What are the treatment options for hydrocele?

Treatment for Hydrocele

Congenital hydroceles in infants should be observed for spontaneous resolution until 18-24 months of age, while symptomatic hydroceles in adults should be treated with surgical hydrocelectomy as first-line therapy, with aspiration and sclerotherapy reserved for patients unfit for surgery. 1, 2

Initial Assessment and Diagnosis

Critical first step: Rule out testicular torsion and inguinal hernia, which are surgical emergencies requiring immediate intervention 1, 3:

• Perform scrotal ultrasonography with Doppler to assess testicular blood flow and differentiate hydrocele from torsion 1, 3
• Evaluate for inguinal hernia, which requires prompt surgical repair rather than observation 1, 2
• Assess timing of onset: sudden onset with severe pain suggests torsion; gradual onset with minimal pain suggests hydrocele 3
• Look for fluctuation in hydrocele size, which indicates a patent processus vaginalis and may require surgical intervention 4

Management by Age Group

Infants and Children (Under 2 Years)

Conservative management is the standard approach 1, 2:

• Observe for spontaneous resolution, as congenital hydroceles typically resolve within 18-24 months 1, 2
• The processus vaginalis normally obliterates during development; incomplete involution causes fluid accumulation 2
• Surgical intervention is indicated only if: there is suspicion of underlying inguinal hernia, the hydrocele persists beyond 18-24 months, or there are signs of complications 1, 2

Adolescents and Adults

Surgical hydrocelectomy via scrotal incision is the standard treatment 4, 5:

• Open hydrocelectomy provides definitive treatment with high success rates 4, 5
• Scrotal ultrasonography is mandatory if the testicle is nonpalpable to rule out underlying testicular mass requiring inguinal exploration 4
• For post-varicocelectomy hydroceles, initial management should include observation with or without aspiration; persistent large hydroceles require open hydrocelectomy 4

Alternative Treatment: Aspiration and Sclerotherapy

For patients unfit for surgery or those preferring nonsurgical options, aspiration and sclerotherapy is an effective alternative 6, 7:

• Sodium tetradecyl sulphate (STDS) is the preferred sclerosing agent with 76% cure rate after single injection and 94% after multiple treatments 7
• Doxycycline sclerotherapy achieves 84% success rate with single treatment for simple nonseptated hydroceles 6
• Patient satisfaction rates reach 95% at mean 40-month follow-up 7
• Complication rates are significantly lower than surgical repair, with moderate pain in some patients resolving in 2-3 days 6, 7

Key selection criteria for aspiration and sclerotherapy 6, 7:

• Simple, nonseptated hydroceles only 6
• Patients unfit for general anesthesia 7
• Patients preferring to avoid surgical complications and longer recovery 7

Management of Complicated Cases

If infection or epididymitis is present 3:

• Initiate appropriate antibiotic therapy 3
• Arrange urological follow-up for definitive management 3

For abdominoscrotal hydrocele 8:

• Surgical repair is technically demanding and may require laparoscopic-assisted approach 8
• Specialized surgical expertise is necessary for optimal outcomes 8

Common Pitfalls to Avoid

• Do not delay evaluation of acute scrotal swelling—testicular torsion must be ruled out emergently as testicular viability is compromised after 6-8 hours 1
• Do not confuse hydrocele with inguinal hernia, which requires more urgent surgical intervention 2
• Do not perform aspiration and sclerotherapy on septated or complex hydroceles—these require surgical management 6
• Do not rush to surgery in infants under 18-24 months unless there is concern for inguinal hernia or complications 1, 2