Costas D. Lallas, MD, FACS
Leonard G. Gomella, MD, FACS
BASICS
DESCRIPTION
• A hydrocele is a collection of serous fluid in some part of the processus vaginalis, usually in the tunica. Can be congenital or acquired
• Translucent swelling in the scrotum or inguinal canal or both
• Aside from congenital hydrocele, it is possible to get examining fingers above the swelling realted to a hydocoele.
• Demonstrated fluctuation in size in congenital hydrocele (also called communicating hydrocele)
EPIDEMIOLOGY
Incidence
• More common in childhood
• 1% of adult males; prevalence: 1,000 in 100,000
• No racial predilection
Prevalence
N/A
RISK FACTORS
• The hydrocele is produced by:
– Connection with the peritoneal cavity (PPV); also known as congenital hydrocele
– Defective absorption of fluid by tunica vaginalis; eg, primary hydrocele (common in adults)
– Excessive production of fluid within the sac; (eg, secondary hydrocele) due to epididymitis, orchitis, testicular torsion causing a “reactive” hydrocele
– Trauma with bleeding (technically a hematocele)
– Lymphatic obstruction; eg, filariasis, scrotal surgery (varicocele), renal transplantation, pelvic radiation, malignancy
– Migration of ventriculoperitoneal (VP) shunt
• Prematurity, low birth weight are risk factors
Genetics
N/A
PATHOPHYSIOLOGY
• Congenital: The PV does not close after testicular descent.
– 80–90% of newborns have patent processus vaginalis with most closing by age 2
• 4 anatomic variants:
– Vaginal (PV around the testis)
– Infantile (PV around testis and cord)
– Congenital communicating (PV communicates with the peritoneal cavity)
– Hydrocele of the cord (PV patent with obliteration above and below)
• Acquired: Can be primary (idiopathic) or secondary to disease of the testis. Secondary hydroceles may present acutely or chronically.
• The hydrocele of the canal of Nuck is comparable in females. The cyst is in relationship with the round ligament and located in the inguinal canal.
• Hydrocele fluid characteristics:
– Amber colored; specific gravity of 1.022–1.024
– Components: Water, inorganic salts, 6% albumin, and fibrinogen
– Nonclotting, unless a drop of blood added
– Chronic hydrocele: Cholesterol-rich
– Occasionally, tyrosine crystals are present
ASSOCIATED CONDITIONS
• Ehlers–Danlos syndrome
• Exstrophy of the bladder
• Indirect inguinal hernia
• Hydrocephalus (with VP shunt)
• Peritoneal dialysis
• Testicular tumors or epididymo-orchitis in secondary hydrocele
• Undescended testicle with patent procesus vaginalis (PPV)
• Varicocele surgery
GENERAL PREVENTION
None other than repair of indirect hernia defect in infants/children
DIAGNOSIS
HISTORY
• Symptoms of epididymitis, UTI, or acute pain:
– Secondary hydrocele with infection, torsion, and trauma usually painful
• Usually not painful
• Sensation of heaviness or discomfort in the scrotum
• Change in size of the swelling (ie, size varies throughout day):
– Suggests congenital communicating hydrocele
• Birth history:
– Hydrocele more common in premature and low–birth-weight infants
• Medical or surgical history:
– Varicocelectomy, renal transplant, VP shunt, trauma to the genitalia can be causes
– Recent inguinal hernia repair (1)
PHYSICAL EXAM
• Transilluminate scrotum:
– If transilluminates, favors simple hydrocele, but is not diagnostic
• Palpation of testes bilaterally:
– Especially in children, need to rule out undescended testicle. Adults, attempt to feel for testicular mass
• Spermatoceles are always located superior to the testis and are palpated as distinct from the testis, which differentiates them from hydroceles.
• Positive pinch test in a secondary hydrocele (ability to pinch the tunica)
• Examine the groin for inguinal hernia.
• Lymphedema of external genitalia or lower extremities:
– Tissue edema can be mistaken for the hydrocele.
• On abdominal exam, concomitant presence of a mass may indicate an abdominoscrotal hydrocele
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis and urine culture if epididymo-orchitis suspected
• Tumor markers (bhCG, AFP) if tumor suspected
Imaging
• Transscrotal US in adults with hydrocele to detect underlying testicular abnormality (ie, tumor) and confirm the nature of the mass as a hydrocele.
• Nuclear scan or Doppler US exam in cases of torsion
Diagnostic Procedures/Surgery
N/A
Pathologic Findings
Fibrous wall lined by mesothelial single layer cuboidal or flattened mesothelial cells; may contain benign mesothelial proliferations
DIFFERENTIAL DIAGNOSIS
• Cord lipoma
• Epididymo-orchitis
• Hydrocele of the spermatic cord
• Inguinal/femoral hernia
• Lymphedema of the external genitalia
– Retroperitoneal process with obstruction of lymphatics (ie, malignancy, lymphatic filiariasis)
– Nephrotic syndrome
– Anasarca (protein-loosing enteropathy, cirrhosis)
• Spermatocele
• Testicular or paratesticular tumors
• Torsion (testis or appendix testis)
• Traumatic injury to the testis (hematocele)
• Varicocele (large)
TREATMENT
GENERAL MEASURES
• Adults:
– No treatment is necessary unless the hydrocele causes discomfort or cosmetic concerns or there is a significant underlying cause present, such as a tumor.
– Communicating hydroceles in older patients may have increased risk of incarceration
• Children:
– Most will resolve in 1st yr of life.
– For newborns and children <1 yr supportive care is indicated
– Persistence beyond age 1 suggests the presence of a patent indirect hernia sac that should be repaired.
MEDICATION
First Line
N/A
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Children:
– Inguinal incision between internal and external rings.
– High ligation of the processus vaginalis and excision of the sac.
– In hydrocele of the cord, the sac can be completely removed. It is imperative that the hydrocele sac be opened when the anatomy is confusing or the sac is very thickened. Failure to do so may result in disastrous consequences if bowel, bladder, or ovary is contained in the sac and not recognized.
• Adults:
– Scrotal approach with drainage of the hydrocele and resection of the tunica vaginalis; scrotal drain for 24–48 hr
Bottle procedure (thin hydrocele sac): Also called Andrews procedure; incise anteriorly, wrap sac back around testicle
Jaboulay–Winkelmann procedure (thick hydrocele sac): Hydrocele sac resected and edge wrapped posteriorly around cord structures (resected edges can also simply be oversewn)
Lord procedure (thin hydrocele sac): Radial sutures used to gather sac posterior to testis
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Aspiration of the hydrocele, with or without the injection of sclerosing agents is not usually recommended
• Nonseptated hydrocele aspiration and sclerotherapy with doxycycline has been reported to have an 84% success rate with a single treatment (2)
• Aspiration may have a role in postoperative hydroceles such as after inguinal hernia repair.
Complementary & Alternative Therapies
Scrotal support may provide relief of discomfort
ONGOING CARE
PROGNOSIS
Many hydroceles do not enlarge and can be observed if confirmed that there is no underlying pathology (based on ultrasound confirmation).
COMPLICATIONS
• Rupture: Usually traumatic
• Hernia of the hydrocele sac: Tension causes herniation through the Dartos muscle.
• Calcification of the wall: May occur with longstanding cases
• Hematocele: Following trauma or aspiration, or presents chronically simulating a neoplasm
• Infection
• Postoperative:
– Testicular atrophy or infarction after repair due to damage to vascular supply to the testicle
– Infection
– Recurrence
FOLLOW-UP
Patient Monitoring
• Periodic follow-up (baseline US) suggested if managed by observation; return for any acute changes in symptoms
• Parents of a newborn with a hydrocele should be instructed in the natural history of the condition in children.
• Following surgical repair, edema may take several weeks to resolve.
Patient Resources
N/A
REFERENCES
1. Gulino G, Antonucci M, Palermo G, et al. Urological complications following inguinal hernioplasty. Arch Ital Urol Androl. 2012;84(3):105–110.
2. Francis JJ, Levine LA. Aspiration and sclerotherapy: A nonsurgical treatment option for hydroceles. J Urol. 2013;189(5):1725–1729.
ADDITIONAL READING
• Lord PH. A bloodless operation for the radical cure of idiopathic hydrocele. Br J Surg. 1964;51:914–916.
• Skoog SJ, Conlin MJ. Pediatric hernias and hydroceles: The urologist’s perspective. Urol Clin North Am. 1995;22:119–130.
• Szabo R, Kessler R. Hydrocele following internal spermatic vein ligation: A retrospective study and review of the literature. J Urol. 1984;132:924–925.
See Also (Topic, Algorithm, Media)
• Canal of Nuck Hydrocele and Cyst (Female Hydrocele)
• Groin/Inguinal Mass, Male and Female
• HIV/AIDS, Urologic Considerations Image 
• Hydrocele of the Spermatic Cord
• Scrotum and Testicle, Mass
• Spermatocele
CODES
ICD9
• 603.8 Other specified types of hydrocele
• 603.9 Hydrocele, unspecified
• 778.6 Congenital hydrocele
ICD10
• N43.2 Other hydrocele
• N43.3 Hydrocele, unspecified
• P83.5 Congenital hydrocele
CLINICAL/SURGICAL PEARLS
• Tenderness, fever, or other symptoms such as nausea, vomiting, abdominal pain associated with an acute hydrocele requires immediate evaluation to rule out other scrotal pathology.
• The inability to transilluminate a hydrocele could be due to a thick-walled or septated hydrocele, another cause of an enlarged scrotum such as tumor or hematocele or the presence of bowel in a large hernia defect.