What are the management options for hydrocele?

Management of Hydrocele

Immediate Assessment: Rule Out Surgical Emergencies First

Before considering hydrocele management, you must immediately rule out testicular torsion and inguinal hernia using scrotal ultrasonography with Doppler, as these are surgical emergencies requiring intervention within 6-8 hours. 1

• Perform scrotal ultrasound with Doppler to assess testicular blood flow and differentiate hydrocele from torsion, which has a sensitivity of 96-100% and specificity of 84-95% for confirming normal testicular perfusion 1
• Evaluate specifically for inguinal hernia, which requires prompt surgical repair rather than observation 1
• In adolescents and young adults, assess for "complex hydrocele" on ultrasound, which warrants high suspicion for testicular malignancy 1

Age-Stratified Management Algorithm

Infants and Children Under 18-24 Months

Conservative management with observation is the standard approach, as congenital hydroceles typically resolve spontaneously within 18-24 months. 1

• Congenital hydroceles result from incomplete involution of the processus vaginalis, which normally obliterates during fetal development 1
• Do not rush to surgery unless there is concern for inguinal hernia or complications 1
• If suspicion exists for underlying inguinal hernia (which may present with fluctuation in size), surgical intervention becomes necessary 1, 2

Children Over 12 Years and Adolescents

For non-communicating hydroceles in children over 12 years, open hydrocelectomy via scrotal incision is the standard treatment. 1

• The scrotal approach has lower morbidity in the absence of a patent processus vaginalis 1
• Taking a thorough history is essential to rule out any fluctuation in size, which indicates a patent processus vaginalis requiring inguinal approach 2
• Scrotal ultrasonography is mandatory in nonpalpable testicles to rule out underlying testicular solid mass requiring inguinal exploration 2
• For communicating hydroceles, the inguinal approach allows for ligation of the patent processus vaginalis, preventing recurrence by addressing the underlying cause 1

Adults

Hydrocelectomy is the standard and definitive treatment for symptomatic hydroceles in adults. 1

Surgical Management (First-Line for Symptomatic Cases)

• The "pull-through" technique allows removal of large hydrocele sacs through a small incision (15 mm) with minimal dissection, resulting in early recovery and minimal complications, with a cure rate of 95% 1
• Hydrocele repair is classified as low risk for surgical bleeding (0-2% risk of bleeding greater than 2 days), facilitating perioperative decision-making in patients with special anticoagulation needs 1
• Consider surgical intervention if the hydrocele is symptomatic, affecting fertility, or impacting daily activities 1

Non-Surgical Management (Alternative for Simple Hydroceles)

Aspiration and sclerotherapy with doxycycline is an effective nonsurgical treatment option for simple nonseptated hydroceles, with 84% success rate after a single treatment. 3

• This approach is successful in correcting 84% of simple nonseptated hydroceles with a single treatment, similar to reported success rates for hydrocelectomy while avoiding hospital expense and many surgical complications 3
• Sclerotherapy with fibrin sealant (Tissucol) after fluid aspiration represents another useful alternative to surgical treatment, with minimal pain when combined with EMLA cream anesthesia 4
• Aspiration alone without sclerotherapy has high recurrence rates and is not recommended as definitive treatment 5, 6

Special Clinical Scenarios

Bilateral Hydroceles in Adults

• Evaluate for epididymo-orchitis if any symptoms are present, as bilateral hydroceles with scrotal wall thickening and increased vascularity suggest infectious etiology 1
• Consider fertility evaluation in men of reproductive age, as bilateral hydroceles can contribute to infertility through increased scrotal temperature and testicular dysfunction 1
• If complex features are present on ultrasound, pursue further evaluation for testicular malignancy with tumor markers and urologic consultation 1

Post-Varicocelectomy Hydrocele

• The risk of hydrocele formation is higher with non-artery-sparing procedures or those performed without microsurgical aid 2
• Initial management should include observation with or without hydrocele aspiration 2
• Large persistent hydroceles are best served by open hydrocelectomy 2

Critical Pitfalls to Avoid

• Never delay evaluation of acute scrotal swelling, as testicular torsion must be ruled out emergently, with testicular viability being compromised after 6-8 hours 1
• Do not confuse hydrocele with inguinal hernia, which requires more prompt surgical intervention 1
• Physical examination with orchidometer is adequate for routine volume assessment, but ultrasound should be reserved for cases with large hydrocele, thickened scrotal skin, or concern for underlying pathology 1
• In infertile males, be aware of an 18-fold higher risk of testicular cancer with testicular microcalcifications, warranting high suspicion for malignancy with "complex hydrocele" findings 1