Causes of Hydrocele in Adults
Primary Causes
In adults, hydrocele is predominantly acquired and idiopathic, resulting from an imbalance between fluid production and reabsorption by the tunica vaginalis. 1
Idiopathic (Most Common)
- The majority of adult hydroceles are idiopathic, caused by disrupted equilibrium in the normal process of fluid production and reabsorption within the tunica vaginalis 1
- Unlike pediatric hydroceles which typically result from patent processus vaginalis, adult hydroceles represent acquired pathology 1
Secondary Causes
Post-Surgical (Varicocelectomy)
- Varicocelectomy is the second most common cause of hydrocele in adolescents and adults 1
- Risk is substantially higher with non-artery-sparing procedures or those performed without microsurgical technique, particularly when extensive cord dissection is required 1
Infectious/Inflammatory
- Epididymo-orchitis can present with reactive hydrocele formation 2
- Bilateral hydroceles with scrotal wall thickening and increased vascularity suggest infectious etiology 3
- Epididymitis is the most common cause of acute scrotal pathology in adults and can present with associated hydrocele 3, 4
Trauma
- Scrotal trauma can lead to reactive fluid accumulation within the tunica vaginalis 2
Testicular Malignancy
- "Complex hydrocele" on ultrasound warrants high suspicion for underlying testicular malignancy, particularly in adolescents and young adults 3
- Testicular cancer must be included in the differential diagnosis of persistent scrotal swelling or pain after completing antimicrobial treatment 4
- Infertile males with testicular microcalcifications have an 18-fold higher risk of testicular cancer 3
Segmental Testicular Infarction
- Can present with reactive hydrocele, typically appearing as wedge-shaped avascular areas on ultrasound 2
- Median age of presentation is 37-38 years 2
Critical Diagnostic Considerations
Rule Out Surgical Emergencies First
- Testicular torsion must be excluded emergently, as testicular viability is compromised after 6-8 hours 3
- Inguinal hernia requires prompt surgical repair rather than observation 3
- Scrotal ultrasonography with Doppler is mandatory to assess testicular blood flow and differentiate hydrocele from torsion 3
Key Clinical Pitfalls
- Do not delay evaluation of acute scrotal swelling—testicular torsion must be ruled out emergently 3
- Any fluctuation in hydrocele size suggests patent processus vaginalis, which is uncommon in adults but requires different surgical approach 1
- In non-palpable testicles, scrotal ultrasonography is mandatory to rule out underlying testicular solid mass requiring inguinal exploration 1
- Physical examination with orchidometer is adequate for routine volume assessment, but ultrasound should be obtained for large hydroceles, thickened scrotal skin, or concern for underlying pathology 3