Management of Hydrocele in Adult Males
Initial Assessment and Diagnosis
For an adult male with painless, progressively enlarging scrotal swelling consistent with hydrocele, the primary management decision hinges on whether the hydrocele is symptomatic, tense, or associated with underlying pathology—and ultrasound is essential to exclude testicular pathology before proceeding with any intervention. 1
Clinical Evaluation
Confirm the diagnosis through transillumination (positive in hydrocele due to clear fluid) and assess for reducibility (hydroceles are non-reducible with negative cough impulse, distinguishing them from inguinal hernias). 2
Obtain scrotal ultrasound with Doppler to confirm the fluid collection between the parietal and visceral layers of the tunica vaginalis, assess testicular morphology, and exclude underlying testicular tumors, epididymitis, or other pathology that may present with reactive hydrocele. 3, 1
Evaluate for secondary causes including trauma, infection, tumor, or systemic conditions that may cause fluid imbalance in the tunica vaginalis, as secondary hydroceles require treatment of the underlying etiology. 1
Classification and Pathophysiology
Primary (idiopathic) hydroceles result from imbalance between secretion and reabsorption of fluid from the tunica vaginalis mesothelial lining, while secondary hydroceles arise from identifiable causes such as infection, trauma, or malignancy. 1
In adults, hydroceles do not communicate with the peritoneal cavity (unlike communicating hydroceles in infants), making spontaneous resolution unlikely and necessitating intervention for symptomatic cases. 4, 1
Management Algorithm
Conservative Management
Asymptomatic, small hydroceles can be observed without intervention, as they pose no threat to testicular function or patient health. 1
Reassure the patient that observation is safe when ultrasound has excluded underlying pathology and the hydrocele causes no discomfort or functional impairment. 1
Indications for Intervention
Progressive enlargement causing discomfort, cosmetic concern, or functional impairment warrants surgical intervention, as these hydroceles will not resolve spontaneously in adults. 1
Tense hydroceles should be treated surgically to prevent potential compression of testicular blood supply, though this is rare in simple hydroceles. 5, 6
Any suspicion of underlying testicular pathology on ultrasound (solid components, septations, irregular walls) mandates surgical exploration rather than simple aspiration. 1
Treatment Options
Definitive Surgical Management (Preferred)
Hydrocelectomy is the definitive treatment with the lowest recurrence rates and should be performed via inguinal or scrotal approach depending on the clinical scenario. 1
Plication of the tunica vaginalis through scrotal approach is effective with minimal morbidity and is particularly useful for straightforward cases without concern for underlying pathology. 5
Excision or eversion of the tunica vaginalis can be performed, with both techniques showing excellent outcomes and low recurrence rates. 6, 1
Aspiration (Temporary Measure Only)
Fluid aspiration provides only temporary relief with high recurrence rates (often within weeks to months) and carries risks of infection, bleeding, and injury to testicular structures. 1
Aspiration may be considered only in patients who are poor surgical candidates due to severe comorbidities or as a temporizing measure, but patients must be counseled about the high likelihood of recurrence. 1
Sclerotherapy following aspiration has been described but is not standard practice due to concerns about chemical injury to the testis and spermatic cord structures. 1
Critical Pitfalls to Avoid
Never assume a scrotal fluid collection is benign hydrocele without ultrasound confirmation, as testicular tumors frequently present with reactive hydrocele, and missing this diagnosis has catastrophic consequences for mortality. 3, 1
Do not perform aspiration without first obtaining ultrasound, as this may delay diagnosis of underlying malignancy or other serious pathology. 1
Avoid expectant management in progressively enlarging hydroceles, as continued growth indicates ongoing fluid accumulation that will not spontaneously resolve in adults and may eventually cause patient distress requiring intervention anyway. 5, 6
In cases with any testicular dysmorphism on ultrasound, proceed directly to surgical exploration rather than simple aspiration, as this may indicate underlying pathology requiring direct visualization. 5, 6
Special Considerations
Bilateral hydroceles warrant careful evaluation for systemic causes of fluid retention (cardiac, hepatic, renal disease) before attributing them to primary scrotal pathology. 1
Postoperative complications of hydrocelectomy include scrotal hematoma, infection, and rarely recurrence, but overall morbidity is low with proper surgical technique. 5
Patients should be counseled that surgical repair is curative in the vast majority of cases, with recurrence rates under 5% when proper technique is employed. 5, 1