In an adult male with a newly noticed painless scrotal swelling suggestive of an inguinal hydrocele, what is the recommended diagnostic work‑up and management?

Inguinal Hydrocele in Adult Males: Diagnostic Work-Up and Management

Initial Diagnostic Approach

In an adult male presenting with painless scrotal swelling suggestive of hydrocele, scrotal ultrasound with Doppler is mandatory to confirm the diagnosis, assess testicular viability, rule out underlying testicular pathology, and evaluate for a patent processus vaginalis. 1

Key Clinical Features to Assess

• Absence of inflammatory signs (warmth, erythema, tenderness) effectively rules out epididymitis and orchitis, which characteristically present with increased vascularity, pain, and inflammatory markers 1
• Transillumination of the scrotal swelling demonstrates the fluid-filled nature of the hydrocele, though this clinical sign alone is insufficient for definitive diagnosis 2
• Painless, fluctuant mass is the hallmark presentation, distinguishing hydrocele from acute inflammatory or torsional pathology 3
• Bilateral versus unilateral presentation and chronicity of symptoms help differentiate congenital from acquired hydroceles 2

Ultrasound Findings

The ultrasound examination should specifically evaluate:

• Anechoic fluid collection between the parietal and visceral layers of the tunica vaginalis 2
• Normal testicular echotexture and vascularity on Doppler to exclude underlying testicular pathology (tumor, torsion, infection) 1
• Patent processus vaginalis if present, which may communicate with the peritoneal cavity 3
• Size and complexity of the hydrocele (simple versus septated/complex) 4

Etiology and Classification

Primary (Idiopathic) Hydroceles

• Most adult hydroceles are idiopathic in origin, resulting from an imbalance between secretion and reabsorption of fluid from the tunica vaginalis 2
• Affects approximately 1% of adult men 4

Secondary Hydroceles

Secondary causes that must be excluded include:

• Prior inguinal surgery or varicocelectomy 4
• Infection or trauma to the scrotum 4
• Underlying testicular tumor (critical to exclude via ultrasound) 5
• Patent processus vaginalis (more common in congenital cases but can persist into adulthood) 3

Management Algorithm

Conservative Management

Conservative observation is appropriate for small, asymptomatic hydroceles that do not interfere with daily activities. 2

• Monitor for complications such as tense hydroceles that can cause testicular dysmorphism and vascular compromise, though this is rare and typically presents with pain or distress 1
• Regular follow-up to assess for growth or development of symptoms 6

Indications for Intervention

Intervention is warranted when:

• Hydrocele grows to a critical size causing discomfort or difficulty walking 6
• Patient discomfort or cosmetic concerns become significant 2
• Tense hydrocele with risk of testicular compression 1
• Underlying testicular pathology is identified on ultrasound 5

Treatment Options

Surgical Hydrocelectomy (Gold Standard)

Surgical removal of hydroceles is the gold standard of care, offering definitive treatment with the lowest recurrence rates. 4

• Open excision with high ligation of the processus vaginalis (if patent) is the definitive approach 7
• Particularly indicated for large, symptomatic, or recurrent hydroceles 6

Aspiration with Sclerotherapy

• Success rates of 85-96% have been reported using aspiration combined with sclerotherapy 4
• Consider for patients who are poor surgical candidates or prefer minimally invasive options 4
• Recurrence risk is higher than with surgical excision 6
• Combination of thrombolytic therapy, catheter drainage, and alcohol ablation has been used successfully for complex recurrent hydroceles 4

Critical Pitfalls to Avoid

Do Not Miss Testicular Torsion

• Although hydrocele presents as painless swelling, any acute scrotal pain must be treated as a potential surgical emergency until torsion is excluded 8
• Testicular torsion presents with sudden severe pain and negative Prehn sign, requiring immediate intervention within 6-8 hours 9, 1
• A reactive ipsilateral hydrocele can be present in cases of testicular torsion, potentially causing diagnostic confusion 9

Do Not Miss Underlying Testicular Tumor

• Ultrasound is mandatory to exclude intratesticular masses, as a painless testicular mass is pathognomonic for testicular tumor 5
• Any suspicious intratesticular abnormality (hypoechoic mass, macrocalcification) identified on ultrasound warrants further evaluation and possible biopsy 5

Recognize Recurrent Hydroceles

• Recurrence despite repeated drainage may indicate communication with the peritoneal cavity or coexistent pathology requiring surgical repair 6
• High ligation of the processus vaginalis is essential during surgical repair to prevent recurrence 7

Special Considerations

Inguinal Hydrocele Versus Scrotal Hydrocele

• Inguinal hydroceles may extend along the spermatic cord and require differentiation from inguinal hernias 7
• In females, hydrocele of the canal of Nuck (analogous to male spermatic cord hydrocele) presents as painless inguinal swelling and is often misdiagnosed as inguinal hernia 7

Complex or Septated Hydroceles

• Complex hydroceles with septations may require combination therapy with thrombolytic agents and sclerotherapy 4
• Ultrasound characterization of simple versus complex fluid collections guides treatment planning 4