Hydrocele– Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

A collection of fluid within the scrotum:

  • Communicating hydrocele:
    • Associated with a patent processus vaginalis
    • Has associated indirect inguinal hernia
  • Noncommunicating hydrocele (the processus vaginalis is not patent):
    • Infantile type: Often spontaneous resolution
    • Adult type: Infrequent resolution
  • Hydrocele of the cord: Distal portion of processus vaginalis has closed, midportion patent and fluid filled, proximal portion open or closed
  • Acute hydrocele: Fluid collection resulting from an acute process within the tunica vaginalis
  • System(s) affected: Reproductive

Pediatric Considerations

In communicating hydrocele, consider contralateral inguinal exploration.

Epidemiology

Predominant age: Childhood

Prevalence

  • 1,000 per 100,000
  • Estimated to be 1% of adult males

Risk Factors

  • Ventriculoperitoneal shunt
  • Exstrophy of the bladder
  • Cloacal exstrophy
  • Ehlers-Danlos syndrome
  • Peritoneal dialysis

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

Commonly Associated Conditions

  • Testicular tumors
  • Trauma
  • Ventriculoperitoneal shunt
  • Nephrotic syndrome
  • Renal failure with peritoneal dialysis

Scrotum, Testicular torsion, communicating hydrocele, peritoneal dialysis, testicular tumors, inguinal canal, peritoneal fluid,

Diagnosis

History

  • Acute or subacute onset of scrotal swelling
  • Frequent changes in size of the hydrocele (indicative of a communication)
  • Swelling in scrotum or inguinal canal
  • Usually not painful
  • Sensation of heaviness in scrotum
  • Pain radiating to back (occasionally)

Physical Exam

  • Swelling in scrotum or inguinal canal
  • Demonstrated fluctuation in size (communicating hydrocele)
  • Fluid collection in scrotum that transilluminates
  • Scrotal mass, usually fluctuant

Diagnostic Tests & Interpretation

Lab

No lab studies usually helpful

Imaging

  • Abdominal radiograph: May be useful to distinguish incarcerated hernias from hydroceles (rarely needed)
  • Inguinoscrotal ultrasound: Can demonstrate the presence of bowel (e.g., distinguish incarcerated hernia from a hydrocele of the cord) as well as presence of testicular torsion
  • Testicular nuclear scan or Doppler ultrasound: To distinguish testicular torsion

Diagnostic Procedures/Surgery

Aspiration of hydrocele for diagnosis 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

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Additional Treatment

Issues for Referral

Recovery should be rapid and complete.

Surgery/Other Procedures

  • 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]:
    • Patients less <12 years old should undergo an inguinal approach, while scrotal approach can be considered in children >12 years old (2)[C].
  • Scrotal approach with internal drainage of hydrocele in adults (highest recurrence rate) (3)[C]
  • Scrotal approach with resection of hydrocele sac (highest complication rate, lowest recurrence rate) (3)[C]
  • Jaboulay-Winkelmann procedure (for thick hydrocele sac): Hydrocele sac wrapped posteriorly around cord structures (3)[C],(4)[A]
  • Lord procedure (for thin hydrocele sac): Radial sutures used to gather hydrocele sac posterior to testis and epididymis (3)[C],(4)[A]
  • Aspiration of the hydrocele with instillation of sclerosing agent (talc is best) has been successfully used in adults (5)[B]:
    • Aspiration with instillation of sodium tetradecyl sulphate was compared prospectively with Jaboulay procedure (30 patients each group) (6)[B]:
      • Aspiration instillation group had fewer complications and was much less expensive, but had recurrence rate of 34% and high rate of patient dissatisfaction

In-Patient Considerations

Initial Stabilization

  • Outpatient surgery
  • Observation in early infancy until definite communication demonstrated or until 1 year old

Ongoing Care

Follow-Up Recommendations

Full activity after surgery

Patient Monitoring

  • Follow at 3-month intervals until decision for/against surgery is made.
  • Postoperative follow-up at 2–4 weeks and then at intervals of 2–3 months until resolution of any postoperative (traumatic) hydrocele

Complications

  • Complication rate for scrotal approach may reach 30% (7)[C].
  • Preoperative antibiotics may be beneficial in reducing postoperative infections (7)[C].
  • Postoperative traumatic hydrocele common. Usually resolves spontaneously.
  • Injury to vas deferens or spermatic vessels
  • Suture granuloma
  • Hematoma
  • Wound infection
  • Recurrence of hydrocele
  • Tense infantile abdominoscrotal hydrocele may have high complication rate (8)[C]:
    • May have significant rate of testicular dysmorphism (including hypoplasia)

References

1. Gahukamble DB, Khamage AS. Prospective randomized controlled study of excision vs. distal splitting of hernial sac and processus vaginalis in the repair of inguinal hernias and communicating hydroceles. J Ped Surg. 1995;30:624–5.

2. Wilson JM, Aaronson DS, Schrader R, et al. Hydrocele in the pediatric patient: inguinal or scrotal approach? J Urol. 2008;180:1724–7; discussion 1727–8.

3. 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;87:82–4.

4. Miroglu C, Tokuc R, Saporta L. Comparison of an extrusion procedure and eversion procedures in the treatment of hydrocele. Int Urol Nephrol. 1994;26:673–9.

5. 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.

6. Khaniya S, Agrawal CS, Koirala R, Regmi R, Adhikary S et al. Comparison of aspiration-sclerotherapy with hydrocelectomy in the management of hydrocele: a prospective randomized study. International journal of surgery (London, England). 2009;7:392–5.

7. Swartz MA, Morgan TM, Krieger JN. Complications of scrotal surgery for benign conditions. Urology. 2007;69:616–9.

8. Cozzi DA, Mele E, Ceccanti S, et al. Infantile abdominoscrotal hydrocele: a not so benign condition. J Urol. 2008;180:2611–5; discussion 2615.

Codes

ICD9

603.9 Hydrocele, unspecified

Snomed

55434001 Hydrocele (disorder)

Clinical Pearls

  • A diagnosis of hydrocele can virtually always be made by physical exam alone. Occasionally, scrotal ultrasound is needed, especially if there is concern about an underlying process.
  • Aspirating a hydrocele as primary treatment is not recommended. If a hydrocele is confused with an incarcerated inguinal hernia, aspiration could result in significant complications. Otherwise, hydroceles simply recur following aspiration unless a sclerosing agent is injected as well.

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