Management of Congenital Hydrocele
Congenital hydroceles typically resolve spontaneously within 18-24 months and should be managed conservatively with observation during this period, with surgery reserved only for those with associated inguinal hernia or development of a huge hydrocele. 1, 2
Understanding the Natural History
Congenital hydroceles result from incomplete obliteration of the processus vaginalis during fetal development, creating a communication between the peritoneal cavity and scrotum. 2 The prevalence of patent processus vaginalis is remarkably high—up to 80% in term male infants—but this declines dramatically to 33-50% by age 1 year and 15% by age 5 years. 2
The spontaneous resolution rate is excellent: 89% of hydroceles presenting in the first year of life will resolve or show marked improvement without intervention. 3 This high resolution rate has been confirmed across multiple studies, with one series showing 62.7% complete resolution by mean age 11.7 months. 4
Initial Assessment
When evaluating a suspected congenital hydrocele, you must first rule out surgical emergencies:
- Perform scrotal ultrasound with Doppler to exclude testicular torsion and inguinal hernia, both of which require immediate surgical intervention. 1
- Testicular torsion compromises viability after 6-8 hours, making urgent evaluation critical. 1
- Physical examination should assess for reducibility and fluctuation in size, which indicate a communicating hydrocele. 4
Management Algorithm by Age
Infants Under 18-24 Months
Conservative management with observation is the standard approach. 1, 2 Here's the specific protocol:
- Follow the infant clinically without surgical intervention for at least 12 months, and up to 18-24 months. 1, 5
- Monitor for changes in size, particularly diurnal fluctuations (present in 92% of cases). 3
- Spontaneous resolution can occur even beyond age 2 years, though the rate decreases with age. 5
Immediate surgical intervention is indicated only for:
- Associated inguinal hernia (7% of cases) 3
- Development of a huge hydrocele causing tension or testicular compromise (3% of cases) 3
Critical Pitfall to Avoid
Do not rush to surgery in infants under 18-24 months unless there is concern for inguinal hernia or complications. 1 The risk of hernia development during observation is 25-50% with a patent processus vaginalis, but actual incarceration is rare—in one series of 110 patients, only 6 developed hernias during observation and none experienced incarceration. 2, 4
Children Over 2 Years
After 18-24 months, if the hydrocele persists without spontaneous resolution, surgical intervention becomes appropriate. 1 The specific approach depends on the type:
- For communicating hydroceles: inguinal approach with high ligation of the patent processus vaginalis to prevent recurrence by addressing the underlying cause. 1
- For non-communicating hydroceles in children over 12 years: scrotal approach (open hydrocelectomy) with lower morbidity in the absence of a patent processus vaginalis. 1
Special Considerations
Bilateral Hydroceles
Most infants (69% in one series) present with bilateral hydroceles. 4 The management approach remains the same—observation during the first 18-24 months. 1
Premature Infants
Neither gestational age at birth nor age at presentation affects resolution rates. 4 Apply the same conservative management strategy regardless of prematurity. 3
Abdominoscrotal Hydrocele
This is a distinct entity requiring different management. Tense infantile abdominoscrotal hydroceles are associated with high rates of testicular dysmorphism (78% in one series) and require early intervention, as testicular abnormalities are often reversed by surgery. 6 These should not be managed expectantly like simple congenital hydroceles.
Complex or Atypical Features
If ultrasound shows complex features (septations, solid components, or thickened walls), further evaluation for testicular malignancy is mandatory, particularly in adolescents where complex hydroceles warrant high suspicion for underlying pathology. 1