What is the appropriate management of a hydrocele in a healthy 25‑year‑old adult male?

Treatment of Hydrocele in a 25-Year-Old Adult

For a healthy 25-year-old adult male with hydrocele, surgical hydrocelectomy is the definitive treatment, though aspiration with sclerotherapy using doxycycline offers an effective nonsurgical alternative with 84% success rates for simple, nonseptated hydroceles.

Initial Diagnostic Confirmation

Before proceeding with treatment, confirm the diagnosis and rule out concerning pathology:

• Physical examination should demonstrate complete transillumination of the scrotal swelling, which is pathognomonic for clear fluid collection characteristic of hydrocele 1
• Scrotal ultrasound is mandatory in young men (particularly those under 40) to exclude underlying testicular tumors, as hydroceles can occasionally mask malignancies 2
• Be particularly cautious of "complex hydrocele" findings on ultrasound showing septations or irregular features in young males, as these may represent testicular tumors rather than simple hydroceles 2
• Ensure the hydrocele is simple and nonseptated on imaging, as this determines treatment eligibility 3

Treatment Algorithm

Conservative Management (Observation)

• Small, asymptomatic hydroceles can be managed conservatively with observation, as they may resolve spontaneously or remain stable without causing functional impairment 4
• This approach is reasonable only when the hydrocele causes no discomfort, cosmetic concerns, or interference with daily activities 4

Nonsurgical Treatment: Aspiration and Sclerotherapy

For patients who prefer to avoid surgery or have medical contraindications, aspiration with doxycycline sclerotherapy achieves 84% success with a single treatment:

• This approach is appropriate only for simple, nonseptated hydroceles confirmed on ultrasound 3
• The procedure involves aspiration of hydrocele fluid followed by injection of doxycycline as a sclerosing agent 3
• Success is defined as decreased scrotal size, improved physical symptoms, and patient satisfaction with mean follow-up of 20.8 months 3
• Moderate pain lasting 2-3 days occurs in approximately 10% of patients but resolves without intervention 3
• If the first treatment fails, a second aspiration and sclerotherapy can be attempted before proceeding to surgery 3
• This success rate (84%) is comparable to surgical hydrocelectomy while avoiding hospital expenses and surgical complications 3

Surgical Treatment: Hydrocelectomy

Surgical hydrocelectomy remains the gold standard definitive treatment:

• Surgery is indicated for symptomatic hydroceles, large hydroceles causing discomfort or cosmetic concerns, or failed sclerotherapy 4
• The standard approach is scrotal or inguinal incision with excision or plication of the tunica vaginalis 4
• Surgical success rates are high and comparable to sclerotherapy (approximately 84-90%), but with the added benefits of direct visualization and ability to address any unexpected pathology 3

Critical Clinical Pitfalls to Avoid

• Never proceed with treatment without ultrasound confirmation in young men, as testicular tumors can present with reactive hydroceles and may be missed on physical examination alone 2
• Do not attempt sclerotherapy on complex or septated hydroceles, as these have lower success rates and may harbor underlying pathology requiring surgical exploration 3
• Be aware that giant or abdominoscrotal hydroceles (extending into the abdomen) always require surgical management, typically via inguinal or combined approaches 5, 6
• Ipsilateral undescended testicle, testicular dysmorphism, or contralateral pathology may accompany hydroceles and should be identified preoperatively 6

Practical Decision-Making Framework

For a typical 25-year-old with confirmed simple hydrocele:

1. If asymptomatic and small: Offer observation with reassurance 4
2. If symptomatic but patient prefers nonsurgical approach: Offer aspiration with doxycycline sclerotherapy as first-line treatment 3
3. If patient prefers definitive treatment or sclerotherapy fails: Proceed with surgical hydrocelectomy 4, 3
4. If ultrasound shows any complexity, septations, or concerning features: Mandatory surgical exploration to exclude malignancy 2

The choice between sclerotherapy and surgery should be based on patient preference, symptom severity, and ultrasound findings, with both approaches offering comparable success rates for appropriately selected simple hydroceles 3.