What is the recommended treatment for an encysted hydrocele?

Treatment of Encysted Hydrocele

Surgical excision is the definitive treatment for encysted hydrocele of the spermatic cord, as conservative management is only appropriate in early infancy and surgical intervention is necessary when the condition persists or presents beyond infancy. 1

Understanding Encysted Hydrocele

Encysted hydrocele of the spermatic cord is a rare variant of hydrocele that differs from typical scrotal hydroceles:

• It presents as inguinal or groin swelling that may extend to the upper scrotum, often mimicking an incarcerated inguinal hernia clinically 1
• Results from incomplete obliteration of the processus vaginalis during fetal development, with fluid becoming trapped in an isolated segment along the spermatic cord 2
• Diagnosis is primarily clinical, though scrotal ultrasonography with Doppler can confirm the diagnosis and rule out surgical emergencies like testicular torsion 2, 3, 1

Treatment Algorithm

Age-Based Management Approach

For infants under 18-24 months:

• Conservative observation is appropriate as congenital hydroceles typically resolve spontaneously within this timeframe 2
• Avoid rushing to surgery unless there is concern for associated inguinal hernia or complications 2

For children over 2 years and adults:

• Surgical excision is the treatment of choice for encysted hydrocele, as spontaneous resolution beyond infancy is extremely rare 1
• The inguinal approach is preferred as it allows for complete excision of the encysted segment and ligation of any patent processus vaginalis, preventing recurrence 2

Surgical Technique Selection

For encysted hydrocele specifically:

• Use the inguinal approach to access the spermatic cord, excise the encysted hydrocele sac, and ligate the processus vaginalis if patent 2
• The procedure can be performed under local anesthesia in adults, avoiding morbidity of general anesthesia with 93% excellent tolerance 4
• Laparoscopic excision has been reported for complex cases like abdominoscrotal hydrocele, offering advantages of minimally invasive surgery 5

Critical Pitfalls to Avoid

• Do not delay evaluation of acute groin/scrotal swelling, as testicular torsion must be ruled out emergently with ultrasound and Doppler assessment, since testicular viability is compromised after 6-8 hours 2, 3
• Do not confuse encysted hydrocele with incarcerated inguinal hernia, which requires immediate surgical repair; ultrasound can differentiate between these conditions 2, 1
• Aspiration and sclerotherapy are NOT appropriate for encysted hydrocele of the spermatic cord, as these techniques are only described for simple scrotal hydroceles and have no role in treating encysted variants 6

Perioperative Considerations

• Hydrocele repair is classified as low bleeding risk (0-2% risk of bleeding >2 days), facilitating perioperative planning in patients requiring anticoagulation 2
• Expected complications include scrotal hematoma (5%), infection (4%), and cardiovascular events (3%) when performed under local anesthesia 4
• Most patients can be discharged within 24 hours with only 7% requiring longer hospitalization 4