceles

• Second most common cause of hydroceles in adolescents
• Initial management should include observation with or without aspiration
• Large persistent hydroceles require open hydrocelectomy 4

Recurrent Hydroceles

• Require careful evaluation for:
  • Patent processus vaginalis
  • Underlying testicular pathology
  • Incomplete prior treatment
• Management options include repeat hydrocelectomy with complete excision of sac 1

Follow-up Recommendations

• Post-sclerotherapy: Follow-up at 1-3 months to assess for recurrence 1
• Post-surgery: Follow-up at 2 weeks for wound check and then at 3-6 months to assess for recurrence 1

Pitfalls and Caveats

• Always rule out underlying testicular pathology before treatment, as hydroceles can mask testicular tumors 1, 4
• Sclerotherapy is contraindicated in septated hydroceles or those with suspected malignancy 3
• Recurrence rates are higher with sclerotherapy compared to surgical management, but sclerotherapy can be repeated 3
• Communicating hydroceles require surgical repair due to the risk of hernia development 1