What are the management options for a patient with hydrocoele (hydrocele)?

Management of Hydrocele

Initial Diagnostic Evaluation

All patients presenting with scrotal swelling require scrotal ultrasonography with Doppler to rule out testicular torsion and inguinal hernia, both of which are surgical emergencies requiring immediate intervention. 1

• Perform scrotal ultrasound with Doppler to assess testicular blood flow, differentiate hydrocele from other pathology, and exclude underlying testicular masses 1
• Ultrasound has 96-100% sensitivity and 84-95% specificity for confirming normal testicular blood flow and excluding torsion 1
• In adolescents and young adults, "complex hydrocele" on ultrasound warrants high suspicion for testicular malignancy 1
• Physical examination with orchidometer is adequate for routine volume assessment; reserve ultrasound for large hydroceles, thickened scrotal skin, or concern for underlying pathology 1

Age-Stratified Management Approach

Infants and Children (Under 18-24 Months)

Conservative management with observation is recommended, 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
• Evaluate carefully for inguinal hernia, which requires prompt surgical repair rather than observation 1

Children Over 2 Years and Adolescents

Surgical intervention via inguinal or scrotal approach is indicated for persistent hydroceles beyond 18-24 months. 1, 2

• Inguinal approach allows for ligation of the patent processus vaginalis, preventing recurrence by addressing the underlying cause 1
• Scrotal approach (open hydrocelectomy via scrotal incision) is the standard treatment for non-communicating hydroceles in children over 12 years, with 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

Adults

Hydrocelectomy is the standard and definitive treatment for symptomatic hydroceles in adults. 1, 3

• Surgery is indicated for functional disorders, significant discomfort, or impact on daily activities 1, 3
• The two principal surgical techniques are Lord's plication procedure and excision 3
• The "pull-through" technique allows removal of large hydrocele sacs through a small incision (15 mm) with minimal dissection, achieving 95% cure rate with early recovery and minimal complications 1
• Main surgical complications include potential hematoma and injury to epididymis, vas deferens, or cord structures 3

Non-Surgical Treatment Options

Aspiration and sclerotherapy with doxycycline is an effective nonsurgical alternative for simple, nonseptated hydroceles, achieving 84% success with a single treatment. 4

• This approach is particularly useful for patients who are poor surgical candidates or prefer to avoid surgery 4
• Success rate of 84% with single treatment is comparable to hydrocelectomy while avoiding hospital expense and many surgical complications 4
• Three patients (10%) reported moderate pain which resolved in 2-3 days 4
• Sclerotherapy has limited indications and is best reserved for simple, nonseptated hydroceles 3, 4
• If initial aspiration and sclerotherapy fails, a second attempt can be made before proceeding to surgical correction 4

Special Clinical Scenarios

Post-Varicocelectomy Hydrocele

• Risk of hydrocele formation is higher with non-artery-sparing procedures or those performed without microsurgical aid, and in surgery requiring cord dissection 2
• Initial management should include observation with or without hydrocele aspiration 2
• Large persistent hydroceles are best served by open hydrocelectomy 2

Bilateral Hydroceles in Adults

• Evaluate for epididymo-orchitis if any symptoms are present 1
• Consider fertility evaluation in men of reproductive age, as bilateral hydroceles can contribute to infertility through increased scrotal temperature and testicular dysfunction 1
• Bilateral hydroceles with scrotal wall thickening and increased vascularity suggest infectious etiology 1

Giant Hydroceles

• Giant hydroceles (equal to or bigger than the patient's head) significantly affect quality of life through complications, infertility, sexual dysfunction, and work capacity 5
• These require surgical management due to their impact on patient function 5

Critical Pitfalls to Avoid

• Never delay evaluation of acute scrotal swelling, as testicular torsion must be ruled out emergently—testicular viability is compromised after 6-8 hours 1
• Do not confuse hydrocele with inguinal hernia, which requires more prompt surgical intervention 1
• Avoid repeating cytology or relying solely on physical examination when ultrasound is indicated 1
• The risk of surgical bleeding for hydrocele repair is classified as low (0-2% risk of bleeding greater than 2 days), facilitating perioperative decision-making in patients with special anticoagulation needs 1

Management Algorithm Summary

1. Obtain scrotal ultrasound with Doppler to exclude emergencies and characterize the hydrocele 1
2. If infant <18-24 months: observe for spontaneous resolution unless hernia suspected 1
3. If child >2 years or adolescent: proceed with surgical correction (inguinal approach if communicating, scrotal if non-communicating) 1, 2
4. If adult with symptomatic hydrocele: offer hydrocelectomy as definitive treatment 1, 3
5. If adult prefers nonsurgical approach or is poor surgical candidate: consider aspiration and sclerotherapy with doxycycline for simple, nonseptated hydroceles 4
6. If complex features present on ultrasound: pursue further evaluation for testicular malignancy with tumor markers and urologic consultation 1