What is the recommended management for an adult male with chronic hydrocele?

Management of Chronic Hydrocele in Adults

Definitive Treatment Recommendation

Surgical hydrocelectomy is the gold standard treatment for chronic hydrocele in adults when functional disorders or symptoms are present 1. The primary surgical techniques include excision (Bergman procedure) or plication (Lord procedure), both of which have proven highly satisfactory with low complication rates 2.

Indications for Surgical Intervention

Surgery should be offered when the hydrocele causes:

• Functional impairment or discomfort 1
• Significant scrotal enlargement affecting daily activities 3
• Persistent pain interfering with quality of life 4
• Concern for underlying testicular pathology 5

Pre-operative Evaluation

Before any surgical intervention, scrotal ultrasound with Doppler imaging must be performed to rule out underlying testicular malignancy, which can be masked by hydrocele fluid 5. This is critical because:

• Infertile males with testicular abnormalities have an 18-fold higher risk of testicular cancer when microcalcifications are present 5
• Ultrasound has 96-100% sensitivity and 84-95% specificity for evaluating testicular pathology 5
• The examination should assess testicular parenchymal architecture, looking for hypoechoic masses or non-homogeneous architecture suggesting malignancy 5

If ultrasound reveals a suspicious intratesticular mass:

• Obtain serum tumor markers (AFP, β-HCG, LDH) 5
• Discuss sperm banking before any intervention 5
• Proceed with radical inguinal orchiectomy (never scrotal approach) if malignancy is confirmed 5

Surgical Technique Selection

Primary Surgical Options

Excision technique (Bergman procedure) was used in 32.81% of cases with excellent outcomes 2. This involves:

• Complete resection of the tunica vaginalis covering sheets as prophylaxis against recurrence 2
• Standard approach for most adult hydroceles 1

Plication technique (Lord procedure) was used in 61.45% of cases with comparable success 2. This approach:

• Involves plication of the hydrocele sac without excision 1
• May be preferred in certain anatomical situations 1

Minimally Invasive Alternative

Individualized minimally invasive hydrocelectomy can be considered for appropriate candidates 3. This technique involves:

• A 2-cm incision in the anterior scrotal wall 3
• Drainage of effusion and partial dissection of tunica vaginalis 3
• Resection scope determined by ultrasound measurements: maximum diameter of resected sheath = approximately πd/2, where d is the maximum diameter of effusion 3
• Median operation time of 18 minutes 3
• Complication rate of only 7.7% (mild scrotal edema, hematoma, or wound infection) 3
• No recurrence, chronic pain, or testicular atrophy during 12-month follow-up 3

Postoperative Management

Immediate postoperative care should include:

• Bed rest and scrotal elevation for the first 24-48 hours to reduce swelling 4
• Regular analgesics and anti-inflammatory medications for pain management 4
• Close monitoring for complications 4

Expected Complications and Their Management

Potential surgical complications include:

• Hematoma (most common): occurred in 1.56% requiring reoperation in one series 2, and 3.8% in minimally invasive series 3
• Infection/suppuration: occurred in 1.02-1.9% of cases 3, 2
• Injury to epididymis, vas deferens, or cord structures 1
• Testicular vascular compromise: rare but requires immediate reoperation 2
• Chronic pain: a potential long-term complication requiring evaluation 4

These complications are typically preventable with:

• Meticulous surgical technique 2
• Adequate hemostasis time 2
• Attention to local tissue status 2

Alternative Non-Surgical Options

Sclerotherapy has limited indications and is not recommended as first-line treatment 1.

Aspiration alone provides only temporary relief with high recurrence rates and should not be used as definitive management 4.

Conservative management with observation may be appropriate only for:

• Asymptomatic small hydroceles 4
• Patients with significant surgical contraindications 4

Critical Clinical Pitfalls to Avoid

Never perform scrotal incision or biopsy when testicular malignancy is suspected, as this violates lymphatic drainage pathways and may require subsequent hemiscrotectomy 5.

Always obtain pre-operative ultrasound to avoid missing underlying testicular pathology 5.

Ensure complete resection of tunica vaginalis as prophylaxis against recurrence 2.