What is the best approach for treating a hydrocele in a teenager?

Hydrocele Treatment in Teenagers

For adolescents with hydrocele, open hydrocelectomy via scrotal incision is the standard definitive treatment, as spontaneous resolution does not occur in this age group unlike in infants. 1, 2

Initial Diagnostic Evaluation

Before proceeding with treatment, rule out surgical emergencies and underlying pathology:

• Obtain scrotal ultrasound with Doppler to exclude testicular torsion (which compromises testicular viability after 6-8 hours) and to evaluate for testicular masses, as "complex hydrocele" in adolescents warrants high suspicion for testicular malignancy 1
• Assess for inguinal hernia, which requires prompt surgical repair rather than observation 1
• Evaluate for fluctuation in hydrocele size during history-taking, as this indicates a patent processus vaginalis requiring different surgical approach 2

Treatment Algorithm for Adolescents

Primary Treatment: Surgical Hydrocelectomy

The scrotal approach is the standard treatment for non-communicating hydroceles in adolescents over 12 years, offering lower morbidity when there is no patent processus vaginalis 1. This differs fundamentally from infants, where observation is appropriate since congenital hydroceles typically resolve within 18-24 months 1.

Key surgical considerations:

• If the testis is palpable: Proceed with open hydrocelectomy via scrotal incision, which is the standard treatment for idiopathic hydroceles in adolescents 2
• If the testis is non-palpable: Scrotal ultrasonography is mandatory to rule out underlying testicular solid mass, which would require inguinal exploration instead 2
• If patent processus vaginalis is present: Use inguinal approach to allow ligation of the patent processus vaginalis, preventing recurrence by addressing the underlying cause 1

Alternative Non-Surgical Option

Aspiration and sclerotherapy with doxycycline can be considered as a non-surgical alternative, with 84% success rate for simple non-septated hydroceles after a single treatment 3. However, this is typically reserved for patients who are poor surgical candidates or refuse surgery, as hydrocelectomy remains the definitive standard treatment 1.

Critical Pitfalls to Avoid

• Do not observe and wait in adolescents as you would in infants under 18-24 months—spontaneous resolution does not occur after early childhood 1, 2
• Do not confuse hydrocele with inguinal hernia, which requires more urgent surgical intervention 1
• Do not delay evaluation of acute scrotal swelling, as testicular torsion must be ruled out emergently 1
• Do not proceed with scrotal approach if testis is non-palpable without first obtaining ultrasound to exclude testicular mass 2

Special Consideration: Post-Varicocelectomy Hydrocele

If hydrocele develops after varicocelectomy (the second most common cause in adolescents), initial management should include observation with or without aspiration, reserving open hydrocelectomy for large persistent hydroceles 2.