DESCRIPTION

• Most common cause of painless scrotal swelling.
• Classified as congenital or acquired (secondary):
  • Congenital result from a patent process vaginalis and communication between tunica vaginalis and peritoneal cavity:
    • Normally occurs spontaneously and most are closed by 2 yr of age
  • Acquired occur secondary to interscrotal infection, neoplasm, inguinal or scrotal surgery, or regional or systemic disease.
• Communicating hydrocele:
  • Patent processus vaginalis
  • Scrotum fills and empties with peritoneal fluid depending on body position and intraperitoneal pressures.
• Noncommunicating hydrocele is due to production of serous fluid by a disease process or impaired absorption within the scrotum itself

ETIOLOGY

• Imbalance between production and resorption of fluid within the space between tunica vaginalis and tunica albuginea.
• Disease processes causing adult noncommunicating hydrocele include:
  • Epididymitis
  • Hypoalbuminemia
  • TB
  • Trauma
  • Mumps
  • Spermatic vein ligation
  • In developing world, hydrocele is primarily caused by infections such as Wuchereria bancrofti or Loa Loa (filariasis is the cause of most hydroceles worldwide)
  • Rarely malignancy (1st-degree testicular neoplasm or lymphoma)
• Rare etiology is the abdominoscrotal hydrocele that may cause hydroureter or unilateral limb edema owing to compression:
  • US reveals single sac extending from scrotum into abdominal cavity via the deep inguinal ring.

Pediatric Considerations

• Congenital in 6% of newborn boys
• Usually diagnosed in newborn nursery
• Caused by patent processus vaginalis, a structure that remains patent in 85% of newborns
• May vary in size owing to position or crying:
  • Patients may present with history of scrotal mass that has resolved.
• Most close by the age of 2 yr

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

Painless scrotal swelling with a sensation of pulling, dragging, or heaviness.

History

History and exam with special attention to identifying torsion of testicle.

Physical Exam

• Mass may be soft and doughy or firm depending on the amount of fluid present.
• Initial evaluation includes transillumination of affected side (looking for a homogeneous area without internal shadows):
  • This is rapidly being replaced as diagnostic test of choice by bedside US.

ESSENTIAL WORKUP

• Bedside US:
  • Allows visualization of hydrocele as well as of testicle
  • Especially in cases of massive fluid collection, bedside US should be the diagnostic test of choice.
  • May help to identify an underlying mass
• Because of possibility in adults that a hydrocele may be owing to a primary neoplasm, the testicle must be palpated in its entirety.

DIAGNOSIS TESTS & INTERPRETATION

Lab

No specific lab testing is indicated unless underlying cause demands it (UA, AFP, hCG).

Imaging

US is diagnostic and allows visualization of testicular anatomy:

• Appears as large anechoic fluid-filled space surrounding the anterolateral testicle

DIFFERENTIAL DIAGNOSIS

• Epididymitis
• Indirect inguinal hernia
• Orchitis
• Testicular neoplasm
• Testicular torsion
• Varicocele

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

INITIAL STABILIZATION/THERAPY

Stabilization should focus on underlying cause (e.g., trauma).

ED TREATMENT/PROCEDURES

Appropriate exam of testicle to exclude primary neoplasm and referral.

MEDICATION

Treat underlying cause.

[Outline]

• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

Patients with secondary hydrocele may need admission for further evaluation of underlying pathology (e.g., neoplasm, trauma).

Discharge Criteria

• Otherwise healthy patients without comorbid illness may be referred for further evaluation to urologist.
• Hydrocele is usually repaired if cosmesis is a factor or in cases where it causes discomfort.
• Repair can be:
  • Surgical:
    • Aspiration or sclerotherapy are alternatives to open hydrocelectomy.
  • Medical:
    • Aspiration of hydrocele contents and sclerotherapy to prevent recurrence.

Pediatric Considerations

• Most hydroceles in infant population will spontaneously resolve by 12 mo of age:
  • Referral and observation are appropriate once diagnosis is made.
• After the age of 12–18 mo, refer for surgical repair as communicating hydroceles usually have hernia that needs repair.

FOLLOW-UP RECOMMENDATIONS

Patients should be referred to Urology.

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

The mass may fail to transilluminate due to thickening of the tunica vaginalis.

• Bedside US should visualize both the fluid-filled mass and the testicle.

ICD9

• 603.1 Infected hydrocele
• 603.9 Hydrocele, unspecified
• 778.6 Congenital hydrocele

ICD10

• N43.1 Infected hydrocele
• N43.3 Hydrocele, unspecified
• P83.5 Congenital hydrocele

[Outline]

• ICD9
• ICD10

• Cokkinos DD, Antypa E, Tserotas P, et al. Emergency ultrasound of the scrotum: A review of the commonest pathologic conditions. Curr Probl Diagn Radiol. 2011;40(1):1–14.
• Hoerauf A. Filiariasis: New drugs and new opportunities for lymphatic filiariasis and onchocerciasis. Curr Opin Infect Dis. 2008;21:673–681.
• Rabinowitz R, Hulbert WC Jr. Acute scrotal swelling. Urol Clin North Am. 1995;22:101–105.
• Wampler SM, Llanes M. Common scrotal and testicular problems. Prim Care. 2010;37(3):613–626.

See Also (Topic, Algorithm, Electronic Media Element)

• Epididymitis/Orchitis
• Hernia
• Testicular Torsion

Jessica L. Osterman