What are the recommended treatment options for a hydrocele, including indications for observation, surgical hydrocelectomy (open or laparoscopic), needle aspiration with sclerotherapy, and postoperative care?

Treatment of Hydrocele

Age-Specific Management Algorithm

Infants and Children Under 18-24 Months

Conservative observation is the recommended first-line approach for congenital hydroceles in infants, as spontaneous resolution occurs in the majority of cases within 18-24 months. 1

• Watchful waiting is appropriate because congenital hydroceles result from incomplete involution of the processus vaginalis and typically resolve without intervention 1
• Immediate surgical referral is required if there is suspicion of an underlying inguinal hernia, which presents as a surgical emergency requiring prompt repair rather than observation 1
• Rule out testicular torsion emergently with scrotal ultrasonography with Doppler in any acute presentation, as testicular viability is compromised after 6-8 hours 1

Critical pitfall: Do not rush to surgery in infants under 18-24 months unless there is concern for inguinal hernia or complications 1

Children Over 12 Years and Adolescents

Open hydrocelectomy via scrotal incision is the standard definitive treatment for non-communicating hydroceles in this age group. 1, 2

• Scrotal approach is preferred because it has lower morbidity in the absence of a patent processus vaginalis 1
• Inguinal approach should be used if there is a patent processus vaginalis requiring ligation to prevent recurrence 1
• Ultrasound is mandatory when the testis is not palpable to rule out underlying testicular malignancy, as "complex hydrocele" warrants high suspicion for testicular cancer 1

Adults

Hydrocelectomy is the standard and definitive treatment for symptomatic hydroceles in adults. 1, 2

Surgical Options:

• The "pull-through" technique allows removal of large hydrocele sacs through a small 15mm incision with minimal dissection, achieving a 95% cure rate with early recovery and minimal complications 1, 3
• Traditional open hydrocelectomy via scrotal incision remains the gold standard 2
• Mean operative time is approximately 27 minutes with the pull-through technique, and patients resume normal activity within 3-21 days (average 6 days) 3

Non-Surgical Alternative:

Aspiration with sclerotherapy using doxycycline is an effective non-surgical option for simple, non-septated hydroceles, achieving 84% success with a single treatment. 4

• This approach is particularly useful for patients who are poor surgical candidates or prefer to avoid surgery 4
• Success rates are comparable to hydrocelectomy while avoiding hospital expense and surgical complications 4
• Moderate pain may occur but typically resolves within 2-3 days 4
• Repeat treatment can be attempted if initial aspiration and sclerotherapy fails 4

Limitation: This technique is only appropriate for simple, non-septated hydroceles 4

Preoperative Evaluation

Scrotal ultrasound with Doppler is recommended to rule out surgical emergencies and underlying pathology, with 96-100% sensitivity for confirming normal testicular blood flow. 1

• Obtain complete blood count (CBC) only if significant perioperative blood loss is anticipated, though hydrocele repair is classified as low bleeding risk (0-2% risk) 1
• Coagulation studies are indicated only if the patient has a history of bleeding disorders or takes anticoagulants 1
• Routine preoperative testing (chest X-ray, ECG) is not required for healthy patients, as this is low-risk surgery 1

Special Considerations

Bilateral Hydroceles in Adults:

• Evaluate for epididymo-orchitis if any symptoms are present, as this is a common cause of acute scrotal pathology that can present with bilateral hydroceles 1
• Consider fertility evaluation in men of reproductive age, as bilateral hydroceles can contribute to infertility through increased scrotal temperature and testicular dysfunction 1
• Pursue further evaluation for testicular malignancy if complex features are present on ultrasound, including tumor markers and urologic consultation 1

Post-Varicocelectomy Hydroceles:

• Initial management should include observation with or without hydrocele aspiration 2
• Open hydrocelectomy is indicated for large persistent hydroceles 2
• Risk is higher with non-artery-sparing procedures or those performed without microsurgical aid 2

Non-Surgical Management for Non-Candidates

For patients with limited visual potential or significant comorbidities, conjunctival flap, amniotic membrane transplant, or scarification procedures may be considered as alternatives to definitive surgery. 5

• Anterior stromal puncture with electrocautery or needle can be effective but requires caution to avoid corneal necrosis and melt 5

Key Clinical Pitfalls

• 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
• Avoid forcing retraction of a phimotic foreskin in children, as this can cause paraphimosis or traumatic injury 6
• Recognize that bilateral hydroceles with scrotal wall thickening suggest infectious etiology requiring antibiotic treatment 1