What is a hydrocele?

Hydrocele Definition and Management

A hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testis and spermatic cord. 1 This condition results from an imbalance in the normal process of fluid production and reabsorption within the tunica vaginalis.

Types and Etiology

Hydroceles can be classified into two main types:

1. Primary (Congenital) Hydrocele:

   • Results from incomplete involution of the processus vaginalis
   • The processus vaginalis normally obliterates during fetal development, leaving the tunica vaginalis as an enveloping layer 2
   • When involution is incomplete, a patent processus vaginalis (PPV) remains, allowing fluid to accumulate extra-abdominally
   • Congenital hydroceles typically resolve spontaneously within 18-24 months 2

2. Secondary (Acquired) Hydrocele:

   • Idiopathic: Most common in adolescents 3
   • Post-surgical: Common after varicocelectomy, especially with non-artery-sparing procedures 3
   • Secondary to other conditions: Infection, trauma, or testicular tumors

Clinical Presentation

Hydroceles typically present as:

• Painless scrotal swelling
• Translucent on transillumination
• Fluctuant on palpation
• May vary in size from small to extremely large ("giant hydrocele") 4

Diagnosis

The diagnosis of hydrocele is primarily clinical, but should include:

• Thorough history to determine:

  • Duration of swelling
  • Fluctuation in size (suggesting patent processus vaginalis) 3
  • Associated symptoms

• Physical examination:

  • Transillumination test (positive in hydrocele)
  • Assessment of testicular position and palpability

• Imaging:

  • Scrotal ultrasound with Doppler is recommended, especially when the testicle is not palpable, to rule out underlying testicular masses 2, 5
  • Ultrasound helps differentiate hydrocele from other scrotal conditions like epididymitis or testicular torsion

Management

Management options include:

1. Conservative approach:

   • Observation for congenital hydroceles in infants (most resolve by 18-24 months) 2
   • Monitoring for small, asymptomatic hydroceles in adults

2. Intervention (for symptomatic or large hydroceles):

   • Aspiration: Temporary solution, often used for post-varicocelectomy hydroceles 3
   • Hydrocelectomy: Standard treatment for persistent idiopathic hydroceles via scrotal incision 3

Important Considerations and Pitfalls

• Masking of Testicular Pathology: A hydrocele can mask underlying testicular tumors, leading to delayed diagnosis of potentially malignant conditions 6

• Recurrence: Hydroceles may recur despite treatment, particularly if there is a patent processus vaginalis or other underlying condition 7

• Differential Diagnosis: Important to distinguish from other scrotal conditions:

  • Inguinal hernia (if processus vaginalis is large enough for bowel herniation) 2
  • Epididymitis/orchitis
  • Testicular torsion
  • Testicular tumors

• Complications: Giant hydroceles can affect quality of life through:

  • Physical discomfort
  • Difficulty walking
  • Potential impact on fertility and sexual function 4

Proper evaluation with ultrasound is crucial to ensure no underlying pathology is missed, especially when the testicle cannot be properly examined due to the surrounding fluid.