Topic Editor: Grant E. Fraser, M.D., FRACGP, FACRRM, ASTEM

Review Date: 01/07/2012

Definition

A hydrocele is a fluid collection between the parietal and visceral layers of the tunica vaginalis, which in males will result in a transilluminating swelling around a testis in the hemiscrotum. This condition can rarely occur in females, when fluid accumulates along the canal of Nuck.

Description

• A hydrocele is a fluid collection in the tunica vaginalis, which appears as a transilluminating hemiscrotal mass. The fluid can result from communication with the peritoneal cavity (persistent patent processus vaginalis) or due to conditions that result in secretion of fluid in the tunica vagainalis out of proportion to absorption
• Types of hydrocele:
• Communicating hydrocele: Develops while the proximal part of the processus vaginalis is patent and thus communicates with the peritoneal cavity. These hydroceles varies in size according to the body position and can increase, for example on valsalva, or in conditions where increased intra-abdominal fluid is present (e.g. ventriculoperitoneal shunt or peritoneal dialysis)
• Noncommunicating hydrocele: Serous fluid is formed secondary to a disease process (processus vaginalis is not patent) where secretion of fluid is in excess to reabsorption. This most commonly occurs due to inflammation or with a viral infection. Filariasis is a common cause worldwide due to decreased lymphatic fluid absorption
• Hydroceles are typically painless and are of little clinical consequence. In some cases mild pain can occur. Their presence typically does not affect fertility
• Hydroceles in infants are typically bilateral with 80-90% of term male infants having a patent processus vaginalis (communicating hydrocele). Only 1 in 20 male infants have a clinically evident hydrocele, with most of these spontaneously resolving before 2 years of age
• It is important to note that even when communicating hydrocele fails to resolve spontaneously within the first 2 years of life, or when found later in life, it is generally a benign condition with indications for treatment being pain, cosmesis, or when the diagnosis is unclear
• When unilateral, hydrocele more commonly affects the right hemiscrotum

Epidemiology

Incidence/Prevalence:

• Approximately 5-10% of male infants present with hydrocele at birth, but the majority of cases resolving spontaneously during the first year of life
• About 12% of children develop a hydrocele following varicocele surgery

Age

• Hydrocele is a primarily a condition affecting infants and children
• Communicating hydroceles result from a persistent patent processus vaginalis. Patent processus vaginalis exists in 80% to 94% of infants and 20% of adults
• The condition is relatively uncommon during adulthood. Adult males may develop a hydrocele due to disturbance between fluid production and absorption, or because of tumor, inflammation, or injury

Gender

• Although hydrocele is primarily a male condition, it may rarely occur in women with involvement of the canal of Nuck, a structure analogous to the processus vaginalis in men

Risk factors

• Abdominal wall defects
• Congenital hip dysplasia
• Connective tissue disorders
• Ehlers-Danlos syndrome
• Marfan syndrome
• Cystic fibrosis
• Family history of hydrocele
• Increased intra-abdominal pressure
• Chronic obstructive pulmonary disease (COPD)
• Peritoneal dialysis
• Ventriculoperitoneal shunts
• Maternal exposure to polybrominated biphenyl or progestins
• Prematurity/low birth weight

Etiology

• Hydroceles in infants and children typically occur congenitally due to a persistent patent processus vaginalis. The majority of term male infants have a patent processus vaginalis, but the minority (5-10%) have a clinically evident hydrocele
• In adults, hydroceles are usually caused by infection, malignancy, filariasis, or trauma, but can also be idiopathic
• Disease processes leading to noncommunicating hydrocele include
• Epididymitis
• Filariasis
• Hypoalbuminemia
• Mumps
• Spermatic vein ligation
• Tuberculosis

[Outline]

• Definition
• Description
• Epidemiology
• Etiology

History

• Feeling of bulkiness/heaviness in the scrotum
• Hemi-scrotal discomfort, which occasionally radiates to the back
• Painless swelling in the scrotum which can change positionally or with valsalva

Physical findings on examination

• Physical examination reveals a cystic, non-tender (unless infection or inflammation is present) hemiscrotal mass with a pear-shaped appearance
• The ipsilateral testicle is often not palpable due to the surrounding hydrocele
• The surface of the scrotum is commonly smooth and non-tender
• Transillumination: As a result of the tunica vaginalis being fluid filled, when illuminated with a strong light source focused on the scrotum, the entire hemiscrotum is "lit up" often with the testis visible within the fluid

[Outline]

• History
• Physical findings on examination

Approach

• Hydroceles are usually diagnosed on the basis of clinical findings alone. Laboratory studies are not required, except in cases where the diagnosis is uncertain

Radiological findings

• Ultrasound:
• Ultrasound is rarely indicated with a simple hydrocele. Scrotal sonography may be indicated if underlying testicular pathology/malignancy is suspected
• Color duplex sonography is also indicated in cases where torsion, varicocele, or epididymitis is a consideration. These conditions can, however, be accompanied by a hydrocele
• Ultrasound findings when a hydrocele is studied will shows an anechoic fluid collection surrounding the testicle. In some cases, there may be scattered echoes resulting from crystals, calculi or septations if inflammatory disease is present
• Ultrasound may not definitively differentiate between hernia and hydrocele
• Fetal hydroceles can be detected after 26 weeks gestation during prenatal ultrasound

[Outline]

• Approach
• Radiological findings

• Epididymal cyst
• Epididymitis
• Epididymo-orchitis
• Indirect inguinal hernia
• Orchitis
• Scrotal edema
• Spermatocele
• Testicular cancer
• Torsion of testicle or appendix testes
• Trauma to testicle
• Varicocele

General treatment items

• Indications for treatment
• The majority of hydroceles in children aged <2 years of age resolve spontaneously. Such cases generally are serially monitored by their primary care doctor. Early surgery in this age group can be indicated if underlying testicular pathology or coexisting inguinal hernia is suspected
• Despite a tradition of surgical therapy for hydroceles that persist at 24 months of age; the natural history beyond this period is unclear and surgical therapy may not benefit all such patients
• Hydrocele repair is indicated in situations resulting in discomfort or cosmetic concerns
• Healthy patients with no comorbidities who desire surgical correction can be referred for consultation with a urologist or general surgeon
• Surgery versus sclerotherapy
• Surgery is generally effective and has a low rate of recurrence
• Aspiration and sclerotherapy (using tetracycline) may be considered for patients in whom surgery is not recommended or who refuse surgery. This treatment has mixed results and can be painful
• A 2012 report using doxycycline had 84% success with a single treatment. This was however primarily in adult patients. Of 29 patients, only 3 reported moderate pain, which resolved in 2-3 days
• As complications and recurrences are higher with sclerotherapy, some clinicians avoid this as primary therapy for young healthy patients
• Removal of a hydrocele can be carried out by the following methods:
• Inguinal approach:
• Surgery of a communicating hydrocele involves tying the processus vaginalis high inside the internal inguinal ring
• In an encysted hydrocele of the spermatic cord, the hydrocele is typically easily dissected
• Scrotal approach:
• This method is generally appropriate for chronic noncommunicating hydroceles
• It is preferred in children >12 years for hydrocele repair via a scrotal incision when there is no evidence of communication
• Lord procedure:
• Used for primary hydrocele, generally with a thin hydrocele sac. This procedure involves radially suturing the hydrocele sac around the back of the testis and epididymis
• Jaboulay-Winkelmann procedure:
• Used for a thick hydrocele sac. This procedure involves excising the hydrocele sac and sewing the edges of the sac posteriorly around the cord structures

Medications indicated with specific doses

N/A

Disposition

• Admission criteria
• Presence of a hydrocele secondary to an underlying condition that requires urgent diagnosis or treatment
• Concern of another hemiscrotal diagnosis (e.g. torsion)
• Discharge criteria
• Discharge home is typical after a diagnosis of hydrocele as it generally requires no urgent treatment and can be reviewed by a urologist or general surgeon routinely
• Discharge criteria following surgical or non-surgical intervention include no evidence of infection, pain controlled, able to maintain oral intake, systemically well, and follow-up arranged

[Outline]

• General treatment items
• Medications indicated with specific doses
• Disposition

Monitoring

• The majority of hydroceles in infants resolve spontaneously with closure of the processus vaginalis during the first 12 to 24 months of life. Surgical intervention is not usually recommended during the first year of life
• Persistence of a simple scrotal hydrocele in children aged >2 years may be appropriate for elective surgical correction

Complications

• Calcification
• Hematocele
• Hernia of the hydrocele sac
• Pyocele
• Testicular atrophy
• Complications of hydrocele surgery
• Hemorrhage
• Hydrocele recurrence
• Pain
• Scrotal cellulitis
• Scrotal edema
• Seroma

[Outline]

• Monitoring
• Complications

Prevention

• Use of less invasive surgical procedures such as mini-laparoscopic herniorrhaphy and microsurgical varicocelectomy may reduce the risk of postoperative hydrocele formation
• Avoid scrotal trauma/injury to reduce the risk of hydrocele development

Prognosis

• Prognosis is excellent as hydroceles do not appear to affect fertility or result in other health complications in most cases
• Most hydroceles resolve within the first 24 months of life

ICD-9-CM

• 603.9 Hydrocele, unspecified

ICD-10-CM

• N43.3 Hydrocele, unspecified

[Outline]

• Prevention
• Prognosis
• ICD-9-CM
• ICD-10-CM

1. Tekgul S, Riedmiller H, Dogan HS, et al. Guidelines on paediatric urology. http://www.uroweb.org/fileadmin/guidelines/2012_Guidelines_large_text_print_total_file.pdf. Updated Feb, 2012. Last accessed Dec 05, 2012.
2. Cimador M, Castagnetti M, De Grazia E. Management of hydrocele in adolescent patients. Nat Rev Urol. 2010;7(7):379-385.
3. Ackerman SJ, Irshad A, Anis M. Ultrasound for pelvic pain: Nongynecologic causes. In: Allison SJ, Wolfman DJ, eds. Gynecologic Ultrasound, an Issue of Ultrasound Clinics. Philadelphia, PA: Elsevier Health Sciences; 2010:240-241.
4. Abantanga FA, Lakhoo K. Inguinal and Femoral Hernias and Hydroceles. In: Ameh EA, Bickler SW, Lakhoo K, eds. Paediatric Surgery: A Comprehensive Text for Africa. Seattle, WA: Global HELP Organization; 2011:358-365.
5. Patel H. Hernias and hydroceles. In: Bauchner H, Vinci R, Kim M. Pocket Clinician: Pediatrics. New York, NY: Cambridge University Press;2003:223-225.
6. Small CM, DeCaro JJ, Terrell ML, et al. Maternal exposure to a brominated flame retardant and genitourinary conditions in male offspring. Environ Health Perspect. 2009;117(7):1175-1179.
7. Sandock D, Herbener TE, Resnick MI. Disorders of the scrotum and its contents: Hydrocele. In: Resnick MI, Older RA. Diagnosis of Genitourinary Disease. New York, NY: Thieme Medical Publishers; 1997:465-484.
8. Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology. 2003;227(1):18-36.
9. Wilson JM, Aaronson DS, Schrader R, Baskin LS. Hydrocele in the pediatric patient: inguinal or scrotal approach? J Urol. 2008;180(4 Suppl):1724-1727.
10. Nesbitt JA. Hydrocele and spermatocele. In: Graham SD, Keane TE. Glenn's Urologic Surgery. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:528-529.
11. Roy H. Short Textbook of Surgery. 1st ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2011.
12. Abdel-Halim AW. Passing the USMLE: Clinical Knowledge. New York, NY: Spring Science + Media Business Media LLC; 2009.
13. Junnila J, Lassen P. Testicular masses. Am Fam Physician. 1998;57(4):685-692.
14. Zhou M, Netto G, Epstein J. Uropathology: A Volume in the High Yield Pathology Series. Philadelphia, PA: Elsevier Saunders; 2012.
15. Esposito C, Valla JS, Najmaldin A, et al. Incidence and management of hydrocele following varicocele surgery in children. J Urol. 2004;171(3):1271-1273.
16. Politoff L, Hadziselimovic F, Herzog B, Jenni P. Does hydrocele affect later fertility? Fertil Steril. 1990;53(4):700-703.
17. Tsai YC, Wu CC, Ho CH, Tai HC, Wu CC, Yang SS. l. Minilaparoscopic herniorrhaphy in pediatric inguinal hernia: a durable alternative treatment to standard herniotomy. J Pediatr Surg. 2011;46(4):708-712.
18. Schiff J, Kelly C, Goldstein M, Schlegel P, Poppas D. Managing varicoceles in children: results with microsurgical varicocelectomy. BJU Int. 2005;95(3):399-402.
19. Ceylan K, Yüksel Y, Hasan G, Alpaslan K. Inguinal approach in adult hydrocele surgery: preliminary randomized study. Adv Ther. 23(1):159-162.
20. Shapiro E. The sonographic appearance of normal and abnormal fetal genitalia. J Urol. 1999;162(2):530-533.
21. Richens J. Genital manifestations of tropical diseases. Sex Transm Infect. 2004;80(1):12-17.
22. Hall NJ, Ron O, Eaton S, Pierro A. Surgery for hydrocele in children-an avoidable excess? J Pediatr Surg. 2011 Dec;46(12):2401-5.
23. Tiemstra JD, Kapoor S. Evaluation of scrotal masses. Am Fam Physician. 2008 Nov 15;78(10):1165-70.
24. Small CM, DeCaro JJ, Terrell ML, Dominguez C, et. al. Maternal exposure to a brominated flame retardant and genitourinary conditions in male offspring. Environ Health Perspect. 2009 Jul;117(7):1175-9.
25. Francis JJ, Levine LA. Aspiration and sclerotherapy: A non-surgical treatment option for hydroceles. J Urol. 2012 Nov 6. S0022-5347(12).