Who manages hydroceles?

Management of Hydrocele

Hydroceles should be managed by urologists, with surgical intervention (hydrocelectomy) being the gold standard treatment for symptomatic cases in adults, while pediatric hydroceles require evaluation and management by pediatric urologists. 1, 2

Definition 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. Hydroceles can be classified as:

• Primary (idiopathic): Result from imbalance in fluid production and reabsorption
• Secondary: Due to underlying conditions such as trauma, infection, or tumors
• Congenital: Associated with patent processus vaginalis in infants and children
• Acquired: Develop later in life, often idiopathic in adults

Diagnostic Approach

Diagnosis is primarily clinical, but should include:

• Assessment of size, tenderness, and transillumination
• Evaluation for fluctuation in size (suggesting patent processus vaginalis)
• Scrotal ultrasonography to rule out underlying testicular pathology, especially when the testicle is not easily palpable 3

Management Algorithm

Adult Hydroceles

1. Asymptomatic small hydroceles:

   • Observation by primary care physician or urologist
   • No intervention required unless symptoms develop

2. Symptomatic hydroceles (causing discomfort, cosmetic concerns, or difficulty walking):

   • Referral to urologist for definitive management
   • Treatment options:
     • Surgical hydrocelectomy (gold standard): Either Lord's plication or excision technique 1
     • Aspiration and sclerotherapy: Alternative non-surgical option with 84% success rate using doxycycline as sclerosing agent 4

3. Recurrent hydroceles:

   • Require urological evaluation for potential underlying causes
   • Surgical correction is typically necessary 5

Pediatric Hydroceles

1. Infants and children:

   • Should be managed by a pediatric urologist 2
   • Congenital hydroceles often resolve spontaneously by age 1-2 years
   • Surgical repair indicated for persistent hydroceles beyond age 1-2 years

2. Adolescents:

   • Evaluation and management by a pediatric urologist
   • Open hydrocelectomy via scrotal incision is standard treatment for idiopathic hydroceles 3
   • Post-varicocelectomy hydroceles may be observed initially with or without aspiration 3

Special Considerations

• Complicated cases: Septated hydroceles or those with suspected underlying pathology require urological management
• Post-surgical hydroceles: May occur after varicocelectomy, with higher risk in non-artery-sparing procedures 3
• Emergency situations: Acute painful scrotal swelling requires immediate evaluation to rule out testicular torsion, which is a surgical emergency 2

Treatment Efficacy and Complications

• Surgical hydrocelectomy: Success rate >90% but carries risks of hematoma, injury to epididymis, vas deferens, or cord structures 1
• Aspiration and sclerotherapy: 84% success rate with single treatment, avoiding hospital expense and surgical complications 4
• Conservative management: Appropriate only for asymptomatic cases or when surgery is contraindicated

In conclusion, while primary care physicians may diagnose hydroceles, definitive management typically falls under the domain of urologists for adults and pediatric urologists for children, with surgical intervention being the standard of care for symptomatic cases.