What is the management approach for scrotal swelling due to an increase in tunica vaginalis (tunica vaginalis) volume, likely indicating a hydrocele?

Management of Hydrocele (Scrotal Swelling from Tunica Vaginalis Fluid)

For idiopathic hydroceles in adolescents and adults, open hydrocelectomy via scrotal incision is the standard definitive treatment. 1

Initial Diagnostic Evaluation

Ultrasound with Doppler is mandatory as the first-line imaging modality to confirm the diagnosis and rule out underlying pathology, particularly testicular masses that would require inguinal exploration rather than scrotal surgery. 2, 3

Key Clinical History Points

• Assess for size fluctuation, which indicates a patent processus vaginalis (communicating hydrocele) requiring high ligation via inguinal approach rather than simple scrotal hydrocelectomy. 1
• Determine onset timing: acute presentation may suggest infection, trauma, or underlying testicular pathology requiring urgent evaluation. 4
• Age matters: communicating hydroceles are more common in children (88% in one series), while idiopathic acquired hydroceles predominate in adolescents and adults. 5

Ultrasound Assessment Requirements

• Both grayscale and color Doppler must be performed to evaluate testicular perfusion and architecture. 2, 3
• Rule out testicular masses: if the testicle is nonpalpable due to hydrocele size, ultrasound is essential to exclude solid masses requiring inguinal orchiectomy. 1
• Evaluate tunica vaginalis characteristics: thickening, nodularity, or septations may indicate tuberculosis, mesothelioma, or inflammatory changes requiring tissue diagnosis. 4, 5, 6
• Power Doppler is particularly valuable for detecting low-flow states and assessing tunica vaginalis vascularity. 3

Treatment Algorithm

Conservative Management (Observation)

• Reserved for small, asymptomatic hydroceles that do not interfere with quality of life, sexual function, or work capacity. 7
• Post-varicocelectomy hydroceles warrant initial observation with or without aspiration, as many resolve spontaneously. 1

Surgical Intervention Indications

• Large or symptomatic hydroceles affecting quality of life, sexual function, fertility, or causing discomfort. 1, 7
• Persistent hydroceles after varicocelectomy that remain large despite observation. 1
• Any hydrocele with concerning ultrasound features (thickened tunica, nodules, septations) requiring tissue diagnosis. 5, 6

Surgical Technique Selection

For idiopathic hydroceles: Open hydrocelectomy via scrotal incision using Jaboulay technique (eversion of tunica vaginalis) or Lord plication. 1, 5

For communicating hydroceles: High ligation of patent processus vaginalis via inguinal approach. Simple fenestration has high recurrence rates and should be avoided. 5

For hydroceles with tunica vaginalis inflammation or thickening: Jaboulay operation (tunica reversion) rather than fenestration to minimize recurrence risk. 5

For nonpalpable testicles or suspected masses: Inguinal exploration to allow for radical orchiectomy if malignancy is confirmed. 1, 6

Critical Pitfalls to Avoid

• Never perform scrotal hydrocelectomy without preoperative ultrasound in nonpalpable testicles, as you may miss an underlying testicular malignancy requiring inguinal orchiectomy. 1
• Do not assume all hydroceles are benign: tuberculosis can present as acute hydrocele with tunica involvement, and mesothelioma can mimic benign hydrocele on imaging. 4, 6
• Avoid simple fenestration when tunica vaginalis shows macroscopic inflammation, thickening, or hemorrhagic infiltration, as recurrence rates approach 100% with this approach. 5
• Send tunica vaginalis tissue for histopathology when abnormal appearance is noted intraoperatively, including Ziehl-Neelsen staining if tuberculosis is suspected. 4, 5
• Giant hydroceles (equal to or larger than patient's head) represent severe neglect and carry significant morbidity affecting fertility, sexual function, and work capacity—these require urgent surgical correction. 7