Guidelines for Hydrocele Management
Initial Assessment and Diagnosis
The primary goal in evaluating hydrocele is to rule out testicular torsion and other surgical emergencies through clinical examination and scrotal ultrasonography with Doppler assessment. 1
Key Clinical Features to Assess
- Onset and timing of symptoms: Sudden onset with severe pain suggests testicular torsion (surgical emergency), while gradual onset with minimal or no pain suggests hydrocele 1
- Fluctuation in size: Diurnal changes in hydrocele size (present in 92% of cases) indicate a patent processus vaginalis and may influence surgical timing 2
- Age of presentation: This is critical for management decisions, as spontaneous resolution rates vary dramatically by age 2
- Testicular palpability: Non-palpable testicles require mandatory scrotal ultrasonography to rule out underlying testicular masses 3
Diagnostic Imaging
- Scrotal ultrasonography with Doppler is the primary diagnostic tool to confirm normal testicular blood flow (distinguishing from torsion), evaluate for epididymitis, and characterize the fluid collection 1
- Ultrasound should assess for septations within the hydrocele, as nonseptated simple hydroceles have better outcomes with nonsurgical treatment 4
Age-Stratified Management Algorithm
Infants (<1 Year of Age)
Observation is the standard approach for hydroceles presenting in the first year of life, as 89% will spontaneously resolve. 2
- Continue observation until the first birthday for uncomplicated hydroceles 2
- Immediate surgical intervention is indicated only for:
- Only 11% of infants with hydroceles ultimately require surgery 2
Children (1-12 Years of Age)
Surgical intervention via open hydrocelectomy is the standard treatment for idiopathic hydroceles in children beyond the first year of life. 3
- Open hydrocelectomy via scrotal incision is the definitive treatment for idiopathic hydroceles 3
- Surgery is particularly indicated when diurnal size changes are present (92% of cases), as this suggests patent processus vaginalis 2
- 83% of pediatric hydroceles requiring surgery present within the first 5 years of age 2
Adolescents and Adults
For adolescents and adults with simple nonseptated hydroceles, aspiration and sclerotherapy with doxycycline is an effective first-line nonsurgical option with 84% success rate. 4
Nonsurgical Approach (First-Line for Simple Hydroceles)
- Aspiration and sclerotherapy with doxycycline achieves success in 84% of simple nonseptated hydroceles with a single treatment 4
- This approach avoids hospital expense and surgical complications while achieving similar success rates to hydrocelectomy 4
- Moderate pain may occur in some patients but resolves within 2-3 days 4
- If first aspiration fails, a second attempt can be considered before proceeding to surgery 4
Surgical Approach
- Open hydrocelectomy via scrotal incision remains the standard for:
Special Circumstances
Post-Varicocelectomy Hydrocele
Initial management should include observation with or without aspiration; large persistent hydroceles require open hydrocelectomy. 3
- Risk is higher with non-artery-sparing procedures or those without microsurgical aid 3
- Conservative management is appropriate initially 3
Hydrocele with Infection
Antibiotic therapy is indicated for hydroceles with signs of infection or associated epididymitis, followed by urological follow-up. 1
Common Pitfalls to Avoid
- Never delay evaluation of acute scrotal swelling: Always rule out testicular torsion first, as the 6-8 hour window for testicular salvage is critical 1
- Do not perform inguinal exploration for simple scrotal hydroceles: Unless there is a non-palpable testicle requiring evaluation for testicular mass 3
- Avoid premature surgery in infants: 89% resolve spontaneously in the first year, so surgery should be reserved for specific indications 2
- Do not assume all hydroceles are simple: Always obtain imaging to rule out underlying pathology, particularly in non-palpable testicles 3