Treatment for Hydrocele
For infants and children under 2 years, observe for spontaneous resolution up to 18-24 months; for older children and adults with symptomatic hydroceles, hydrocelectomy via appropriate surgical approach is the definitive treatment. 1, 2
Initial Emergency Assessment
Before considering any treatment, immediately rule out surgical emergencies:
- Perform scrotal ultrasound with Doppler to exclude testicular torsion (viability compromised after 6-8 hours) and inguinal hernia, both requiring immediate surgical intervention 1
- In adolescents and young adults, complex hydroceles on ultrasound warrant high suspicion for testicular malignancy, particularly in infertile males who have 18-fold higher risk with testicular microcalcifications 1
- Bilateral hydroceles with scrotal wall thickening and increased vascularity suggest epididymo-orchitis requiring antibiotic treatment before addressing the hydrocele 1
Treatment Algorithm by Age and Clinical Scenario
Infants and Children Under 18-24 Months
Conservative management with observation is recommended, as congenital hydroceles from incomplete processus vaginalis involution typically resolve spontaneously within this timeframe 1, 2
Critical exception: Do not delay surgery if there is suspicion of underlying inguinal hernia, which requires prompt surgical repair rather than observation 1, 2
Children Over 2 Years and Adolescents
Surgical intervention is indicated when hydrocele persists beyond 24 months or symptoms become significant 2
- Inguinal approach is preferred when patent processus vaginalis is present, allowing ligation to prevent recurrence by addressing the underlying cause 1
- Scrotal approach (open hydrocelectomy) is the standard for non-communicating hydroceles in children over 12 years, offering lower morbidity when no patent processus vaginalis exists 1, 3
Adults
For symptomatic hydroceles, hydrocelectomy is the standard and definitive treatment with 95% cure rate 1
Surgical technique options:
- The "pull-through" technique allows removal of large hydrocele sacs through small incisions (15 mm) with minimal dissection, resulting in early recovery and minimal complications 1
- Scrotal approach hydrocelectomy remains the standard surgical treatment 3
For asymptomatic or minimally symptomatic cases, observation is reasonable 2
For patients who decline surgery or are poor surgical candidates, aspiration and sclerotherapy with doxycycline is an effective alternative with 84% success rate after single treatment 2, 4
Special Clinical Considerations
Bilateral Hydroceles in Adults
- Evaluate for epididymo-orchitis if symptomatic 1
- Consider fertility evaluation in men of reproductive age, as bilateral hydroceles can contribute to infertility through increased scrotal temperature and testicular dysfunction 1
- Surgical intervention is recommended if affecting fertility or impacting daily activities 1
Post-Varicocelectomy Hydroceles
Initial management should include observation with or without aspiration; large persistent hydroceles are best treated with open hydrocelectomy 3
Common Pitfalls to Avoid
- Never delay evaluation of acute scrotal swelling—testicular torsion must be ruled out emergently 1
- Do not rush to surgery in infants under 18-24 months unless there is concern for inguinal hernia or complications 1
- Do not confuse hydrocele with inguinal hernia, which requires more prompt surgical intervention 1
- Physical examination with orchidometer is adequate for routine assessment; reserve ultrasound for large hydroceles, thickened scrotal skin, or concern for underlying pathology 1
Perioperative Considerations
Hydrocele repair is classified as low bleeding risk (0-2% risk of bleeding >2 days), facilitating perioperative decision-making in patients with special anticoagulation needs 1