Treatment of Hydrocele in Boys
For boys with confirmed hydrocele on ultrasound, conservative management with observation is recommended for those under 18-24 months of age, as congenital hydroceles typically resolve spontaneously during this period. 1
Age-Based Treatment Algorithm
Infants and Young Children (Under 18-24 Months)
- Observe for spontaneous resolution, as congenital hydroceles result from incomplete obliteration of the processus vaginalis and typically resolve within 18-24 months without intervention 1, 2
- The prevalence of patent processus vaginalis declines from 80% in term male infants to 33-50% by age 1 year and 15% by age 5 years 2
- Do not rush to surgery unless there is concern for inguinal hernia or complications, as this is a common pitfall 1
Children Over 2 Years and Adolescents
Surgical intervention is indicated when hydroceles persist beyond 18-24 months or become symptomatic. 1, 3
Surgical Approach Selection:
For children under 12 years of age:
- Use the inguinal approach as first-line, since children in this age group are more likely to have a patent processus vaginalis (PPV) requiring ligation 4
- The inguinal approach allows for ligation of the PPV, preventing recurrence by addressing the underlying cause 1
- Studies show that 61% of adolescents treated via inguinal approach had a PPV requiring ligation 4
For adolescents 12 years and older:
- Consider the scrotal approach (Jaboulay procedure) as first-line when history does not suggest a communicating hydrocele 4
- The scrotal approach 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
- This approach offers shorter operative time (30.94±3.95 minutes vs 38.02±7.12 minutes), shorter hospital stay, and lower postoperative complication rates (3.2% vs 10.9%) compared to inguinal approach 5, 6
Critical Exclusions Before Treatment
Before initiating any treatment plan, immediately rule out surgical emergencies:
- Testicular torsion must be excluded emergently with scrotal ultrasound with Doppler, as testicular viability is compromised after 6-8 hours 1, 7
- Inguinal hernia requires prompt surgical repair rather than observation, and carries a 25-50% risk with patent processus vaginalis 1, 2
- Ultrasound with Doppler has 96-100% sensitivity and 84-95% specificity for confirming normal testicular blood flow 1
Special Considerations
Reactive Hydrocele
- If the hydrocele is secondary to epididymitis or other inflammatory conditions, treat the underlying cause first with conservative management (bed rest, scrotal elevation, analgesics) 7
- Most reactive hydroceles resolve spontaneously with successful treatment of the underlying condition 7
Complex Features on Ultrasound
- In adolescents, "complex hydrocele" on ultrasound warrants high suspicion for testicular malignancy and requires further evaluation with tumor markers and urologic consultation 1
Common Pitfalls to Avoid
- Never delay evaluation of acute scrotal swelling, as testicular torsion must be ruled out emergently 1
- Do not perform surgery in infants under 18-24 months unless there is concern for inguinal hernia or complications 1
- Do not assume all hydroceles in adolescents are communicating—age less than 12 years is associated with presence of PPV, but older adolescents may have non-communicating hydroceles better served by scrotal approach 4
- Always obtain ultrasound when clinical diagnosis is uncertain or to exclude underlying testicular pathology, particularly solid masses 2, 3