What is the treatment for a hydrocele?

Hydrocele Treatment

The first-line treatment for hydrocele depends on symptoms and patient characteristics: observation for asymptomatic small hydroceles, surgical hydrocelectomy for symptomatic or large hydroceles, and sclerotherapy as an alternative for high-risk surgical patients. 1

Diagnosis and Classification

Hydrocele is defined as an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testicle 1, 2. Before treatment, proper diagnosis is essential:

• Clinical evaluation: Assess for size, symptoms, and fluctuation in size (which may indicate a patent processus vaginalis)
• Ultrasound: Mandatory for non-palpable testicles to rule out underlying testicular masses 1, 3

Hydroceles can be classified as:

• Primary/Idiopathic: Due to imbalance in fluid production and reabsorption
• Secondary: Due to underlying conditions (post-varicocelectomy, trauma, infection)
• Congenital: Present at birth due to patent processus vaginalis

Treatment Algorithm

1. Asymptomatic Hydroceles

• Recommendation: Observation and reassurance 1
• No intervention needed unless patient develops symptoms or complications

2. Pediatric/Congenital Hydroceles

• First approach: Observation for 18-24 months as most resolve spontaneously 1
• Surgical intervention indicated if:
  • Persistence beyond 2 years of age
  • Association with inguinal hernia
  • Communicating hydrocele with risk of incarceration 1

3. Symptomatic Adult Hydroceles

Surgical Management (First-line for most patients)

• Open hydrocelectomy via scrotal incision is the standard approach 1, 3
• Indications:
  • Symptomatic hydroceles causing discomfort
  • Large hydroceles affecting daily activities
  • Failed sclerotherapy
  • Cosmetic concerns 1
• Success rate: Approximately 84% (16% recurrence rate) 1
• Potential complications: Hematoma, infection, chronic pain, injury to scrotal contents, recurrence 1

Sclerotherapy (Alternative approach)

• Indications:
  • Elderly patients
  • High surgical risk patients
  • Patient preference for non-surgical approach
  • Non-septated simple hydroceles 1, 4
• Procedure: Local anesthesia, aspiration of fluid, injection of sclerosing agent 1, 4, 5
• Success rate: 84% with a single treatment 1, 4
• Advantages:
  • Avoids hospital expenses
  • Fewer complications compared to surgery
  • Outpatient procedure 1, 4
• Complications: Moderate pain, infection, recurrence 1

Special Considerations

Post-Varicocelectomy Hydroceles

• More common with non-artery-sparing procedures or those without microsurgical aid 3
• Initial management: Observation with or without aspiration
• For persistent large hydroceles: Open hydrocelectomy 3

Recurrent Hydroceles

• Require evaluation for patent processus vaginalis, underlying testicular pathology 1
• Management options:
  • Repeat hydrocelectomy with complete excision of sac
  • Consider Lord's plication technique 1
  • Communicating hydroceles require surgical repair due to hernia risk 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

Clinical Pitfalls to Avoid

• Failing to perform ultrasound in non-palpable testicles, potentially missing underlying malignancy
• Attempting sclerotherapy for septated or complex hydroceles, which have lower success rates
• Neglecting to evaluate for underlying causes in secondary hydroceles
• Performing unnecessary surgery on congenital hydroceles before allowing time for spontaneous resolution