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BASICS

Description

  • Fluid collection between parietal and visceral tunica vaginalis layers within the scrotum.
  • Communicating hydrocele: patent processus vaginalis with peritoneal fluid communication; often with indirect inguinal hernia; size fluctuates with position.
  • Noncommunicating hydrocele: no connection with peritoneal cavity; fluid produced by tunica vaginalis.
  • Acute hydrocele: fluid from acute process in tunica vaginalis, usually scrotal.

Pediatric Considerations

  • Most congenital communicating hydroceles resolve spontaneously by 2 years.

EPIDEMIOLOGY

  • Predominant age: childhood
  • Incidence: 0.7-4.7% of male infants
  • Prevalence: ~1,000/100,000
  • Adult prevalence: ~1%

ETIOLOGY AND PATHOPHYSIOLOGY

  • Incomplete closure of processus vaginalis traps peritoneal fluid.
  • Imbalance of secretion/reabsorption in tunica vaginalis lining.
  • Causes include infection, tumors, trauma, renal transplantation disrupting spermatic cord.

RISK FACTORS

  • Adults: ventriculoperitoneal shunt, Ehlers-Danlos syndrome, peritoneal dialysis, history of scrotal surgery.
  • Congenital: exstrophy of bladder, cloacal exstrophy.

ASSOCIATED CONDITIONS

  • Testicular tumors
  • Scrotal trauma
  • Ventriculoperitoneal shunt complications
  • Nephrotic syndrome
  • Renal failure with peritoneal dialysis

DIAGNOSIS

History

  • Scrotal/inguinal swelling: acute, subacute, or chronic.
  • Size variation with position/activity suggests communicating hydrocele.
  • Usually painless unless acute.
  • Heaviness or pressure sensation.
  • Possible radiating pain to flank/back.

Physical Exam

  • Fluctuant scrotal or inguinal swelling.
  • Transillumination positive.
  • Size fluctuation with position (communicating).
  • Reducibility with gentle pressure differentiates communicating vs noncommunicating.

Differential Diagnosis

  • Indirect inguinal hernia
  • Orchitis, epididymitis
  • Varicocele
  • Traumatic testicular injury
  • Testicular torsion
  • Testicular neoplasm

Diagnostic Tests

  • Inguinoscrotal ultrasound (US): distinguishes hydrocele from hernia, assesses testicular torsion.
  • Testicular MRI if US inconclusive.
  • Doppler US or nuclear scan for torsion.

Alert: Aspiration for diagnosis is contraindicated due to risk of bowel injury if hernia is present.

TREATMENT

Referral

  • Urology referral for symptomatic adults or unclear diagnosis.
  • Pediatric urology/surgery referral if hydrocele persists beyond 2 years or symptomatic.

Surgery and Procedures

Children

  • Observation until 2 years recommended; many resolve spontaneously.
  • Surgical repair (open or laparoscopic) for persistent or symptomatic cases.
  • Laparoscopic repair allows contralateral exploration and less pain.
  • Open scrotal approach ligates processus vaginalis, better cosmesis.
  • Open inguinal approach ligates processus vaginalis and treats hydrocele sac.

Adults

  • Observation if asymptomatic.
  • Aspiration with sclerotherapy may be used but has higher recurrence.
  • Surgical resection (various techniques) has ~6% recurrence.
  • Lord's repair associated with fewer complications and hematoma.

ONGOING CARE

Follow-Up

  • 4–6 weeks after treatment to assess resolution.
  • Postoperative visits at 2–4 weeks, then every 2–3 months if needed.

PROGNOSIS

  • Most pediatric hydroceles resolve by age 2.
  • Surgical intervention has low morbidity.
  • Adult hydroceles generally resolve with treatment; underlying causes influence outcome.

COMPLICATIONS

  • Up to 30% complication rate with scrotal approach surgery.
  • Postoperative hematoma common.
  • Injury to vas deferens or spermatic vessels.
  • Suture granuloma, wound infection.
  • Recurrence.

REFERENCES

  1. Hall NJ, Ron O, Eaton S, et al. Surgery for hydrocele in children—an avoidable excess? J Pediatr Surg. 2011;46(12):2401-2405.
  2. Alp BF, Irkilata HC, Kibar Y, et al. Comparison of the inguinal and scrotal approaches for the treatment of communicating hydrocele in children. Kaohsiung J Med Sci. 2014;30(4):200-205.
  3. Tsai L, Milburn PA, Cecil CL IV, et al. Comparison of recurrence and postoperative complications between 3 different techniques for surgical repair of idiopathic hydrocele. Urology. 2019;125:239-242.

Clinical Pearls

  • Hydrocele usually diagnosed clinically by swelling and transillumination.
  • Ultrasound is essential if diagnosis is uncertain or to exclude other pathology.
  • Aspiration is contraindicated as primary treatment due to recurrence and risk of bowel injury.
  • Pediatric hydroceles often resolve spontaneously; observation up to 2 years is safe.
  • Adult surgical resection has higher cost and complications but lower recurrence compared to aspiration/sclerotherapy.