What area should be ultrasounded to assess for hydrocele?

Ultrasound Assessment for Hydrocele

For assessment of hydrocele, ultrasound examination should focus on the scrotum with visualization of the testicle and surrounding fluid collection between the parietal and visceral layers of the tunica vaginalis. 1, 2

Imaging Approach

• Scrotal ultrasound is the first-line and most appropriate imaging modality for evaluation of hydrocele, with high sensitivity for detection of scrotal abnormalities 1
• The examination should include both grayscale and color Doppler assessment of the entire scrotum 1
• Specific areas to evaluate include:
  • The testicle itself (to rule out underlying testicular pathology that may be masked by the hydrocele) 3, 4
  • The space between the parietal and visceral layers of the tunica vaginalis (where hydrocele fluid accumulates) 2, 5
  • The epididymis (to identify potential inflammatory causes of reactive hydrocele) 2
  • The spermatic cord (to evaluate for extension of hydrocele or other pathology) 6

Technical Considerations

• Use a high-frequency linear transducer (typically 7.5-15 MHz) for optimal resolution of scrotal structures 1
• Position the patient supine with the scrotum supported (may use a towel underneath) 1
• Scan in both transverse and longitudinal planes through the entire scrotum 1
• Apply gentle pressure to displace the hydrocele fluid when necessary to better visualize the testicular parenchyma 3, 4
• Include color Doppler assessment to evaluate for:
  • Normal testicular blood flow (ruling out torsion) 1
  • Increased blood flow in adjacent structures (suggesting inflammation in reactive hydrocele) 2

Imaging Findings

• Typical hydrocele appears as an anechoic (black) fluid collection surrounding the testicle 2, 7
• Important features to document:
  • Size of the hydrocele 7, 5
  • Simple versus complex appearance (septations, debris, or internal echoes may suggest infection, hemorrhage, or underlying pathology) 4
  • Testicular appearance and size (to rule out underlying mass) 3, 4
  • Epididymal appearance (normal versus inflamed) 2

Clinical Pitfalls to Avoid

• Failure to adequately visualize the entire testicle when obscured by large hydrocele may miss underlying testicular tumors 3, 4
• Misdiagnosing complex hydroceles that may represent cystic testicular tumors 4
• Not evaluating for potential causes of reactive hydrocele, such as epididymitis 2
• Inadequate assessment of both testicles for comparison 1

Follow-up Considerations

• Follow-up ultrasound may be necessary if:
  • The hydrocele persists despite treatment of underlying condition 2
  • There are complex features requiring monitoring 4
  • The testicular parenchyma was not adequately visualized on initial examination 3

Remember that while hydrocele is typically benign, it can occasionally mask underlying testicular pathology, making thorough ultrasound assessment of the entire scrotal contents essential 3, 4.