How should a hydrocele be diagnosed and managed in infants, children, and adults?

Hydrocele: Diagnosis and Management

Immediate Diagnostic Priorities

The first step is to perform scrotal ultrasonography with Doppler to rule out testicular torsion and inguinal hernia, which are surgical emergencies requiring immediate intervention. 1

• Ultrasound has 96-100% sensitivity and 84-95% specificity for confirming normal testicular blood flow and excluding testicular torsion 1
• Color Doppler assessment is critical because testicular viability is compromised after 6-8 hours of torsion 1
• Physical examination alone is inadequate when large hydrocele, thickened scrotal skin, or concern for underlying pathology exists 1

Age-Specific Management Algorithm

Infants and Children Under 18-24 Months

Conservative management with observation is recommended, as congenital hydroceles typically resolve spontaneously within 18-24 months. 1

• Hydroceles result from incomplete involution of the processus vaginalis, which normally obliterates during fetal development 1
• When the processus vaginalis remains patent, peritoneal fluid accumulates in the scrotum 1
• Do not rush to surgery unless there is concern for inguinal hernia or complications 1
• Inguinal hernia requires prompt surgical repair rather than observation and must be distinguished from simple hydrocele 1

Children Over 12 Months and Adolescents

Surgical intervention is indicated if the hydrocele persists beyond 18-24 months or if inguinal hernia is suspected. 1

• The 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
• In adolescents and young adults, "complex hydrocele" on ultrasound warrants high suspicion for testicular malignancy 1

Adults

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

• The "pull-through" technique allows removal of large hydrocele sacs through a small incision (15 mm) with minimal dissection, achieving a 95% cure rate 1
• For bilateral hydroceles, evaluate for epididymo-orchitis if symptoms are present, and 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 requiring antibiotic treatment 1

Surgical Decision-Making

Surgery is indicated when hydroceles are symptomatic, affecting fertility, or impacting daily activities. 1

• Hydrocele repair is classified as low bleeding risk (0-2% risk of bleeding >2 days) 1
• Routine preoperative testing (chest X-ray, ECG) is not required for healthy patients undergoing hydrocele surgery 1
• Complete blood count should be obtained only if significant perioperative blood loss is anticipated 1
• Coagulation studies are needed only if the patient has a history of bleeding disorders or is taking anticoagulants 1

Alternative Management Options

For patients who decline surgery or have contraindications, aspiration with sclerotherapy can provide temporary relief, though recurrence is common. 2

• Aspiration of hydrocele fluid can provide temporary relief for persistent pain despite conservative management 2
• Multiple studies report 85-96% success rates using aspiration combined with sclerotherapy 3
• Conservative measures include local heat or cold application, bed rest during acute episodes, and analgesics 2

Critical Pitfalls to Avoid

Never delay evaluation of acute scrotal swelling, as testicular torsion must be ruled out emergently. 1

• Do not confuse hydrocele with inguinal hernia, which requires more prompt surgical intervention 1
• If complex features are present on ultrasound, pursue further evaluation for testicular malignancy with tumor markers and urologic consultation 1
• In pediatric patients, avoid unnecessary surgery in infants under 18-24 months unless hernia or complications are present 1

Specialist Referral Criteria

Pediatric urologist consultation should be obtained for complex cases, suspected malignancy, or when inguinal hernia cannot be excluded. 4

• Pediatric urologists have completed 2-year pediatric urology fellowship after urology training and board certification 4
• Solid malignancies of the testicle should be treated from the outset by a pediatric urologist in conjunction with a pediatric medical cancer specialist 4