HYDROCELE

HYDROCELE - Timothy L. Black, MD; James P. Miller, MD
BASICS
DESCRIPTION
Hydrocele is a collection of fluid within the scrotum.
• Communicating hydrocele
- Associated with a patent processus vaginalis
- Has associated indirect inguinal hernia
• Noncommunicating hydrocele
- Infantile typeFrequent spontaneous resolution
- Adult typeInfrequent resolution
• Hydrocele of the cord: Distal portion of processus vaginalis has closed, midportion patent and fluid filled, proximal portion may be open or closed
• Acute hydrocele: Acute fluid collection resulting from an acute process within the tunica vaginalis
• System(s) Affected: Reproductive
ALERT
Pediatric Considerations
In communicating hydrocele, consider contralateral inguinal exploration.
EPIDEMIOLOGY
• Predominant age: Childhood
• Predominant sex: Male only
Prevalence
• 1,000 per 100,000
• Estimated to be 1% of adult males
RISK FACTORS
• Ventriculoperitoneal shunt
• Exstrophy of the bladder
• Ehlers-Danlos syndrome
• Peritoneal dialysis
Genetics
Unknown
ETIOLOGY
• Closure of processus vaginalis trapping peritoneal fluid (noncommunicating)
• Closure of distal processus, trapping fluid in midportion of processus vaginalis (hydrocele of cord)
• Failure of closure of processus vaginalis (communicating hydrocele)
• Infection
• Tumors
• Trauma
• Ipsilateral renal transplantation
ASSOCIATED CONDITIONS
• Testicular tumors
• Trauma
• Ventriculo-peritoneal shunt
• Nephrotic syndrome
• Renal failure with peritoneal dialysis

DIAGNOSIS
SIGNS AND SYMPTOMS
• Swelling in scrotum or inguinal canal
• Demonstrated fluctuation in size (communicating hydrocele)
• Usually not painful
• Sensation of heaviness in scrotum
• Pain radiating to back (occasionally)
• Fluid collection in scrotum that transilluminates
History
• Acute or subacute onset of scrotal swelling
• Frequent changes in size of the hydrocele (indicative of a communication)
Physical Exam
Scrotal mass, usually fluctuant
TESTS
Imaging
• Abdominal radiographmay be useful to distinguish incarcerated hernias from hydroceles (rarely needed)
• Inguinoscrotal ultrasoundcan demonstrate presence of bowel, e.g., distinguish incarcerated hernia from a hydrocele of the cord as well as the presence of testicular torsion.
• Testicular nuclear scan or Doppler ultrasoundto distinguish testicular torsion
Diagnostic Procedures/Surgery
Aspiration of hydrocele should be discouraged
Pathological Findings
Patent processus vaginalis in communicating hydroceles
DIFFERENTIAL DIAGNOSIS
• Indirect inguinal hernia
• Orchitis
• Epididymitis
• Traumatic injury to testicle
• Torsion of testicle or torsion of appendix testes
TREATMENT
STABILIZATION
• Outpatient surgery
• Observation in early infancy until definite communication demonstrated or until 1 year of age
GENERAL MEASURES
Diet
Regular
Activity
Full activity after surgery
SURGERY
• In adults no therapy is needed unless hydrocele causes discomfort or unless there is a significant underlying cause such as tumor
• Inguinal approach with ligation of processus vaginalis and excision, or distal splitting, or drainage of hydrocele sac in children. (In hydrocele of cord, sac can be completely removed.) (1)[B]
• Scrotal approach with internal drainage of hydrocele in adults (highest recurrence rate) (2)[C]
• Scrotal approach with resection of hydrocele (highest complication rate, lowest recurrence rate). (2)[C]
• Jaboulay-Winkelmann procedure (for thick hydrocele sac)hydrocele sac wrapped posteriorly around cord structures (2)[C] (3)[A]
• Lord procedure (for thin hydrocele sac)radial sutures used to gather hydrocele sac posterior to testis and epididymis (2)[C] (3)[A]
• Aspiration of the hydrocele with instillation of sclerosing agent (talc is best) has been successfully used in adults (4)[B]
FOLLOW-UP
PROGNOSIS
Recovery should be rapid and complete.
COMPLICATIONS
• Postoperative traumatic hydrocele common. Usually resolves spontaneously
• Injury to vas deferens or spermatic vessels
• Suture granuloma
• Hematoma
• Wound infection
• Recurrence of hydrocele
PATIENT MONITORING
• Follow at 3-month intervals until decision for/against surgery made.
• Postoperative, follow-up at 2-4 weeks and then at 2-3-month intervals until resolution of any postoperative (traumatic) hydrocele.
REFERENCES
1. Gahukamble DB, Khamage AS. Prospective randomized controlled study of excision versus distal splitting of hernial sac and processus vaginalis in the repair of inguinal hernias and communicating hydroceles. J Ped Surg. 1995; 30:624-625.
2. Ku JH, Kim ME, Lee NK, et al. The excisional placation and internal drainage techniques: A comparison of the results for idiopathic hydrocele. BJU. 2001;87:82-84.
3. Miroglu C, Tokuc R, Saporta L. Comparison of an extrusion procedure and eversion procedures in the treatment of hydrocele. Int Urol Nephrol. 1994;26:673-679.
4. Yilmaz U, Ekmekcioglu O, Tatlisen A, et al. Does pleurodesis for pleural effusions give bright ideas about the agents for hydrocele sclerotherapy? Int Urol Nephrology. 2000;32:89-92.