What is the treatment (Tx) of hydrocele?

Treatment of Hydrocele

The treatment of hydrocele should be surgical hydrocelectomy for most cases, with aspiration and sclerotherapy as an alternative non-surgical option for patients who are poor surgical candidates or prefer to avoid surgery. 1

Types and Diagnosis

Hydrocele is defined as an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testis. Hydroceles can be classified as:

• Primary (idiopathic): Result from imbalance in fluid production and reabsorption
• Secondary: Due to underlying conditions like trauma, infection, or testicular tumors

Diagnosis is primarily clinical, but should include:

• Thorough history to determine if size fluctuates (suggesting patent processus vaginalis)
• Transillumination to confirm fluid-filled nature
• Scrotal ultrasound (mandatory for nonpalpable testicles) to rule out underlying testicular mass 2

Treatment Options

1. Conservative Management

• Appropriate for small, asymptomatic hydroceles
• Observation is reasonable for:
  • Congenital hydroceles in infants (often resolve spontaneously within 18-24 months) 3
  • Post-varicocelectomy hydroceles (initial management should include observation) 2

2. Aspiration and Sclerotherapy

• Success rate of 84% with a single treatment using doxycycline as sclerosing agent 4
• Advantages:
  • Avoids hospital expense and surgical complications
  • Minimally invasive
  • Can be performed in outpatient setting
• Best for:
  • Patients with comorbidities making surgery risky
  • Patients who prefer non-surgical approach
  • Non-septated simple hydroceles

3. Surgical Management (Hydrocelectomy)

• Gold standard treatment for persistent or symptomatic hydroceles
• Surgical techniques include:
  • Winkelmann procedure: Eversion of the sac behind the testis
  • Bergman procedure: Resection of the redundant tunica vaginalis
  • Pull-through technique: Newer method allowing removal of large hydrocele sacs through small incision 5

The pull-through technique has shown promising results with:

• Mean operative time of 27.3 minutes
• Minimal postoperative complications
• Early recovery (average return to normal activity in 6 days)
• 95% cure rate 5

Treatment Algorithm

1. For infants with congenital hydrocele:

   • Observe for spontaneous resolution until 18-24 months of age
   • Surgical repair only if persistent beyond 2 years

2. For adults with primary hydrocele:

   • Small, asymptomatic: Observation
   • Symptomatic or large:
     • First-line: Surgical hydrocelectomy (preferably with newer techniques like pull-through)
     • Alternative: Aspiration and sclerotherapy with doxycycline (84% success rate)

3. For secondary hydroceles:

   • Treat underlying cause (infection, trauma, tumor)
   • Consider surgical exploration if testicular malignancy suspected

Complications and Follow-up

Potential complications of surgical treatment include:

• Hematoma
• Infection
• Persistent swelling
• Chronic pain
• Decreased fertility

The pull-through technique may reduce these complications by minimizing dissection and allowing direct visualization of testicular structures 5.

Follow-up should include assessment for:

• Recurrence of hydrocele
• Wound healing
• Resolution of symptoms
• Testicular function

Special Considerations

• Always rule out testicular malignancy before proceeding with hydrocele treatment
• Consider resection of covering sheets of the testis as a prophylactic measure against recurrence 6
• For hydroceles occurring after varicocelectomy, initial management should include observation with or without aspiration 2