What is the recommended treatment for a complex moderate sized hydrocele?

Management of Complex Moderate-Sized Hydrocele

Surgical intervention is the recommended treatment for complex moderate-sized hydroceles, with open hydrocelectomy via a scrotal incision being the standard approach for definitive correction.

Diagnostic Approach

• Ultrasound with Doppler is the first-line imaging for evaluation of scrotal pathology, allowing differentiation between hydrocele and other causes of scrotal swelling 1
• Clinical examination is usually sufficient for diagnosis, but imaging is mandatory in cases with nonpalpable testicles to rule out underlying testicular masses 2
• A thorough history should assess for fluctuation in size, which may indicate a patent processus vaginalis requiring different surgical approach 2

Treatment Options

Surgical Management (Primary Recommendation)

• Open hydrocelectomy via scrotal incision is the standard treatment for complex moderate-sized hydroceles 2
• Surgical techniques include:
  • Winkelmann procedure (excision and eversion of the hydrocele sac) - used in approximately 61% of cases 3
  • Bergman procedure (resection of the hydrocele sac) - used in approximately 33% of cases 3
  • For large hydroceles, excision of redundant scrotal skin may be necessary to prevent postoperative discomfort 4

Nonsurgical Management (Alternative Option)

• Aspiration and sclerotherapy with doxycycline can be considered as a nonsurgical alternative 5
• Success rates of 84% have been reported with a single aspiration and sclerotherapy procedure for simple nonseptated hydroceles 5
• This approach avoids hospital expenses and many complications associated with surgery 5

Factors Influencing Treatment Selection

• Size of the hydrocele (larger hydroceles may require more extensive surgical intervention) 4
• Complexity of the hydrocele (septated vs. nonseptated) 5
• Patient's overall health status and surgical risk
• Patient preference after discussing risks and benefits of each approach

Potential Complications and Management

• Surgical complications may include:
  • Wound infection (reported in approximately 1% of cases) 3
  • Hematoma formation 3
  • Testicular vessel compression requiring reoperation (rare) 3
• Sclerotherapy complications may include:
  • Moderate pain lasting 2-3 days (reported in some patients) 5
  • Potential need for repeat procedure if initial treatment fails 5

Follow-up Recommendations

• For surgical patients, routine postoperative follow-up to assess wound healing
• For patients undergoing sclerotherapy, follow-up evaluation to assess treatment success, with consideration for repeat procedure or surgical intervention if unsuccessful 5

Special Considerations

• In cases of extremely large hydroceles with altered local skin, a multidisciplinary approach involving urologic and plastic surgery may be beneficial 6
• Recurrence prevention is important, with resection of the covering sheets of the testis recommended as a prophylactic measure 3