Hydrocele: The Right Clinical Information, Right Where It's Needed

Hydrocele
The right clinical information, right where it's needed
Last updated: Jan 03, 2018

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 5
Aetiology 6
Pathophysiology 6
Classification 9
Prevention 11
Diagnosis 12
Case history 12
Step-by-step diagnostic approach 12
Risk factors 13
History & examination factors 14
Diagnostic tests 15
Differential diagnosis 15
Treatment 17
Step-by-step treatment approach 17
Treatment details overview 18
Treatment options 20
Follow up 23
Recommendations 23
Complications 23
Prognosis 24
Guidelines 25
Diagnostic guidelines 25
Treatment guidelines 25
Online resources 26
References 27
Images 29
Disclaimer 32
Summary
◊ A collection of serous fluid between the layers of the membrane (tunica vaginalis) that surrounds the
testis or along the spermatic cord. Rarely, similar fluid collection can occur in females along the canal
of Nuck.
◊ Common in male infants and the newborn. Most paediatric hydroceles are congenital and, in the
majority of cases, resolve within the first year of life.
◊ May occur in adult men where they are found secondary to minor trauma, infection, testicular torsion,
epididymitis, varicocele operation, or testicular tumour.
◊ The main symptom is a painless, swollen scrotum on 1 or both sides, which feels like a water-filled
balloon.
◊ Treatment depends on the age of the patient and the degree of discomfort caused by the hydrocele.
Surgery will only be performed if the hydrocele is causing problems.
Hydrocele Basics
Definition
Hydrocele is a collection of serous fluid between the layers of the membrane (tunica vaginalis) that surrounds
the testis or along the spermatic cord. Rarely, similar fluid collection can occur in females along the canal of
BASICS
Nuck. There are 2 types of hydroceles: communicating and non-communicating (simple).
In communicating hydroceles, a patent processus vaginalis connects the peritoneum with the tunica
vaginalis, which allows peritoneal fluid to flow freely between both structures. If the connection is large,
abdominal contents (bowel, bladder, or omentum) may enter the groin, and this complication is termed an
inguinal hernia. Inguinal hernias are classified into either direct or indirect, based on the relationship of the
sac to the inferior epigastric artery. In a direct inguinal hernia, the hernial sac lies medial to the artery and the
deep inguinal ring. In an indirect inguinal hernia, the hernial sac lies lateral to the artery (see our full content
on inguinal hernia).[1]
A non-communicating or simple hydrocele occurs when the processus vaginalis is closed and more fluid is
being produced by the tunica vaginalis than is being absorbed.
Communicating hydrocele
Created by the BMJ Group
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jan 03, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Hydrocele Basics
BASICS
Non-communicating hydrocele
Epidemiology
Hydroceles predominantly occur in males and are rare in females. They are common in male infants and
children and in many cases are associated with an indirect inguinal hernia.[5] Approximately 1% to 3% of full-
term infants have a hydrocele or hernia.[3] Hydroceles are more prevalent in premature infants and in infants
whose testes descend relatively late. Autopsy findings suggest patent processus vaginalis is present in 80%
to 94% of infants and 15% to 30% of adults.[6] [7] [8] [9] In the presence of a patent processus vaginalis,
the incidence of a contralateral patent processus vaginalis has been found to be 15% to 22%.[2] In the
majority of cases, the processus vaginalis closes within the first year of life and so the incidence of hydrocele
decreases.[6] [7] [8] [9] Intrauterine exposure to polybrominated biphenyl, a brominated flame retardant and
endocrine disruptor, has been found to increase the risk of hydrocele/hernia.[10]
The incidence in adult men is not known. Up to 20% of patients develop a hydrocele after varicocelectomy.
However, with some highly specialised microsurgical techniques, the occurrence rate may be decreased
to less than 1%.[11] [12] [13] Approximately 10% of testicular malignancies are thought to present with
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jan 03, 2018.
5
Hydrocele Basics
hydroceles.[6] Filariasis is common in many countries worldwide and is often associated with hydroceles that
occur as a result of lymphatic obstruction.[14]
Aetiology
BASICS
Most paediatric hydroceles are congenital and, in the majority of cases, resolve within the first year of life.
Most adult hydroceles are acquired. Non-communicating hydroceles are found secondary to minor trauma,
infection, testicular torsion, epididymitis, varicocele operation, or testicular tumour.[6] Communicating
hydroceles may occur following increased intra-abdominal fluid or pressure (due to shunts, peritoneal
dialysis, or ascites) if there is a patent processus vaginalis.[2] [3] [7] Patients with connective tissue disorders
have a high risk of communicating hydroceles.[3] Hydroceles may also be seen in patients with filariasis as a
result of lymphatic obstruction.[14]
Pathophysiology
During fetal development, an extension of the peritoneum migrates distally through the inguinal canal with the
gubernaculum in the first trimester. Normally, this thin membrane that extends through the inguinal canal and
descends into the scrotum (processus vaginalis) is obliterated proximally at the internal inguinal ring, and the
distal portion forms the tunica vaginalis.[3] [7]In the majority of cases, the processus vaginalis closes within
the first year of life.[6] [7] [8] [9] If it is not obliterated at the internal ring, it is referred to as a patent processus
vaginalis, and the tunica vaginalis communicates with the peritoneum, so that peritoneal fluid flows freely
between both structures and a communicating hydrocele forms. If the communication is large enough, intra-
abdominal structures, such as intestine, omentum, bladder, or genital contents, may be found in the inguinal
canal, and this complication is known as an indirect inguinal hernia.[2] [3]
While the processus vaginalis forms in both sexes in the first trimester, it does not enlarge in females.
Hydrocele of the canal of Nuck is rare and results from the failure of the processus vaginalis to close, which
causes fluid to accumulate within the inguinal canal.
A non-communicating or simple hydrocele occurs in cases where the processus vaginalis is obliterated and
secretion exceeds absorption of fluid from the tunica vaginalis. An abdominoscrotal hydrocele is a simple
hydrocele that enlarges through the inguinal canal resulting in an abdominal component. A hydrocele of the
spermatic cord is the result of segmental closure of the processus vaginalis. It is loculated and usually does
not communicate with the peritoneal cavity.[2]
Hydrocele Basics
BASICS
Normal anatomy
7
BASICS Hydrocele Basics
Hydrocele Basics
BASICS
Non-communicating hydrocele
Classification
Common terminology[2] [3]
Congenital hydrocele
• Results from a congenital malformation of tunica vaginalis.

Acquired hydrocele
• Primary (or idiopathic): cause for this is unclear and is produced by defective absorption of fluid in
tunica vaginalis
• Secondary: caused by infection or trauma to testis.
Non-communicating (simple) hydrocele
9
Hydrocele Basics
• Accumulation of fluid around the testis without communication to the abdominal cavity.
• Passage of peritoneal fluid to the scrotum through a patent processus vaginalis.

BASICS
Abdominoscrotal hydrocele
• A huge form of simple hydrocele that extends into the abdomen.

Hydrocele of the cord
• A loculated hydrocele of the spermatic cord that occurs as a result of segmental closure of the
processus vaginalis.
Hydrocele Prevention
PREVENTION
11
Hydrocele Diagnosis
Case history
Case history #1
A 12-month-old boy presents to his primary care physician with a right scrotal mass. The mass is smaller
in the morning than in the evening and increases significantly in size during crying. It gets smaller
again when he is lying down. He has no gastrointestinal or urinary symptoms. Physical examination
demonstrates normal findings on the left side of the scrotum and a non-tender soft swelling on the right
side. The mass is transilluminated when a light is shone on the scrotum, suggesting it is fluid-filled. The
right testicle is palpable after gentle pressure reduces the swelling.
Other presentations
A hydrocele may present with scrotal pain in patients with accompanying acute epididymitis. In addition,
irritability, vomiting, and abdominal distention may be the signs of an incarcerated hernia, especially in a
baby with a communicating hydrocele. Rarely, hydroceles can occur in females along the canal of Nuck.
Contralateral hydrocele may be present in neonates who have neonatal testicular torsion.[4]
Step-by-step diagnostic approach

Hydroceles are relatively straightforward to diagnose. History and physical examination should be diagnostic
and other tests are rarely needed. Hydroceles predominantly occur in males and are rare in females.
History
Patients almost always present with scrotal swelling, the size of which varies during the day. It is usually
smaller in the morning and enlarges with any increase in intra-abdominal pressure (e.g., coughing,
straining, crying). If the swelling involves the inguinal area as well as the scrotum, and in children is
DIAGNOSIS
accompanied by vomiting, irritability, and significant feeding problems, these may be the symptoms
of incarcerated inguinal hernia.[6] Communicating hydrocele is common in children. In adults non-
communicating hydroceles are much more common and present with scrotal swelling and a vague
sensation of heaviness. Non-communicating hydrocele may occur after trauma, testicular infection, or
testicular torsion.[16]
Physical examination
A scrotal mass that is not tender will usually be demonstrated on physical examination. The mass is likely
to be soft if the communication is large or tense if it is small. It may be restricted to the scrotum or it may
extend into the inguinal canal. Female patients with hydrocele of the canal of Nuck present with inguinal
swelling. In communicating hydroceles, gentle pressure on the fluid will allow it to be reduced into the
abdomen.[6] [7] An inguinal bulge that cannot be reduced is an important indication for incarcerated (fixed
within the sac) inguinal hernia.
Palpation of the testis is important in order to diagnose any acute testicular pathology. However, in cases
of tense hydroceles or thick sacs, the testis may not be palpable.[2] Increasing abdominal pressure by
manoeuvres such as crying or raising the arms helps the hydrocele to be palpated if it is small at the time
of examination.[2] [3] [6] [7]
Hydrocele Diagnosis
Transillumination is an important tool in physical examination of hydroceles. In nearly all hydroceles, the
fluid will be transilluminated when the scrotum is investigated with a focused beam of light. Omentum or
bowel in the scrotum prevents transillumination. If there is bowel in the scrotum, septations may be seen.
If the hydrocele cannot be demonstrated on physical examination, even though the history is clear, the
family should be requested to take photographs of the patient's scrotum at home when it is distended.
Imaging
History and a physical examination are usually sufficient for diagnosis. The inability to palpate the testis
or suggestion of underlying pathology (e.g., fever, gastrointestinal symptoms such as vomiting, diarrhoea,
or constipation, shadow on transillumination) should raise the suggestion of a different diagnosis or some
additional underlying pathology and requires the use of scrotal ultrasound. Ultrasound has nearly 100%
sensitivity in detecting intrascrotal lesions.[17] Ultrasound of the inguinal area may also be helpful in rare
cases of female hydroceles.
Risk factors
Strong
male sex
• Approximately 85% of patients with paediatric hydroceles or hernias are male.[7] In girls, hydrocele of
the canal of Nuck is rare.
prematurity and low birth weight

• The incidence of hydroceles and hernias in newborns is 20-fold higher in those with a birth weight
<1500 g than in those weighing >1500 g.[2]
• Prematurity and low birth weight are also risk factors for bilateral hydroceles.
infants <6 months of age
DIAGNOSIS
• Approximately 30% of all paediatric hydroceles and hernias occur in infants <6 months of age.[6]
infants whose testes descend relatively late

• These infants often have hydroceles.
increased intraperitoneal fluid or pressure

• Communicating hydroceles or hernias may occur following increased intra-abdominal fluid or pressure
(e.g., following shunts, peritoneal dialysis, or ascites) if there is a patent processus vaginalis.[2] [3] [7]
This is especially a risk for contralateral symptomatic hernia/hydrocele.[15]
inflammation or injury within the scrotum

• Non-communicating hydroceles can arise after minor trauma, infection, testicular torsion, or
epididymitis.
testicular cancer
• Approximately 10% of testicular malignancies are thought to present with hydroceles.[6]
13
Hydrocele Diagnosis
connective tissue disorders
• These patients have a high risk of communicating hydroceles.[3] They also have a higher risk of
recurrence after surgery for the communicating hydroceles.
Weak
varicocelectomy
• Hydrocele is the most common complication of varicocelectomy. Depending on the technique of
repair, up to 20% of patients develop a hydrocele; however, with some highly specialised microsurgical
techniques, the occurrence rate can be decreased to <1%.[11] [12] [13]
filariasis
• The tropical parasitic infection filariasis can cause hydroceles as a result of lymphatic obstruction.[14]
maternal exposure to polybrominated biphenyl

• Intrauterine exposure to polybrominated biphenyl, a brominated flame retardant and endocrine
disruptor, has been found to increase the risk of hydrocele/hernia.[10]
History & examination factors

Key diagnostic factors
presence of risk factors (common)
• Key risk factors include male sex, prematurity and low birth weight, infants <6 months of age, infants
whose testes descend relatively late, increased intraperitoneal fluid or pressure, inflammation or injury
within the scrotum, and connective tissue disorders.
scrotal mass (common)

• The mass is likely to be soft if the communication is large or tense if it is small. It may be restricted to
DIAGNOSIS
the scrotum or it may extend into the inguinal canal.
transillumination (common)
• Because of the fluid, most hydroceles are easily transilluminated when a focused beam of light is
shone on the scrotum.
enlargement of scrotal mass following activity (common)

• Increasing intra-abdominal pressure makes the peritoneal fluid flow into the scrotal sac. Therefore, the
mass increases in size with activities such as coughing, straining, crying, or raising the arms.[2] [3] [6]
[7]
variation in scrotal mass during the day (common)

• Increasing intra-abdominal pressure makes the peritoneal fluid flow into the scrotal sac. Therefore, the
size of the mass will be smaller in the morning than in the evening and after lying down.
Hydrocele Diagnosis
Diagnostic tests
1st test to order
Test Result
clinical diagnosis features of hydrocele
• Usually no tests are necessary.
Other tests to consider
Test Result
ultrasound males: scrotal ultrasound
confirms presence or
• The inability to palpate the testis or suggestion of underlying
absence of normal/
pathology (e.g., fever, gastrointestinal symptoms such as vomiting,
abnormal testis; females:
diarrhoea, or constipation, shadow on transillumination) should raise
the suggestion of a different diagnosis or some additional underlying inguinal ultrasound
confirms presence or
pathology and requires the use of scrotal ultrasound. Ultrasound has
absence of hydrocele
nearly 100% sensitivity in detecting intrascrotal lesions.[6] [17] [18]
• Ultrasound of the inguinal area may also be helpful in rare cases of
female hydroceles.
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Inguinal hernia • An incarcerated inguinal • A groin ultrasound will show
hernia may be difficult to abnormal ballooning of the
distinguish from a hydrocele. anteroposterior diameter
DIAGNOSIS
of the inguinal canal.
Occasionally, a segment of
omentum (fat) or a segment
of the bowel is seen.
Testicular cancer • These will usually be solid, • Scrotal ultrasound will

firm masses that are not confirm the diagnosis.[18]
transilluminated. However, Testicular tumour markers,
tumours may have reactive such as alpha-fetoprotein or
hydroceles surrounding beta-hCG, may also be used
them, and these will be to indicate tumour activity.
transilluminated.
Epididymitis • Clinically the patient has • Colour Doppler

pain and tenderness in ultrasonography will confirm
the scrotum, and local the diagnosis.[2]
inflammatory changes can
be seen.[19]
15
Hydrocele Diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Epididymo-orchitis • Scrotal tenderness and • Color Doppler
swelling. Clinically, the ultrasonography will confirm
patient has pain and the diagnosis.[2]
tenderness in the scrotum,
and local inflammatory
changes can be seen.[19]
Epididymal cyst • Scrotal mass that can • Scrotal ultrasound may

be transilluminated. The assist in making the
position of the cyst helps the diagnosis.
diagnosis. The cyst can be
palpated separately from the
testis, lying posterior and
superior to it.[19]
Scrotal oedema • Thickening of the scrotal • Diagnosis is best made

wall. by scrotal examination.
Scrotal ultrasound may be
beneficial.[18]
Testicular torsion • Extreme tenderness, • Color Doppler

elevation of the testis, loss ultrasonography will confirm
of landmarks, and absence the diagnosis.[2]
of a cremasteric reflex
are characteristic signs of
torsion.
Varicocele • Palpation of enlarged veins • Physical examination is

during Valsalva manoeuvre diagnostic, but colour
is diagnostic on physical Doppler ultrasonography can
examination. be used for confirmation.[2]
DIAGNOSIS
Hydrocele Treatment
Step-by-step treatment approach

Hydroceles predominantly occur in males and are rare in females. Treatment depends on the age of the
patient and the degree of discomfort or complications caused by the hydrocele.
Children ≤2 years of age

Many hydroceles resolve spontaneously before the age of 2 years and so observation is usually
appropriate. Although, European guidelines suggest surgical correction may be indicated after 12 months,
the clinical impression is that some cases will resolve and it is safe to wait for 2 years, unless there
is bowel palpable in the groin and provided the testis has been evaluated and there is no evidence of
underlying pathology.[2] [17] However, if there is an inguinal component or abdominal contents are in the
hydrocele sac, spontaneous resolution is unlikely and surgery is recommended.
Children 2-11 years of age

Open repair
• Surgical repair is indicated for the persistence of a hydrocele beyond 2 years of age. The surgical
approach involves open repair with an inguinal exploration, careful dissection of the hernia sac
(processus vaginalis) from the cord structures, and a high ligation of the sac at the internal ring.
Although there is no need to fix the distal hydrocele sac, if it remains tense, then it is best to incise
it widely and sew it back upon itself to allow better drainage.[12] In hydrocele of the spermatic cord,
the cystic mass is excised or unroofed.[17]
Laparoscopic exploration
• Contralateral symptomatic hydrocele may be present in 3% to 5 % of patients.[15] While a

contralateral open inguinal exploration may be used to investigate a contralateral patent processus
vaginalis, endoscopy of the contralateral side through the ipsilateral hydrocele sac can be easily
performed and obviates open exploration when the processus is closed.[15]
Bilateral repair
• This is indicated for patients with an open contralateral internal ring, inguinal or scrotal pathology, or
increased intraperitoneal fluid (e.g., following shunts, peritoneal dialysis, or ascites).
Abdominoscrotal hydroceles
• These require surgery with an abdominal incision, and the entire abdominal component should be
removed. By opening a large window in the abdominal portion of the hydrocele, the fluid may well
drain continuously into the peritoneum where it will be reabsorbed.
• A novel method involving laparoscopic marsupialisation of the abdominal component followed by
hydrocelectomy by an inguinal incision has also been reported as successful.[20]
Adolescents 12-18 years of age

TREATMENT
Adolescents most commonly have non-communicating hydroceles. In most cases they are idiopathic. The
testis should always be examined, as rarely testicular pathology can lead to a reactive hydrocele. A review
classified the treatment options for adolescent hydrocele.[16]
Idiopathic hydrocele
17
Hydrocele Treatment
• In most cases, observation is appropriate. If the hydrocele gets very large and uncomfortable,
surgery may be considered. Aspiration is possible, but the long-term success rate seems to be
poor.
• When treatment is needed, surgical repair is the definitive management. There are different
methods for performing surgical hydrocelectomy in adolescents, such as excision of the hydrocele
or plication of the hydrocele wall and internal drainage.[16]
Hydrocele after varicocelectomy
• The incidence of post-varicocelectomy hydrocele has decreased due to technical improvements

such as microsurgical methods or sclerotherapy of internal spermatic veins. However, if hydrocele
occurs after varicocelectomy conservative management should be choosen for the initial approach.
• Surgery should be second line for those who do not benefit from conservative management.
Filarial-related hydrocele
• Complete excision of the tunica vaginalis is appropriate treatment.
Adults
In adults, once the underlying pathology has been excluded by examination, hydroceles can be managed
conservatively with reassurance and scrotal support. Surgery may be appropriate if the hydrocele is large
and uncomfortable. During surgery, the sac is usually everted and sewn in that position. For hydroceles
with large, thick-walled, or multilocular sacs, excision of the hydrocele sac is more appropriate. With either
approach, extreme care must be taken to avoid injury to the vas deferens in younger patients to avoid loss
of fertility.
For symptomatic patients who are unsuitable for or unwilling to have surgery and when fertility is not
an issue, aspiration of the hydrocele followed by sclerotherapy can be considered. In general, it is
considered second-line treatment. A small amount of local anaesthetic is injected into the skin of the
scrotum. A needle is passed into the hydrocele through the anaesthetised area and the fluid is removed.
After the removal of fluid, a sclerosing agent such as tetracycline, polidocanol, or 95% alcohol may be
instilled. A success rate up to 90% was reported by 1 to 4 injections of polidocanol with a complication
rate of 30%.[21] The sclerosant may be drained or allowed to be reabsorbed. However, postoperative
pain and recurrence are 2 major complications associated with the sclerosing technique. Recurrent
hydroceles tend to be multilocular (hydroceles that have multiple compartments).[19] One study has
shown that aspiration, up to 3 times, without injecting a sclerosing agent has a success rate of 60% in
patients with hydroceles after a varicocelectomy.[22] A review indicated that observation with or without
hydrocele aspiration should be the initial management and surgery should be considered as a second-
line procedure.[16]
Treatment details overview

Consult your local pharmaceutical database for comprehensive drug information including contraindications,
TREATMENT
drug interactions, and alternative dosing. ( see Disclaimer )
Ongoing ( summary )
children
Hydrocele Treatment
Ongoing ( summary )
≤2 years old 1st observation
2-11 years old 1st surgery
adolescents
idiopathic 1st surgery
post-varicocelectomy 1st observation +/- aspiration
2nd surgery
filarial-related hydrocele 1st surgery
adults
without discomfort or 1st observation

infection
with discomfort or 1st surgery or aspiration and sclerotherapy

infection
TREATMENT
19
Hydrocele Treatment
Treatment options
Ongoing
children
≤2 years old 1st observation
» Many hydroceles resolve before the age of 2

years and so observation is usually appropriate,
provided the testis has been evaluated and there
is no evidence of underlying pathology.[2]
2-11 years old 1st surgery
» Elective surgical repair is indicated for

persistence of a hydrocele beyond 2 years of
age to avoid complications such as incarcerated
inguinal hernia.
» The surgical approach involves open repair

with an inguinal exploration, careful dissection
of the hernia sac (processus vaginalis) from the
cord structures, and a high ligation of the sac at
the internal ring. Although there is no need to fix
the distal hydrocele sac, if it remains tense, then
it is best to incise it widely and sew it back upon
itself to allow better drainage.[12]
» In hydrocele of the spermatic cord, the cystic

mass is excised or unroofed.[13]
» Many clinicians perform laparoscopy via

the ipsilateral hydrocele sac to investigate
whether there is a contralateral patent processus
vaginalis.
» Bilateral repair is indicated for patients with

an open contralateral internal ring, inguinal or
scrotal pathology, or increased intraperitoneal
fluid (ventriculoperitoneal shunt, peritoneal
dialysis).
adolescents
idiopathic 1st surgery
» In most cases, observation is appropriate. If

the hydrocele gets very large and uncomfortable,
surgical repair is the definitive management.
There are different methods for performing
surgical hydrocelectomy in adolescents, such
TREATMENT
as excision of the hydrocele or plication of the

hydrocele wall and internal drainage.[16]
post-varicocelectomy 1st observation +/- aspiration
Hydrocele Treatment
Ongoing
» Post-varicocelectomy hydroceles should be
observed with or without aspiration.[16]
2nd surgery
» Surgery should be second line for those who

do not benefit from conservative management.
It is the best therapy for large, persistent post-
varicocelectomy hydroceles.
filarial-related hydrocele 1st surgery
» Complete excision of tunica vaginalis is

appropriate treatment.
adults
without discomfort or 1st observation

infection
» In adults, once underlying pathology has
been excluded, hydroceles can be managed
conservatively with reassurance and scrotal
support.
with discomfort or 1st surgery or aspiration and sclerotherapy
infection
» Surgery may be appropriate if the hydrocele is
large or uncomfortable (dragging sensation) or
becomes infected.
» Excision of the hydrocele sac is appropriate

for hydroceles with thick-walled sacs and
multiloculated sacs.
» Extreme care must be taken to avoid injury to

the vas deferens in younger patients to avoid
loss of fertility.
» Aspiration and sclerotherapy may be an

alternative for adult patients who are poor
surgical candidates or unwilling to have surgery
and fertility is not an issue. Repeated aspirations
without injecting a sclerosing agent have a
success rate of 60% in patients with a hydrocele
post-varicocelectomy.[22]
» A small amount local anaesthetic is injected

into the skin of the scrotum. A needle is passed
into the hydrocele through the anaesthetised
area and the fluid is removed. After the removal
of fluid, a sclerosing agent such as tetracycline,
polidocanol, or 95% alcohol may be instilled. A
success rate up to 90% was reported by 1 to
TREATMENT
4 injections of polidocanol with a complication

rate of 30%.[21] Sclerosant may be drained or
allowed to be re-absorbed.
21
Hydrocele Treatment
Ongoing
» Post-operative pain and recurrence are 2
major complications. Recurrent hydroceles tend
to be multiloculated.[18]
TREATMENT
Hydrocele Follow up
Recommendations
Monitoring
FOLLOW UP
The majority of hydroceles in infants resolve spontaneously in the first 2 years of life. Children under
2 years of age with a hydrocele should be examined regularly and an inguinal component excluded.
[American Urological Association Urology Care Foundation: Hydroceles and inguinal hernias] [American
Academy of Family Physicians: Testicular masses]
Patient instructions
Parents should be advised to look out for symptoms of incarceration, such as vomiting, abdominal pain,
and a non-reducible inguinal mass. In adults that do not have an underlying pathology, self-monitoring of
the hydrocele is sufficient. [American Urological Association Urology Care Foundation: Hydroceles and
inguinal hernias]
Complications
Complications Timeframe Likelihood

haematoma variable high
Most common (with an incidence of 10%) complication after surgery in adults; rare in children.[19] Most
will reabsorb spontaneously over weeks, but some require operative drainage.
inguinal hernia variable low
Inguinal hernia may be classified as reducible or incarcerated.
Patients with incarcerated hernias usually present with vomiting and abdominal pain. On physical
examination, there will be a non-reducible inguinal mass.
Manual reduction, usually facilitated by sedation to relax the abdomen, is the first step. Urgent surgical
repair should be performed once the hernia is reduced. If it is not possible to reduce the hernia, immediate
surgical repair is indicated.[6]
testicular injury after surgery variable low
Incidence of testicular injury is very low (0.3%).[18] [19]
pain in inguinal area radiating to abdomen variable low
A rare complication of untreated abdominoscrotal hydrocele.
lower extremity oedema variable low
A rare complication of untreated abdominoscrotal hydrocele.
testicular atrophy variable low
A complication of late treatment of an incarcerated or strangulated hernia due to vascular obstruction.
23
Hydrocele Follow up
Complications Timeframe Likelihood

hydronephrosis variable low
FOLLOW UP
A very rare complication of untreated abdominoscrotal hydrocele.
infertility variable low
Can be caused by injury to the epididymis and vas deferens during surgery. It is more common after
sclerotherapy.[19]
Prognosis
The majority of non-communicating (simple) hydroceles resolve within the first 2 years of life. Persistence
of a hydrocele beyond 2 years of age may be an indication for surgical correction. In expert hands, the
incidence of testicular damage during hydrocele repair has been reported to be low (0.3%).[18] [19] The
recurrence rate of hydroceles is low. It has been reported that 2% of patients develop a recurrent inguinal
hernia within 5 years of surgery.[6] This only occurs when the processus vaginalis is not adequately
dissected and ligated at the time of the initial repair. Reoperation is the only appropriate treatment for these
patients.
Hydrocele Guidelines
Diagnostic guidelines
Europe
Guidelines on paediatric urology

Published by: European Association of Urology; European Society for Last published: 2017
Paediatric Urology
International
IPEG guidelines for inguinal hernia and hydrocele

Published by: International Pediatric Endosurgery Group Last published: 2009
Treatment guidelines
GUIDELINES
Europe
Guidelines on paediatric urology

Published by: European Association of Urology; European Society for Last published: 2017
Paediatric Urology
International
IPEG guidelines for inguinal hernia and hydrocele

Published by: International Pediatric Endosurgery Group Last published: 2009
25
Hydrocele Online resources
Online resources
1. American Urological Association Urology Care Foundation: Hydroceles and inguinal hernias (external
link)
2. American Academy of Family Physicians: Testicular masses (external link)

ONLINE RESOURCES
Hydrocele References
Key articles
• Schneck FX, Bellinger MF. Abnormalities of testis and scrotum and their surgical management. In:
REFERENCES
Wein AJ, Kavoussi LR, Novick AC, et al, eds. Campbell-Walsh urology. 9th ed. Philadelphia, PA: WB
Saunders; 2007:3761-3798.
• Baskin LS, Kogan BA. Hydrocele/hernia. In: Gonzales ET, Bauer SB, eds. Pediatric urology practice.
Philadelphia, PA: Lippincott, Williams & Wilkins; 1999:649-653.
• Bronsther B, Abrams MW, Elboim C. Inguinal hernias in children - a study of 1,000 cases and a review
of the literature. J Am Med Womens Assoc. 1972;27:522-525. Abstract
• Esposito C, Valla JS, Najmaldin A, et al. Incidence and management of hydrocele following varicocele
surgery in children. J Urol. 2004 Mar;171(3):1271-3. Abstract
• Tekgül S, Dogan HS, Hoebeke P, et al; European Association of Urology. Guidelines on paediatric
urology. 2017. http://www.uroweb.org/ (last accessed 3 October 2017). Full text
• Dogra VS, Gottlieb RH, Oka M, et al. Sonography of the scrotum. Radiology. 2003;227:18-36. Abstract
References
1. International Pediatric Endosurgery Group. IPEG guidelines for inguinal hernia and hydrocele. J
Laparoendosc Adv Surg Tech A. 2010;20:x-xiv. Full text Abstract
2. Schneck FX, Bellinger MF. Abnormalities of testis and scrotum and their surgical management. In:
Wein AJ, Kavoussi LR, Novick AC, et al, eds. Campbell-Walsh urology. 9th ed. Philadelphia, PA: WB
Saunders; 2007:3761-3798.
3. Baskin LS, Kogan BA. Hydrocele/hernia. In: Gonzales ET, Bauer SB, eds. Pediatric urology practice.
Philadelphia, PA: Lippincott, Williams & Wilkins; 1999:649-653.
4. Kaefer M, Agarwal D, Misseri R, et al. Treatment of contralateral hydrocele in neonatal testicular

torsion: is less more? J Pediatr Urol. 2016;12:306.e1-306.e4. Abstract
5. Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am.
1998;45:773-789. Abstract
6. Skoog SJ. Benign and malignant pediatric scrotal masses. Urol Clin North Am. 1997;44:1229-1250.
Abstract
7. Barthold JS, Kass EJ. Abnormalities of the penis and scrotum. In: Belman AB, King LR, Kramer SA,
eds. Guide to clinical pediatric urology. London: Martin Dunitz; 2002:267-298.
8. Rowe MI, Copelson LW, Clatworthy HW. The patent processus vaginalis and the inguinal hernia. J
Pediatr Surg. 1969;4:102-107. Abstract
27
Hydrocele References
9. Bronsther B, Abrams MW, Elboim C. Inguinal hernias in children - a study of 1,000 cases and a review
of the literature. J Am Med Womens Assoc. 1972;27:522-525. Abstract
REFERENCES
10. 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;117:1175-1179. Full text
Abstract
11. Esposito C, Valla JS, Najmaldin A, et al. Incidence and management of hydrocele following varicocele
surgery in children. J Urol. 2004 Mar;171(3):1271-3. Abstract
12. Lipshultz LI, Thomas AJ, Khera M. Surgical management of male infertility. In: Wein AJ, Kavoussi LR,
Novick AC, et al, eds. Campbell-Walsh urology. 9th ed. Philadelphia, PA: WB Saunders; 2007:665.
13. Al-Kandari AM, Shabaan H, Ibrahim HM, et al. Comparison of outcomes of different varicocelectomy
techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized
clinical trial. Urology. 2007;69:417-420. Abstract
14. Streit T, Lafontant JG. Eliminating lymphatic filariasis: a view from the field. Ann N Y Acad Sci.
2008;1136:53-63. Abstract
15. Kogan BA. Communicating hydrocele/hernia repair in children. BJU Int. 2007;100:703-714. Abstract
16. Cimador M, Castagnetti M, De Grazia E. Management of hydrocele in adolescent patients. Nat Rev
Urol. 2010;7:379-385. Abstract
17. Tekgül S, Dogan HS, Hoebeke P, et al; European Association of Urology. Guidelines on paediatric
urology. 2017. http://www.uroweb.org/ (last accessed 3 October 2017). Full text
18. Dogra VS, Gottlieb RH, Oka M, et al. Sonography of the scrotum. Radiology. 2003;227:18-36. Abstract
19. Sandlow JI, Winfield HN, Goldstein M. Surgery of the scrotum and seminal vesicles. In: Wein AJ,
Kavoussi LR, Novick AC, et al, eds. Campbell-Walsh urology. 9th ed. Philadelphia, PA: WB Saunders;
2007:1105-1106.
20. Abel EJ, Pettus JA, Snow B. Laparoscopic marsupialization before inguinal repair of large
abdominoscrotal hydroceles in infants: observation of natural history and description of technique.
Urology. 2009;73:507-509. Abstract
21. Jahnson S, Sandblom D, Holmang S. A randomized trial comparing 2 doses of polidocanol

sclerotherapy for hydrocele or spermatocele. J Urol. 2011;186:1319-1323. Abstract
22. Zampieri N, El-Dalati G, Ottolenghi A, et al. Percutaneous aspiration for hydroceles after
varicocelectomy. Urology. 2009;74:1122-1124. Abstract
Hydrocele Images
Images
IMAGES
Figure 1: Communicating hydrocele
29
IMAGES Hydrocele Images
Figure 2: Non-communicating hydrocele

Hydrocele Images
IMAGES
Figure 3: Normal anatomy
31
Hydrocele Disclaimer
Disclaimer
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Contributors:
// Authors:
Barry A. Kogan, MD
Professor of Surgery and Pediatrics
Albany Medical College, Albany, NY
DISCLOSURES: BAK has no competing interests.
Erim Erdem, MD
Professor of Urology
Mersin University School of Medicine, Department of Urology, Mersin, Turkey
DISCLOSURES: EE is an associate member of the Paediatric Urology Guidelines Working Panel.
// Peer Reviewers:
Edmund Sabanegh, MD
Director
Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland, OH
DISCLOSURES: ES declares that he has no competing interests.
Daniel H. Williams, IV, MD

Assistant Professor
Department of Urology, Head, Section of Male Infertility and Andrology, University of Wisconsin School of
Medicine and Public Health, Madison, WI
DISCLOSURES: DHW declares that he has no competing interests.
Marcus Drake, MA, DM, FRCS (Urol)

Senior Lecturer in Urology
University of Bristol, Bristol, UK
DISCLOSURES: MD declares that he has no competing interests.

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Hydrocele

The right clinical information, right where it's needed

Last updated: Jan 03, 2018

Nuck. There are 2 types of hydroceles: communicating and non-communicating (simple).

• Results from a congenital malformation of tunica vaginalis.

• Passage of peritoneal fluid to the scrotum through a patent processus vaginalis.

• A huge form of simple hydrocele that extends into the abdomen.

Step-by-step diagnostic approach

prematurity and low birth weight

infants <6 months of age

infants whose testes descend relatively late

increased intraperitoneal fluid or pressure

inflammation or injury within the scrotum

maternal exposure to polybrominated biphenyl

History & examination factors

scrotal mass (common)

the scrotum or it may extend into the inguinal canal.

enlargement of scrotal mass following activity (common)

variation in scrotal mass during the day (common)

Other tests to consider

Condition Differentiating signs / Differentiating tests

Testicular cancer • These will usually be solid, • Scrotal ultrasound will

Epididymitis • Clinically the patient has • Colour Doppler

Condition Differentiating signs / Differentiating tests

Epididymal cyst • Scrotal mass that can • Scrotal ultrasound may

Scrotal oedema • Thickening of the scrotal • Diagnosis is best made

Testicular torsion • Extreme tenderness, • Color Doppler

Varicocele • Palpation of enlarged veins • Physical examination is

Step-by-step treatment approach

Children ≤2 years of age

Children 2-11 years of age

• Contralateral symptomatic hydrocele may be present in 3% to 5 % of patients.[15] While a

Adolescents 12-18 years of age

• The incidence of post-varicocelectomy hydrocele has decreased due to technical improvements

• Complete excision of the tunica vaginalis is appropriate treatment.

Treatment details overview

drug interactions, and alternative dosing. ( see Disclaimer )

≤2 years old 1st observation

2-11 years old 1st surgery

idiopathic 1st surgery

post-varicocelectomy 1st observation +/- aspiration

filarial-related hydrocele 1st surgery

without discomfort or 1st observation

with discomfort or 1st surgery or aspiration and sclerotherapy

≤2 years old 1st observation

» Many hydroceles resolve before the age of 2

» Elective surgical repair is indicated for

» The surgical approach involves open repair

» In hydrocele of the spermatic cord, the cystic

» Many clinicians perform laparoscopy via

» Bilateral repair is indicated for patients with

idiopathic 1st surgery

» In most cases, observation is appropriate. If

as excision of the hydrocele or plication of the

» Surgery should be second line for those who

» Complete excision of tunica vaginalis is

without discomfort or 1st observation

» Excision of the hydrocele sac is appropriate

» Extreme care must be taken to avoid injury to

» Aspiration and sclerotherapy may be an

» A small amount local anaesthetic is injected

4 injections of polidocanol with a complication

Complications Timeframe Likelihood