Hydrocele Treatment
For symptomatic hydroceles in adults and children over 18-24 months, surgical hydrocelectomy via scrotal or inguinal approach is the definitive treatment, while congenital hydroceles in infants typically resolve spontaneously and should be observed. 1
Initial Assessment and Diagnosis
Before treating any scrotal swelling, immediately rule out testicular torsion and inguinal hernia—both are surgical emergencies requiring intervention within 6-8 hours. 2, 1 Perform scrotal ultrasonography with Doppler to assess testicular blood flow and differentiate hydrocele from these life-threatening conditions. 1
Key diagnostic features on ultrasound include: 3
- Simple fluid collection between parietal and visceral layers of tunica vaginalis
- Normal testicular blood flow on color Doppler (sensitivity 96-100%) 1
- Absence of solid masses or complex features
In adolescents and young adults, any "complex hydrocele" on ultrasound warrants high suspicion for testicular malignancy and requires tumor marker evaluation and urologic consultation. 1
Age-Stratified Management Algorithm
Infants and Children Under 18-24 Months
Conservative observation is the standard approach, as congenital hydroceles typically resolve spontaneously within 18-24 months. 1, 4 These result from incomplete obliteration of the processus vaginalis during fetal development. 1
Critical exception: If there is fluctuation in hydrocele size or suspicion of inguinal hernia (which indicates a patent processus vaginalis), proceed directly to surgical repair via inguinal approach to ligate the patent processus vaginalis. 1 Do not delay—inguinal hernias require prompt surgical intervention, not observation. 1
Children Over 2 Years and Adolescents
Surgical hydrocelectomy is indicated for persistent hydroceles beyond 18-24 months. 1, 4
Surgical approach selection: 1
- Inguinal approach: Use when patent processus vaginalis is suspected (communicating hydrocele), as this allows ligation to prevent recurrence
- Scrotal approach: Standard for non-communicating hydroceles in children over 12 years, with lower morbidity when no patent processus vaginalis exists
The "pull-through" technique achieves 95% cure rate with minimal complications and early recovery through a small 15mm incision. 1
Adults
Symptomatic hydroceles require surgical hydrocelectomy, which is the definitive treatment. 1, 3 Indications for surgery include: 1
- Bothersome symptoms (discomfort, heaviness)
- Impact on daily activities or sexual function
- Fertility concerns (bilateral hydroceles increase scrotal temperature and impair testicular function)
- Large size affecting quality of life
For small, asymptomatic bilateral hydroceles in adults: Obtain scrotal ultrasound with Doppler to exclude underlying pathology, consider fertility evaluation in men of reproductive age, and observe if truly asymptomatic. 1
Non-Surgical Treatment Options
Aspiration and sclerotherapy with doxycycline is an effective alternative for patients who are poor surgical candidates or refuse surgery, with 84% success rate after a single treatment. 5 This approach:
- Avoids hospital expense and surgical complications
- Achieves success rates similar to hydrocelectomy
- Works best for simple, non-septated hydroceles 5
- May cause moderate pain for 2-3 days 5
If initial aspiration and sclerotherapy fails, a second attempt can be made before proceeding to surgical hydrocelectomy. 5
Common Pitfalls to Avoid
Never delay evaluation of acute scrotal swelling—testicular torsion must be excluded emergently, as testicular viability is compromised after 6-8 hours. 2, 1 Even if hydrocele is suspected, obtain immediate Doppler ultrasound to confirm normal testicular perfusion.
Do not rush infants under 18-24 months to surgery unless there is concern for inguinal hernia or complications. 1 Most congenital hydroceles resolve spontaneously.
Recognize tension hydrocele as a rare but emergent cause of compromised testicular perfusion requiring immediate operative drainage. 6 This presents with acute pain, large hydrocele, and decreased testicular blood flow on Doppler.
In post-varicocelectomy hydroceles, initial management should include observation with or without aspiration, as many resolve spontaneously. 4 Reserve hydrocelectomy for large persistent hydroceles.
Surgical Risk Stratification
Hydrocele repair is classified as low bleeding risk (0-2% risk of bleeding >2 days), facilitating perioperative anticoagulation management decisions. 1