Treatment of Septated Left Hydrocele (1.8 x 1.2 x 1.6 cm)
For a small septated hydrocele of this size (approximately 1.8 cm), initial conservative management with observation is recommended, as most small hydroceles remain asymptomatic and do not require intervention unless they cause discomfort or continue to enlarge. 1
Initial Management Approach
Observation is the preferred first-line strategy for small hydroceles, particularly those under 3-4 cm in diameter that are not causing symptoms. 1 The presence of septations does not change this initial conservative approach, though it does affect treatment options if intervention becomes necessary.
When to Observe vs. Intervene
Asymptomatic hydroceles of this size should be monitored clinically with periodic physical examination and ultrasound if needed to assess for growth or changes. 1
Intervention is indicated only if the hydrocele causes: significant scrotal discomfort, cosmetic concerns that affect quality of life, or progressive enlargement on serial examinations. 2, 1
The septated nature is an important consideration because it significantly reduces the success rate of aspiration and sclerotherapy procedures. 3
Treatment Options If Intervention Becomes Necessary
Aspiration and Sclerotherapy (Limited Role for Septated Hydroceles)
Aspiration with sclerotherapy is NOT recommended for septated hydroceles because the septations prevent adequate distribution of the sclerosing agent throughout the hydrocele sac, leading to treatment failure. 3
For nonseptated hydroceles, aspiration with doxycycline sclerotherapy achieves 84% success with a single treatment, but this study specifically excluded septated hydroceles. 3
Alternative sclerosing agents include fibrin sealant (Tissucol), which can be performed with topical EMLA cream anesthesia for pain control, though again this is primarily studied in nonseptated hydroceles. 4
Polidocanol injection has been reported as effective in case reports, but evidence is limited and applicability to septated hydroceles is unclear. 5
Surgical Hydrocelectomy (Definitive Treatment)
Open hydrocelectomy via scrotal incision is the standard definitive treatment for septated hydroceles when intervention is required, as it allows complete excision or eversion of the tunica vaginalis including all septations. 2, 1
Surgical success rates approach 95-100% with low recurrence rates and is the only reliable option for septated hydroceles. 2
Surgery should be considered when: the hydrocele causes persistent symptoms, continues to enlarge despite observation, or when the patient desires definitive correction. 2, 1
The septated nature makes surgical excision more technically appropriate than aspiration-based procedures because the surgeon can directly visualize and remove all septations. 2
Clinical Decision Algorithm
If asymptomatic and stable: Continue observation with clinical follow-up every 6-12 months. 1
If mildly symptomatic but small: Trial of observation for 3-6 months to assess natural history. 1
If symptomatic or enlarging: Proceed directly to surgical hydrocelectomy given the septated nature (skip aspiration/sclerotherapy). 3, 2
If patient refuses surgery: Aspiration alone for temporary relief is possible, but expect recurrence and understand this is palliative only. 3, 1
Critical Pitfalls to Avoid
Do not attempt sclerotherapy on septated hydroceles expecting the same success rates as nonseptated hydroceles—the septations create multiple compartments that prevent adequate sclerosant distribution. 3
Always perform scrotal ultrasound if the testis is not clearly palpable to rule out underlying testicular masses that may present with secondary hydrocele. 2
Do not rush to intervention for small asymptomatic hydroceles—the risks of surgery (infection, hematoma, recurrence) may outweigh benefits when the hydrocele is not causing problems. 2, 1
Recognize that hydrocele size alone does not mandate treatment—patient symptoms and quality of life impact should drive the decision to intervene. 2, 1