What is the recommended treatment for hydrocele?

Management of Hydrocele

Surgical intervention is the recommended treatment for symptomatic hydrocele in adults, while observation is appropriate for asymptomatic congenital hydrocele in children, which typically resolves spontaneously within 18-24 months. 1

Understanding Hydrocele

• Hydrocele is an abnormal collection of fluid between the parietal and visceral layers of the tunica vaginalis of the testis 2
• In children, it results from incomplete involution of the processus vaginalis, which normally obliterates during fetal development 1
• In adults, hydrocele may be idiopathic or secondary to trauma, infection, or testicular pathology 3

Management Approach

Conservative Management

• For congenital hydrocele in children:
  • Observation for 18-24 months is recommended as most cases resolve spontaneously 1
  • Surgical intervention is indicated only if the hydrocele persists beyond 2 years or if there is suspicion of an underlying inguinal hernia 1

Surgical Management

• Surgical intervention is the gold standard treatment for symptomatic hydrocele in adults 4
• The most established surgical techniques include:
  • Winkelmann's procedure - eversion of the sac (used in 61.45% of cases in one study) 4
  • Bergman's procedure - resection of the sac (used in 32.81% of cases) 4
• Resection of the covering sheets of the testis is recommended as a prophylactic measure against recurrence 4
• Surgery can be performed under local anesthesia with sedation, avoiding the morbidity of more aggressive anesthetic techniques 5
  • Local anesthesia protocol: 2% mepivacaine (10-20 cc) injected into the spermatic cord and scrotal wall 5
  • Sedation with midazolam, meperidine, and atropine may be administered 20 minutes before the procedure 5

Alternative Non-surgical Options

1. Aspiration and Sclerotherapy

   • Effective and safe non-surgical treatment option with 84% success rate after a single treatment 6
   • Procedure involves:
     • Aspiration of hydrocele fluid
     • Injection of a sclerosing agent (doxycycline has shown better results than tetracycline) 6
   • Benefits include avoiding hospital expense and surgical complications 6
   • Best suited for non-septated simple hydroceles 6

2. Fibrin Adhesive Sclerotherapy

   • Can be performed with EMLA cream (lidocaine and prilocaine) for cutaneous anesthesia 7
   • Fibrin sealant (Tissucol) is injected into the sac after fluid aspiration 7
   • Patients experience minimal pain during the procedure 7

3. Silicone Catheter Technique

   • Minimally invasive approach using a silicone catheter with holes to enable drainage 2
   • Procedure takes approximately 15 minutes 2
   • Does not require dissection or manipulation of scrotal contents 2
   • Shows low recurrence rates during 1-3 years of follow-up 2

Potential Complications of Surgical Treatment

• Scrotal hematoma (5% of cases) 5
• Wound infection (4% of cases) 5
• Bradycardia and hypotension (3% of cases) 5
• Compression of testicular blood vessels (rare) 4
• Suppuration of the operative wound (1.02% of cases) 4

Clinical Decision-Making Algorithm

1. For children with hydrocele:

   • Observe for spontaneous resolution up to 24 months 1
   • Proceed to surgery only if:
     • Hydrocele persists beyond 24 months
     • There is suspicion of an underlying inguinal hernia
     • Symptoms become significant

2. For adults with hydrocele:

   • Asymptomatic or minimally symptomatic: Consider observation
   • Symptomatic (pain, discomfort, or cosmetic concerns):
     • First option: Surgical treatment (Winkelmann or Bergman procedure) 4
     • Alternative for patients who decline surgery or are poor surgical candidates: Consider aspiration and sclerotherapy with doxycycline 6