What is the treatment for a hydrocele?

Treatment of Hydrocele

Hydrocele treatment should be conservative initially with observation, followed by aspiration for symptomatic cases, and surgical hydrocelectomy reserved for persistent or large hydroceles that fail conservative management. 1, 2, 3

Diagnosis and Assessment

• Definition: A hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis of the testicle 2
• Diagnostic evaluation:
  • Clinical examination to confirm fluid collection in scrotum
  • Scrotal ultrasound with Doppler to:
    • Rule out testicular torsion or masses
    • Confirm diagnosis of hydrocele
    • Assess for any underlying pathology 1
  • Differentiate from other scrotal conditions using these features:

Feature	Hydrocele	Testicular Torsion
Onset	Gradual	Sudden
Pain relief with elevation	Yes (Prehn sign)	No
Cremasteric reflex	Present	Absent
Testicular position	Normal	High-riding
Doppler ultrasound	Normal blood flow	Decreased/absent blood flow

Treatment Algorithm

1. Conservative Management

• Observation is appropriate for:
  • Asymptomatic hydroceles
  • Small to moderate-sized hydroceles
  • Post-varicocelectomy hydroceles (initially) 2
• Duration: Observation for 18-24 months is reasonable as some hydroceles resolve spontaneously 4

2. Aspiration

• Indications:
  • Symptomatic hydroceles causing discomfort
  • Difficulty walking due to size
  • Cosmetic concerns 5
• Technique:
  • Local anesthesia (EMLA cream can provide painless anesthesia) 6
  • Needle aspiration of fluid
  • Multiple aspirations may be needed (at least 3 before considering surgery) 4
• Prognostic factor: Hydroceles with <50 mL fluid volume per aspiration have better resolution rates (60% success) 4

3. Sclerotherapy

• Indication: Symptomatic hydroceles after aspiration
• Technique:
  • Aspiration followed by injection of sclerosing agent (doxycycline)
  • Success rate: 84% with a single treatment 3
  • Advantages: Avoids surgery, hospital expenses, and complications
  • Complications: Moderate pain for 2-3 days in some patients 3

4. Surgical Hydrocelectomy

• Indications:
  • Failed aspiration (≥3 attempts)
  • Large persistent hydroceles
  • Recurrent hydroceles after sclerotherapy 4, 2
• Technique:
  • Open hydrocelectomy via scrotal incision is standard for idiopathic hydroceles 2
  • For communicating hydroceles (with patent processus vaginalis), inguinal approach may be needed

Special Considerations

Post-Varicocelectomy Hydroceles

• Common complication (11% incidence) 4
• Management approach:
  1. Observation for 18-24 months
  2. Aspiration if symptomatic (minimum 3 attempts)
  3. Surgical correction only after failed conservative management 4, 2

Recurrent Hydroceles

• Consider underlying causes:
  • Patent processus vaginalis
  • Peritoneal communication
  • Underlying testicular pathology 5
• May require more aggressive surgical approach with attention to complete excision of hydrocele sac

Complications to Watch For

• Infection after aspiration or sclerotherapy
• Hematoma formation
• Persistent or recurrent hydrocele
• Testicular atrophy (rare complication of surgery)

By following this stepwise approach from conservative management to more invasive interventions, most hydroceles can be effectively treated while minimizing complications and unnecessary procedures.