What is the primary treatment for symptomatic hydroceles in adults?

Primary Treatment for Symptomatic Hydroceles in Adults

Surgical hydrocelectomy is the primary treatment for symptomatic hydroceles in adults, offering the highest cure rates and lowest recurrence compared to aspiration and sclerotherapy.

Surgical Hydrocelectomy: The Gold Standard

Surgical repair remains the definitive treatment for symptomatic adult hydroceles, with established techniques including:

• Excision and eversion of the tunica vaginalis (Jaboulay procedure) or plication (Lord's procedure) through scrotal incisions are the traditional approaches 1
• Subinguinal approach with gubernaculum preservation ("Snip, Stitch & Tug" technique) achieves 92% cure rates with minimal complications through a small subinguinal incision 1
• Surgical repair provides superior long-term outcomes with significantly lower recurrence rates compared to non-surgical alternatives 2

Aspiration and Sclerotherapy: Alternative for Select Patients

While surgery is primary treatment, aspiration with sclerotherapy serves as an alternative in specific clinical scenarios:

• Sodium tetradecyl sulphate (STDS) demonstrates the best sclerosant outcomes, achieving 76% cure after single injection and 94% cure after multiple treatments, with 95% patient satisfaction at 40 months follow-up 3
• Doxycycline sclerotherapy shows 84% success with single treatment for nonseptated hydroceles, avoiding hospital expenses and surgical complications 4
• Meta-analysis reveals significantly higher recurrence with sclerotherapy versus surgery (RR 9.43,95% CI 1.82-48.77), though clinical cure rates show no significant difference initially 2

Appropriate Candidates for Sclerotherapy

Consider aspiration and sclerotherapy for:

• Patients at high surgical risk or unfit for general anesthesia 3, 2
• Patients who explicitly wish to avoid surgery and accept higher recurrence risk 3
• Simple, nonseptated hydroceles only—septated hydroceles respond poorly 4

Common pitfall: Simple aspiration alone without sclerosant injection has no lasting therapeutic effect and should not be performed 5

Treatment Algorithm

1. Symptomatic hydrocele confirmed by physical exam and ultrasound
2. Assess surgical candidacy: comorbidities, anesthetic risk, patient preference
3. If good surgical candidate: Proceed with hydrocelectomy (scrotal or subinguinal approach based on surgeon experience) 1
4. If high surgical risk or patient refuses surgery: Offer aspiration with STDS or doxycycline sclerotherapy, counseling about 9-fold higher recurrence risk 3, 2, 4
5. If sclerotherapy fails: Consider repeat sclerotherapy (one additional attempt) or proceed to surgical repair 4

Complications Comparison

Sclerotherapy complications are generally lower than surgery:

• Fever, infection, and hematoma rates show no significant difference between approaches 2
• Sclerotherapy may cause moderate pain lasting 2-3 days 4
• Surgical complications include hematoma, infection, and recurrence, though recurrence rates are substantially lower than sclerotherapy 1, 2