What is the treatment approach for a scrotum hydrocele?

Treatment Approach for Scrotal Hydrocele

For adults and adolescents with symptomatic hydroceles, surgical hydrocelectomy via scrotal incision is the definitive treatment, while infants and children under 18-24 months should be managed conservatively with observation for spontaneous resolution. 1

Initial Diagnostic Evaluation

Before initiating treatment, critical surgical emergencies must be excluded:

• Rule out testicular torsion immediately with scrotal ultrasound and Doppler assessment, as testicular viability is compromised after 6-8 hours of ischemia 1, 2
• Evaluate for inguinal hernia, which requires prompt surgical repair rather than observation, particularly in pediatric patients 1
• Perform scrotal ultrasonography to assess testicular blood flow (sensitivity 96-100%, specificity 84-95%) and differentiate hydrocele from other acute scrotal pathology 1, 2
• In cases of large hydrocele, thickened scrotal skin, or nonpalpable testis, ultrasound is mandatory to exclude underlying testicular masses, as infertile males have an 18-fold higher risk of testicular cancer with microcalcifications 3, 1

Age-Stratified Management Algorithm

Infants and Children (Under 18-24 Months)

• Conservative management with observation is recommended, as congenital hydroceles typically resolve spontaneously within 18-24 months due to closure of the patent processus vaginalis 1
• Surgical intervention is indicated only if there is concern for inguinal hernia or complications develop 1

Adolescents and Adults

Surgical hydrocelectomy is the standard definitive treatment for symptomatic hydroceles in this age group 1, 4

Surgical Approach Selection:

• Scrotal approach (open hydrocelectomy) is the standard for non-communicating hydroceles in patients over 12 years, offering lower morbidity when no patent processus vaginalis is present 1
• Inguinal approach is preferred when a patent processus vaginalis is suspected, allowing ligation to prevent recurrence 1
• The "pull-through" technique enables removal of large hydrocele sacs through a 15mm incision with minimal dissection, achieving 95% cure rates with early recovery 1

Indications for Surgery:

• Symptomatic hydroceles causing discomfort or impacting daily activities 1
• Large hydroceles affecting fertility through increased scrotal temperature and testicular dysfunction 1
• Bilateral hydroceles in men of reproductive age warrant fertility evaluation 1

Alternative Non-Surgical Treatment

Aspiration and sclerotherapy with doxycycline is an effective alternative for patients who are poor surgical candidates or prefer non-surgical management:

• Success rate of 84% with single treatment for simple, non-septated hydroceles 5
• Comparable success rates to hydrocelectomy while avoiding hospital expense and surgical complications 5
• Moderate pain may occur but typically resolves in 2-3 days 5
• Failed cases can undergo repeat sclerotherapy or proceed to surgical hydrocelectomy 5
• Fibrin adhesive sclerotherapy with EMLA cream anesthesia represents another painless alternative with minimal recurrence 6

Special Clinical Considerations

Complex or Bilateral Hydroceles:

• "Complex hydrocele" on ultrasound in adolescents/young adults warrants high suspicion for testicular malignancy, requiring tumor markers and urologic consultation 1
• Bilateral hydroceles with scrotal wall thickening and increased vascularity suggest infectious etiology (epididymo-orchitis), requiring appropriate antibiotic therapy and re-evaluation after treatment 1, 2

Post-Varicocelectomy Hydroceles:

• Higher risk with non-artery-sparing procedures or those without microsurgical aid 4
• Initial management should include observation with or without aspiration 4
• Large persistent hydroceles require open hydrocelectomy 4

Giant Abdominoscrotal Hydroceles:

• Rare entity extending beyond scrotum into abdomen via inguinal canal 7
• Requires surgical approach, typically via scrotal incision for complete cyst removal 7

Critical Pitfalls to Avoid

• Never delay evaluation of acute scrotal swelling without first ruling out testicular torsion emergently 1
• Do not rush to surgery in infants under 18-24 months unless inguinal hernia or complications are present 1
• Physical examination with orchidometer is adequate for routine volume assessment; reserve ultrasound for cases with large hydrocele, thickened scrotal skin, or concern for underlying pathology 1
• The perioperative bleeding risk for hydrocele repair is classified as low (0-2% risk of bleeding >2 days), facilitating decision-making in patients requiring anticoagulation 1