What are the etiologies and recommended treatment options for hydrocele?

Hydrocele: Etiology and Treatment

Etiology

Hydroceles result from an imbalance between secretion and reabsorption of fluid from the tunica vaginalis, with the underlying cause differing by age group. 1

Congenital/Pediatric Causes

• Incomplete obliteration of the processus vaginalis during fetal development allows peritoneal fluid to accumulate in the scrotum, creating a communicating hydrocele 2
• The processus vaginalis normally closes during gestation; when it remains patent, fluid travels from the peritoneal cavity into the scrotal sac 2
• This represents the most common etiology in infants and young children 2

Acquired/Secondary Causes

• Reactive hydroceles develop secondary to epididymo-orchitis, with inflammation and edema causing fluid accumulation 3
• Testicular tumors can present with complex hydroceles, particularly in adolescents and young adults 2
• Trauma to the scrotal contents may result in hydrocele formation 3
• In adults, hydroceles typically represent primary idiopathic fluid accumulation without a patent processus vaginalis 1

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Treatment Algorithm

Step 1: Rule Out Surgical Emergencies

Immediate scrotal ultrasound with Doppler is mandatory to exclude testicular torsion and inguinal hernia, which require emergent surgical intervention. 2

• Testicular torsion must be ruled out within 6-8 hours to prevent testicular loss 3, 2
• Color Doppler has 96-100% sensitivity and 84-95% specificity for confirming normal testicular blood flow 2
• Evaluate for inguinal hernia, which requires prompt surgical repair rather than observation 2

Step 2: Age-Based Management Strategy

Infants and Children Under 18-24 Months

Conservative management with observation is recommended, as congenital hydroceles typically resolve spontaneously within 18-24 months. 2

• Do not rush to surgery unless there is concern for inguinal hernia or complications 2
• The processus vaginalis often closes spontaneously during this period 2
• Re-evaluate if the hydrocele persists beyond 24 months or increases in size 2

Children 2-12 Years Old

Surgical repair via inguinal approach is indicated for persistent hydroceles, as the majority have a patent processus vaginalis requiring high ligation. 2, 4

• The inguinal approach allows ligation of the patent processus vaginalis, preventing recurrence by addressing the underlying cause 2
• Children younger than 12 years should undergo inguinal exploration for hydrocele repair 4
• This approach has lower recurrence rates compared to scrotal approaches in this age group 4

Children Over 12 Years and Adults

Scrotal approach (open hydrocelectomy via scrotal incision) is the standard treatment, as 86.4% of hydroceles in children over 12 years are non-communicating. 2, 4

• In children older than 12 years, 82-86% have non-communicating hydroceles without a patent processus vaginalis 4
• The scrotal approach has lower morbidity when there is no patent processus vaginalis 2
• Use inguinal approach only if clinical history suggests communication (fluctuating size, reducibility) 4
• The "pull-through" technique allows removal of large hydrocele sacs through a 15mm incision with 95% cure rate and minimal complications 2

Step 3: Evaluate for Underlying Pathology

In adolescents and adults, complex hydroceles on ultrasound warrant high suspicion for testicular malignancy and require tumor markers and urologic consultation. 2

• Infertile males with testicular microcalcifications have an 18-fold higher risk of testicular cancer 2
• Bilateral hydroceles with scrotal wall thickening and increased vascularity suggest epididymo-orchitis requiring antibiotic treatment 2
• Physical examination with orchidometer is adequate for routine assessment; reserve ultrasound for large hydroceles, thickened scrotal skin, or concern for underlying pathology 2

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Surgical Considerations

Preoperative Assessment

Hydrocele repair is classified as low bleeding risk (0-2% risk of bleeding >2 days), requiring minimal preoperative testing in healthy patients. 2

• Obtain CBC only if significant perioperative blood loss is anticipated 2
• Coagulation studies are needed only with history of bleeding disorders or anticoagulant use 2
• Routine chest X-ray and ECG are not required for healthy patients undergoing this low-risk surgery 2

Special Situations

Tense infantile abdominoscrotal hydroceles require early intervention due to high rates of testicular dysmorphism (78% in one series), which is often reversed by surgery. 5

• Simple transscrotal plication of the tunica vaginalis is effective with decreased postoperative complications compared to inguinal approach 5
• Expectant management may allow spontaneous resolution of the abdominal component, but scrotal surgery is ultimately required 5

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Critical Pitfalls to Avoid

• Never delay evaluation of acute scrotal swelling—testicular torsion must be excluded emergently, as viability is compromised after 6-8 hours 2
• Do not confuse hydrocele with inguinal hernia, which requires more prompt surgical intervention 2
• Avoid operating on infants under 18-24 months unless hernia or complications are present, as most resolve spontaneously 2
• Do not use scrotal approach in children under 12 years, as the majority have patent processus vaginalis requiring inguinal ligation 4
• Consider fertility evaluation in men of reproductive age with bilateral hydroceles, as they can contribute to infertility through increased scrotal temperature and testicular dysfunction 2