How should a hydrocele be diagnosed and managed in an adult male when it is small and asymptomatic versus when it is large, painful, or causing functional/cosmetic concerns?

Hydrocele Management in Adult Males

Initial Diagnostic Approach

For any adult male presenting with scrotal swelling concerning for hydrocele, scrotal ultrasound with Doppler imaging should be performed to evaluate testicular parenchyma and rule out underlying testicular malignancy, which can be masked by the hydrocele fluid 1.

Key Clinical Features to Assess

• Transillumination test: Positive transillumination suggests fluid-filled hydrocele, though severe scrotal edema may distort results 2
• Size and symptoms: Document whether the hydrocele is small/asymptomatic versus large with pain or functional impairment 3
• Age consideration: Infertile males and those with testicular abnormalities have an 18-fold higher risk of testicular cancer when testicular microcalcifications are present 1

Ultrasound Evaluation Protocol

• Assess testicular parenchymal architecture for hypoechoic masses, macrocalcifications, or non-homogeneous architecture suggesting dysgenesis or malignancy 1
• Evaluate Color Doppler flow patterns to assess vascular supply and rule out torsion or inflammatory processes 1
• Examine contralateral testis as standard practice 1
• Scrotal ultrasound has 96-100% sensitivity and 84-95% specificity for evaluating testicular pathology, making it the gold standard 1

Management Algorithm Based on Clinical Presentation

Small, Asymptomatic Hydrocele

Conservative management is appropriate for small, asymptomatic hydroceles once malignancy has been excluded by ultrasound 3, 4.

• Observation alone is sufficient if ultrasound shows no suspicious findings 4
• No routine follow-up imaging is required unless symptoms develop or size increases 4
• Patient education about warning signs (rapid enlargement, pain, firmness) that warrant re-evaluation

Large, Painful, or Functionally Limiting Hydrocele

Surgical hydrocelectomy is indicated for hydroceles causing pain that interferes with daily activities, cosmetic concerns, or those that have failed conservative management 3.

Conservative Measures to Trial First

• Local heat or cold application over the affected area to reduce pain and inflammation 3
• Bed rest during acute pain episodes may provide temporary relief 3
• Pain management with analgesics to maximize function while minimizing side effects 3

Aspiration as Temporizing Measure

• Aspiration of hydrocele fluid can provide temporary relief for persistent pain despite conservative management, though recurrence is common 3
• This is not definitive treatment but may be useful for patients who are poor surgical candidates

Definitive Surgical Management

Hydrocelectomy is the definitive treatment for symptomatic hydroceles 3, 4.

• Surgical approach: Scrotal or inguinal approach depending on hydrocele type 4
• Timing: Surgery is indicated when conservative management fails or for non-communicating hydroceles persisting beyond 12-18 months with size progression 5
• Postoperative care: Bed rest and scrotal elevation for 24-48 hours, with regular analgesics and anti-inflammatory medications 3

Critical Pitfall to Avoid

Never perform scrotal incision or biopsy when testicular malignancy is suspected on ultrasound, as this violates lymphatic drainage pathways and may require subsequent hemiscrotectomy 1.

• If ultrasound shows suspicious intratesticular mass, obtain serum tumor markers (AFP, β-HCG, LDH) and discuss sperm banking before any intervention 1
• Proceed with radical inguinal orchiectomy (not scrotal approach) if malignancy is confirmed 1

Special Considerations

Incidental Findings on Ultrasound

• Testicular microcalcifications: Infertile males with this finding require closer surveillance due to 18-fold increased cancer risk 1
• Testicular dysmorphism: May be associated with certain hydrocele types, particularly abdominoscrotal variants 6

Surgical Complications

• Infection risk: Monitor closely postoperatively 3
• Chronic pain: Possible complication requiring evaluation for persistent pain or recurrence 3
• Overall complication rate: Approximately 3.2% in surgical series 7

Rare Variants Requiring Special Attention

• Encysted spermatic cord hydrocele: Often mistaken for inguinal hernia; requires surgical excision for non-communicating types persisting beyond 12-18 months 5, 8
• Abdominoscrotal hydrocele: Rare variant with abdominal component requiring surgical treatment as spontaneous resolution never occurs 6