Hydrocele

Practice Essentials

A hydrocele is a fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord.^[1] These fluid collections may represent persistent developmental connections along the spermatic cord or an imbalance of fluid production versus absorption. In rare cases, similar fluid collections can develop in females along the canal of Nuck.^{[2, 3, 4]} See the image below.

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Young girl with groin bulge, which, at surgery, was a hydrocele of along the canal of Nuck.

By themselves, hydroceles pose little risk of clinical consequence. However, the potential for more than fluid to appear within developmental connections between the abdominal cavity and the scrotum or the association with underlying scrotal pathology requires that hydroceles be evaluated with due prudence. See the image below.

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Hydrocele that extended retrograde into the abdominal compartment.

In endemic tropical regions, scrotal hydrocele may occur in males of any age as a result of filariasis, especially from Wuchereria bancrofti infection.^[5] See Filarial Hydrocele.

For additional information on hydroceles, see Hydrocele in Emergency Medicine and Pediatric Hydrocele and Hernia Surgery.

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History of the Procedure

The description of the abdominal cavity parietes to the tunica vaginales is attributed to Galen in 176 AD. However, the clear description of the inguinal anatomy and its relationship to groin hernias and hydroceles was not recorded until the 19th century.

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Problem

The presence of fluid within the hemiscrotum has little clinical impact on the testis. However, determining the cause for the increased fluid, specifically any associated clinically significant pathology, remains the primary concern with regard to hydroceles. Once pathology that is more ominous has been excluded, persistence of the hydrocele or associated discomfort may indicate the need for surgical intervention.

Patients who have undergone varicocelectomy may be an important exception in which a hydrocele may be of clinical importance. This procedure is usually performed when dilated vessels around the testes are believed to increase intratesticular temperatures, thereby leading or contributing to male infertility. Varicocelectomy may damage nearby lymphatic vessels, which may lead to the formation of postvaricocelectomy hydroceles in approximately 7% of patients, potentiating the insulation of the testicle and leading to persistent problems with sperm production. The use of microscopes during this procedure has significantly decreased the incidence of lymphatic obliteration and, therefore, hydrocele formation.

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Epidemiology

Frequency

A patent processus vaginalis is found in 80-90% of term male infants at birth. This frequency rate steadily decreases until age 2 years, at which point it appears to plateau at approximately 25-40%. Indeed, autopsy series of men have identified a frequency rate of 20% of the processus vaginalis remaining patent until late in life. However, clinically apparent scrotal hydroceles are evident in only 6% of term males beyond the newborn period. Certain conditions, such as breech presentation, gestational progestin use, and low birth weight, have been associated with an increased risk of hydroceles. The incidence of hydroceles in men is less well known. See the image below.

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Hydrocele. Small patent processus vaginalis (indicated by the bubbles) as viewed laparoscopically.

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Etiology

The causes of hydroceles are legion. In children, most hydroceles are of the communicating type, in which patency of the processus vaginalis allows peritoneal fluid to flow into the scrotum, particularly during Valsalva maneuvers.

In the adult population, filariasis, a parasitic infection caused by Wuchereria bancrofti, accounts for most causes of hydroceles worldwide, affecting more than 120 million people in more than 73 countries (see Hydrocele, Filarial). However, this condition is virtually nonexistent in the United States, where iatrogenic causes of hydroceles predominate. Following laparoscopic or transplant surgery in males, inadequate irrigation fluid aspiration may cause hydroceles in patients with a patent processus vaginalis or a small hernia. Careful aspiration of fluid at the end of laparoscopic procedures helps prevent this complication. In noncommunicating hydroceles, for both children and adults, the balance between fluid production within the tunica and the fluid absorption is altered.

A few studies have attempted to show a link between certain molecular derangements and an increased incidence of patent processus vaginales (and therefore hydroceles and indirect hernias). Two such examples include increases in maternal estrogen concentrations during pregnancy and abnormalities in the calcitonin gene-related peptide (CGRP) released by the genitofemoral nerve.^[6]

Mesotheliomas of the tunica vaginalis are rare, but should be considered in patients with a history of asbestos exposure who have a complex hydrocele with hypervascular parietal vegetations.^{[7, 8, 9]}

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Pathophysiology

The pathophysiology of hydroceles requires an imbalance of scrotal fluid production and absorption. This imbalance can be divided further into exogenous fluid sources or intrinsic fluid production.

Alternatively, hydroceles can be divided into those that represent a persistent communication with the abdominal cavity and those that do not. Fluid excesses are from exogenous sources (the abdomen) in communicating hydroceles, whereas noncommunicating hydroceles develop increased scrotal fluid from abnormal intrinsic scrotal fluid shifts.

Communicating hydroceles

With communicating hydroceles, simple Valsalva maneuvers probably account for the classic variation in size during day-sleep cycles. Nonetheless, with the incidence of patent processus so great, why children with clinically apparent hydroceles are relatively few remains somewhat inexplicable. Chronically increased intra-abdominal pressure (eg, as in chronic lung disease) or increased abdominal fluid production (eg, children with ventriculoperitoneal shunts) probably warrants early surgical intervention.

Noncommunicating hydroceles

Noncommunicating hydroceles may result from increased fluid production or impaired fluid absorption. A sudden onset of scrotal hydrocele in older children has been noted after viral illnesses. In such cases, viral-mediated serositis may account for the net increased fluid production. Posttraumatic hydroceles likely occur secondary to increased serosal fluid production due to underlying inflammation. Although rare in the United States, filarial infestations are a classic cause of the decreased lymphatic fluid absorption resulting in hydroceles.

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Presentation

Hydroceles typically manifest as a soft nontender fullness within the hemiscrotum. The testis is generally palpable along the posterior aspect of the fluid collection. When the scrotum is investigated with a focused beam of light, the scrotum transilluminates, revealing a homogeneous glow without internal shadows.

Hydroceles of the canal of Nuck in female patients typically present as soft, nontender inguinal or labial swelling. Like hemiscrotal hydroceles, labial hydroceles transilluminate readily.^{[3, 4]}

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Indications

Indications for intervention in hydroceles include the following:

• Inability to distinguish from an inguinal hernia
• Failure of the hydrocele to resolve spontaneously after an appropriate interval of observation
• Inability to clearly examine testis
• Association of hydroceles with suggestive pathology (eg, torsion, tumor)
• Pain or discomfort
• Male infertility
• Cosmesis

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Relevant Anatomy

The developmental anatomy of the inguinal canal is responsible for the genesis of pediatric communicating hydroceles. As the testis descends from the posterolateral genitourinary ridge at the beginning of the third trimester of fetal gestation, a saclike extension of peritoneum descends in concert with the testis. As descent progresses, the sac envelops the testis and epididymis. The result is a serosal-lined tubular communication between the abdomen and the tunica vaginalis of the scrotum.

The peritoneum-derived serosal communication is the processus vaginalis, and the serosa of the hemiscrotum becomes the tunica vaginalis. At term, or within the first 1-2 years of life, the processus vaginalis of the spermatic cords fuse, thereby obliterating the communication between the abdomen and the scrotum. The processus fuses distally as far as the lower epididymal pole and anteriorly to the upper epididymal pole. Failure of complete fusion may result in communicating hydroceles, indirect inguinal hernias, and the bell-clapper deformity of abnormal testicular fixation in the scrotum.^[1]

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Contraindications

Seemingly, no true absolute contraindications exist for repair of hydroceles. However, given the minimal clinical consequence of the hydrocele itself, any condition that classifies patients as poor surgical or anesthetic risk may be considered a relative contraindication to surgical repair.

Additionally, while a slight majority of pediatric surgeons across North America would repair any communicating hydrocele (somewhat irrespective of age) if it were clearly communicating, waiting until the child is 1-2 years old is certainly reasonable. Finally, small atrophic testes, or solitary testes, should be approached with great caution to minimize the risk of anorchia.

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Prognosis

In a review of data from 355 pediatric patients with hydroceles, Acer-Demir et al reported high rates of spontaneous resolution, with virtually all children older than 1 year of age who did not undergo surgery showing spontaneous recovery within 1 year. These authors recommend monitoring congenital hydroceles until at least 1 year and preferably 2 years of age, unless strong evidence of hydrocele-induced testicular damage arises, and recommend monitoring noncongenital hydroceles for at least 6 months and preferably 1 year if the patient has no associated pathology indicating the need for earlier surgery.^[15]

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Approach Considerations

Simple hydroceles are diagnosed on clinical grounds. Clinical findings that should raise the suggestion of a different diagnosis or some additional underlying pathology include the following:

• Inability to clearly delineate or palpate the testicular structure
• Local tenderness, fever, or any gastrointestinal symptoms (eg, vomiting, constipation, diarrhea)
• Internal shadows on transillumination

Scrotal ultrasonography is the next logical step in such cases.

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Laboratory Studies

Few laboratory tests, if any, are warranted specifically for simple hydroceles, communicating or noncommunicating. Concomitant medical conditions may be indications for preoperative laboratory studies. Laboratory studies may be indicated to exclude other surgical or medical conditions that may be in the differential diagnosis.

Inguinal hernia

While laboratory studies are not warranted in routine inguinal herniorrhaphy, a possible incarcerated inguinal hernia may be difficult to distinguish from a hydrocele.

Findings that may favor urgent exploration in this setting include the following:

• Failure to clearly transilluminate
• Palpable bowel at the internal ring during the rectal examination
• An elevated white blood cell count

Testicular tumor

Approximately 10% of patients with testicular teratomas may present with a cystic mass that may transilluminate during the physical examination. Similarly, adults with testicular tumors may present with new-onset scrotal swelling. If this diagnosis is considered, measuring serum alpha-fetoprotein and human chorionic gonadotropin (hCG) levels is indicated to exclude malignant teratomas or other germ cell tumors.

Epididymitis/orchitis

Occasionally, a reactive hydrocele occurs in association with underlying testicular infection. Urinalysis and urine culture may be beneficial. Although urinalysis and/or culture results are positive in only 30% of such cases, a positive culture result may be useful in guiding antimicrobial treatment. Symptoms are treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and scrotal elevation.

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Imaging Studies

The radiographic evaluation of hydroceles is controversial. Communicating hydroceles in patients (infants in particular) with a classic presentation and palpable testicle do not require radiographic studies. However, findings from radiographic or ultrasonographic studies can help evaluate for other underlying processes, such as a tumor or torsion, and can be useful in the setting of a non-communicating hydrocele or inability to palpate the testicle, acute onset of swelling/pain, or other atypical findings on presentation or examination.

Ultrasonography

Ultrasonography provides excellent detail of the testicular parenchyma. Spermatoceles can be clearly distinguished from hydroceles on sonograms. If a testicular tumor is a diagnostic consideration, ultrasonography is an excellent screening study.

In addition, testicular atrophy suggesting chronic torsion and a reactive hydrocele can be seen on sonograms. Failure to clearly delineate testicular anatomy with palpation indicates the need for further diagnostic imaging such as ultrasonography.

Duplex ultrasonography

Duplex studies may provide substantial information regarding testicular blood flow when a hydrocele may be associated with chronic torsion.

Additionally, epididymitis associated with a reactive hydrocele can be distinguished based on findings from duplex scanning, as evidenced by increased epididymal flow.

Finally, duplex studies may help identify Valsalva-augmented regurgitant flow in patients with varicoceles.

Plain abdominal radiography

Plain radiography may be useful for distinguishing an acute hydrocele from an incarcerated hernia. Gas overlying the groin may indicate an incarcerated hernia.

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Histologic Findings

If a hernia is identified along with the hydrocele, the sac may be removed following high ligation and sent for pathological analysis. In this case, the histology findings are consistent with peritoneal lining.^[10]

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Approach Considerations

Asymptomatic adults with isolated noncommunicating hydroceles can be observed indefinitely or until they become symptomatic, as complications such as infection or testicular compromise are exceedingly rare. However, if the diagnosis is in question or underlying pathology cannot be excluded, operative exploration is warranted.

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Surgical Therapy

Surgical therapy can be divided into three approaches: inguinal, scrotal, and sclerotherapy. For more information on surgery in children, see Pediatric Hydrocele and Hernia Surgery.

Inguinal

The inguinal approach, with ligation of the processus vaginalis high within the internal inguinal ring, is the procedure of choice for pediatric hydroceles (typically, communicating). If a testicular tumor is identified on testicular ultrasonography, an inguinal approach with high control/ligation of the cord structures is mandated.

In a study by Saka et al, 69 patients with hydrocele underwent either laparoscopic percutaneous extraperitoneal closure (40 patients) or open repair (29 patients), and the safety and efficacy of the two approaches were compared. There were no significant differences in length of operation, anesthesia, or complications for the two procedures; and no recurrences were observed for either procedure.^[11]

In addition, the authors reported on the features of the internal inguinal ring (IIR) found in cases of hydrocele and in cases of inguinal hernia treated during the study period. In the cases of hydrocele, 59.1% of the IIRs were narrow patent processus vaginalis (PPV) with a peritoneal veil; for patients with inguinal hernia, 92% of the IIRs were widely opened PPV.^[11]

Peng et al reported the successful use of minilaparoscopic procedures in 125 boys (age range, 12-68 months) with multiple peritoneal folds in the hydrocele sac orifice. Modified single-port, double-needle, minilaparoscopic surgery in which an Endo Close needle was used to spread the peritoneal folds and facilitate circular extraperitoneal suturing produced outcomes comparable to those with a two-port laparoscopic procedure, during which a 3-mm grasping forceps was used to grasp the folds around the internal inguinal ring. The authors suggest that the modified single-port technique is safe, effective, and more cosmetically appealing for the management of complicated pediatric hydroceles.^[12]

Wang et al reported success with single-site laparoscopic percutaneous extraperitoneal closure of the internal ring in 483 children with hydrocele. Their technique, which uses an epidural and spinal needle, required a median operation time of 18 minutes (range, 10-30 min) and no patient developed intraoperative or postoperative complications.^[13]

Scrotal

The scrotal approach, with excision or eversion and suturing of the tunica vaginalis, is recommended for chronic noncommunicating hydroceles. This approach should be avoided upon any suspicion for underlying malignancy.

In contrast, Alp et al report that the scrotal approach is an effective alternative for the treatment of communicating hydrocele in pediatric patients. In their study of 43 boys (46 testicular units) treated with the classic inguinal approach and 27 boys (30 testicular units) treated with a scrotal approach, operative time was significantly lower in the scrotal group (P <  0.0001), the early minor complication rate did not differ between the two groups, no major complications noted, and none of the patients had hydrocele recurrence after a mean follow-up of 6 months.^[16]

Sclerotherapy

An additional adjunctive, if not definitive, procedure, is scrotal aspiration and sclerotherapy of the hemiscrotum using tetracycline or doxycycline solutions. Recurrence after sclerotherapy is common, as is significant pain and epididymal obstruction, making this treatment a last resort in poor surgical candidates with symptomatic hydroceles and in men in whom fertility is no longer an issue.

A review by Taylor et al of aspiration and sclerotherapy treatment for hydroceles in aging men concluded that sodium tetradecyl sulphate (STDS) is the sclerosing agent with the best cure rate after a single injection and rates of adverse effects. Cure rates with STDS were 76% after a single aspiration and injection and 94% after multiple treatments. Patient satisfaction rates at a mean of 40 months were 95%. Complication rates were generally low and much lower than those seen with surgical repair.^[17]

Lund et al, in a study of 76 patients with hydrocele testis, found that aspiration and sclerotherapy with polidocanol is an effective treatment with a low recurrence rate. In this prospective, double-blind, randomized study, 36 patients given polidocanol (group 1) were compared with 41 patients given placebo (group 2). Recurrence after the first treatment was seen in 16 (44%) of the polidocanol patients and in 32 (78%) of the placebo patients. Recurrence after re-treatment with polidocanol in both groups was seen in four patients (25%) in group 1 and in 14 patients (44%) in the former placebo group. The overall success rate of treatment in group 1 was 89%.^[14]

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Preoperative Details

Preoperative considerations are minimal because outpatient treatment is the routine. Nothing by mouth (NPO) provisions are age- and institution-dependent. Proper provisions for postoperative transportation and observation are arranged prior to surgery.

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Intraoperative Details

Intraoperative considerations during inguinal repair include meticulous attention to spermatic cord structures. A "no-touch" approach to the reactive testicular vessels and delicate vasa helps minimize complications. Excessive dissection around the testicular vessels may result in thrombophlebitis of the pampiniform plexus. The distal processus is spatulated widely to provide free drainage of scrotal fluid. The proximal processus is ligated above (deep to) the internal inguinal ring. Failure to identify a patent processus during inguinal exploration should prompt (1) a thorough reexamination of the cord structures and (2) partial or complete excision of the hydrocele or needle aspiration of only the hydrocele prior to closing.

During scrotal approaches, excision of redundant tunica vaginalis (with or without eversion) and suturing of the reflected tunica behind the epididymis results in a postoperative testis that is more easily and more reliably examined. Care must be taken to not injure the vas or epididymis during this procedure. A running hemostatic suture around the line of excision is helpful for assuring hemostasis. Plication of the sac (Lord procedure) is another technique useful for management of large hydroceles. Electrocautery fulguration of the edge of the excised tunica vaginalis promotes scarring and decreases recurrence while decreasing operative time.

Unexpected findings may be dealt with, as appropriate, either for the scrotal approach or by converting to an inguinal approach (eg, testicular tumors). If a testicular tumor is encountered, biopsy with frozen section and orchiectomy with resection of the spermatic cord up to the internal ring is warranted if tumor is confirmed. Placing a drain in the dependent portion of the scrotum is prudent for large hydroceles. A nonsuction drain such as a Penrose can be removed within the first 24-48 hours after surgery. If a drain is not used, expect a large hematoma and significant edema. Often, this enlargement is worse than the original problem, although it is almost always transient.

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Postoperative Details

Children undergoing inguinal herniorrhaphies for repair of communicating hydroceles generally recuperate with minimal discomfort and exceedingly few restrictions. Tub baths are to be avoided for 5-7 days. The wounds of diaper-aged children are sealed with tissue adhesive or occlusive dressing. No activity restrictions are required, and nonnarcotic analgesics are used minimally.

Patients undergoing scrotal approaches benefit from supportive dressings in a scrotal support or athletic supporter. Rest and avoidance of vigorous activity help minimize discomfort. Showers may be resumed within 24-48 hours. Occasional doses of synthetic or semisynthetic narcotics may help relieve postoperative discomfort. Adult patients should be counseled that the hydrocele may transiently reaccumulate for a month or so postoperatively owing to edema.

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Follow-up

At least one postoperative follow-up visit is recommended. For small infants, patients with chronic recurring hydroceles, or patients with unsuspected intraoperative findings, more protracted follow-up evaluations may be warranted biweekly, monthly, or every 2-3 months to ensure complete recovery and normal testicular size and architecture.

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Complications

Complications are largely avoided with meticulous dissection and gentle tissue handling. In addition, extensive dissection should be avoided, as it increases the risk for nerve damage, vascular damage leading to testicular atrophy, and postoperative hematomas.

• Injury to spermatic cord structures: The vas or testicular vessels may be injured in 1-3% of inguinal approaches. Some testicular shrinkage has been described in nearly 10% of children undergoing inguinal hernia repair.
• Recurrence: Recurrence of the hydrocele after inguinal approaches is most often reactive in nature and usually resolves within several months. Rarely, aspiration or scrotal surgery is warranted.
• Bleeding/scrotal hematoma: Either poor intraoperative hemostasis or excessive cord dissection (with inguinal approaches) may result in postoperative bleeding. Hematomas typically resolve over time. If the patient has evidence of ongoing bleeding or is extremely symptomatic, exploration and hematoma evacuation is warranted.
• Ilioinguinal/genitofemoral nerve injury: These nerves may be entrapped or divided during inguinal approaches. The injury may be temporary or permanent.
• Wound infection: Postoperative wound infections are quite uncommon, particularly in children. Wound infections should be managed with antibiotics and, if necessary, opening the wound.

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Outcome and Prognosis

Inguinal repairs of communicating hydroceles are exceedingly successful, with a less than 1% recurrence rate. If a unilateral approach is completed, the small but recognized risk for a metachronous hydrocele or inguinal hernia developing remains, but the rate is likely less than 10%. Likewise, recurrence after tunica excision is also uncommon.

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Future and Controversies

Many surgeons have begun to advocate routine diagnostic laparoscopy of the contralateral groin in patients (particularly children) with unilateral hernias. The premise is that unsuspected contralateral hernias are repaired prior to clinical recognition. However, many more patent processus are being ligated than true hernias are being repaired. Whether an increased use of this technique will reduce the incidence of hydroceles in older children or adults remains to be seen. Furthermore, whether utilization of this intraoperative modality is of any utility in inguinal hydrocele repairs is open for debate.

Medical management, or, more importantly, prevention of patent processus vaginalis, has been theorized as possible after full elucidation of the intricate molecular processes that control fetal cell migration, proliferation, and adherence. Although the idea of preventing hydroceles or indirect hernias is interesting, it is far from being applicable in clinical medicine.

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