Treatment of Hydrocele
The standard treatment for symptomatic hydrocele is surgical hydrocelectomy, while asymptomatic hydroceles can be managed conservatively with observation. 1, 2
Definition and Classification
A hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testicle. Hydroceles can be classified as:
- Primary (idiopathic): Due to imbalance between fluid secretion and reabsorption
- Secondary: Associated with underlying conditions such as infection, trauma, or testicular tumors
Diagnosis
Diagnosis is primarily clinical, with key features including:
- Painless scrotal swelling
- Transillumination (positive)
- Ability to palpate above the swelling
- Normal testicular examination
Ultrasound with Doppler is indicated when:
- The testicle cannot be palpated separately
- There is suspicion of underlying testicular mass
- The hydrocele is associated with pain or rapid growth
- To differentiate from other scrotal pathologies 3, 4
Management Algorithm
1. Asymptomatic Hydroceles
- Conservative management with observation
- No intervention required unless the patient develops symptoms
2. Symptomatic Hydroceles
- Surgical hydrocelectomy via scrotal approach is the standard treatment 1
- Indications for surgery include:
- Discomfort or pain
- Large size causing difficulty with walking or activities
- Cosmetic concerns
- Suspicion of underlying pathology
3. Alternative Treatments
- Aspiration with sclerotherapy may be considered in:
- Elderly patients with comorbidities
- Patients who refuse surgery
- Recurrent hydroceles after surgery 5
- Note: Higher recurrence rates compared to surgery
Surgical Approaches
Open Hydrocelectomy (Standard Treatment)
- Scrotal incision with excision or plication of the hydrocele sac
- Lord's procedure (plication without excision) for smaller hydroceles
- Jaboulay's procedure (partial excision and eversion) for larger hydroceles
Aspiration with Sclerotherapy
- Less invasive option
- Various sclerosing agents can be used (tetracycline, fibrin adhesive)
- Higher recurrence rate compared to surgical treatment 5
Special Considerations
Pediatric Hydroceles
- Most congenital hydroceles resolve spontaneously by age 1-2 years
- Surgical repair indicated if persists beyond 2 years of age
- Associated with patent processus vaginalis requiring inguinal approach 4
Recurrent Hydroceles
- May indicate underlying pathology requiring further investigation
- Consider ultrasound to rule out testicular mass
- May require more extensive surgical exploration 6
Giant Hydroceles
- Can cause significant morbidity including difficulty walking, sexual dysfunction
- May require more complex surgical management
- Higher risk of complications during and after surgery 7
Complications of Treatment
- Hematoma
- Infection
- Recurrence (more common with aspiration than surgery)
- Chronic pain
- Injury to testicular vessels or vas deferens
Follow-up
- Routine follow-up at 2-4 weeks post-procedure
- Ultrasound if recurrence or new symptoms develop
- Long-term follow-up not typically required after successful treatment
The management of hydrocele should focus on addressing symptoms and ruling out underlying pathology, with surgical hydrocelectomy remaining the gold standard for definitive treatment of symptomatic cases.