What are the treatment options for hydrocele?

Treatment Options for Hydrocele

The standard treatment for symptomatic hydrocele is surgical intervention through hydrocelectomy, while asymptomatic cases can be managed conservatively with observation. 1, 2

Understanding Hydrocele

• Hydrocele is defined as an abnormal collection of serous fluid between the parietal and visceral layers of the tunica vaginalis surrounding the testicle 3
• The condition results from an imbalance in the normal process of fluid production and reabsorption within the tunica vaginalis 3, 2
• Hydroceles can be classified as primary (idiopathic) or secondary (resulting from underlying conditions such as infection, trauma, or following procedures like varicocelectomy) 3, 2

Diagnostic Approach

• Diagnosis is primarily clinical, based on physical examination findings of a non-tender, fluctuant scrotal swelling 3
• A thorough history is essential to rule out fluctuations in size, which may indicate a patent processus vaginalis 3
• Scrotal ultrasonography with Doppler assessment is recommended to:
  • Confirm the diagnosis of hydrocele 1
  • Rule out other causes of scrotal swelling, particularly testicular torsion which is a surgical emergency 1
  • Evaluate for potential underlying testicular masses in cases with non-palpable testicles 3

Treatment Options

1. Conservative Management

• Observation is appropriate for asymptomatic or minimally symptomatic hydroceles 2
• This approach is particularly suitable for small hydroceles that don't cause discomfort or cosmetic concerns 2

2. Aspiration and Sclerotherapy

• Hydrocele aspiration and sclerotherapy with agents like doxycycline is an effective nonsurgical treatment option 4
• Success rates of 84% have been reported with a single treatment using doxycycline sclerotherapy 4
• This approach avoids hospital expenses and many complications associated with surgery 4
• Best suited for simple, nonseptated hydroceles 4

3. Surgical Management (Hydrocelectomy)

• Open hydrocelectomy via a scrotal incision is the standard treatment for symptomatic idiopathic hydroceles 3
• Common surgical techniques include:
  • Winkelmann's procedure - reported in 61.45% of cases in one study 5
  • Bergman's procedure - reported in 32.81% of cases in the same study 5
• Resection of the covering sheets of the testis is recommended as a prophylactic measure against recurrence 5
• Laparoscopic approaches may be considered for specific types of hydroceles, particularly in females with hydroceles of the canal of Nuck 6

Special Considerations

• For hydroceles that develop after varicocelectomy, initial management should include observation with or without hydrocele aspiration 3
• Large persistent post-varicocelectomy hydroceles are best treated with open hydrocelectomy 3
• If hydrocele presents with signs of infection or associated epididymitis, appropriate antibiotic therapy should be considered 1

Complications of Treatment

• Potential complications of surgical treatment include:
  • Wound infection (reported in 1.02% of cases) 5
  • Bleeding leading to hematoma formation 5
  • Compression of testicular blood vessels 5
  • Recurrence (which proper surgical technique aims to prevent) 5

Treatment Algorithm

1. For asymptomatic or minimally symptomatic hydroceles:

   • Conservative management with observation 2

2. For symptomatic hydroceles:

   • First-line option: Surgical hydrocelectomy (Winkelmann's or Bergman's procedure) 3, 5
   • Alternative option: Aspiration and sclerotherapy with doxycycline for patients who prefer nonsurgical management or are poor surgical candidates 4

3. For post-varicocelectomy hydroceles:

   • Initial observation with or without aspiration 3
   • Hydrocelectomy for large persistent hydroceles 3