Hydrocele in Adults and Adolescents

Background

• A hydrocele is an abnormal, painless accumulation of fluid between the parietal and visceral layers of the tunica vaginalis and/or along the spermatic cord, leading to swelling in the scrotum or groin.
• Hydroceles are either communicating or noncommunicating.
  • Communicating hydroceles are the result of an incomplete closure of the processus vaginalis. Almost all hydroceles in adults are noncommunicating, but adolescents will sometimes have communicating hydroceles.
  • Noncommunicating hydroceles are most often idiopathic, but may also be reactive. Idiopathic hydroceles are thought to represent an imbalance in the rates of fluid secretion and reabsorption within the closed sac of the tunica vaginalis. Reactive hydroceles may be secondary to trauma, infection, or malignancy.

Evaluation

• The diagnosis is based on physical exam findings, which usually consist of a painless, tense, fluid-filled swelling in the scrotum or groin that easily transilluminates. Hydrocele typically are reported to have gradually enlarged over time.
• Ultrasound may be required to confirm the diagnosis if palpation and transillumination are inconclusive.
• The differential diagnosis includes other scrotal abnormalities, which can usually be excluded on clinical grounds, including varicocele, testicular cancer, and testicular torsion.

Management

• A period of watchful waiting should precede surgery if the hydrocele is small and asymptomatic.
• The 2 main treatment modalities are surgical hydrocelectomy and aspiration and sclerotherapy.
  • The goal of surgical treatment is to permanently expose the secretory surface of the tunica vaginalis to the absorbing surface of the scrotal wall.
  • The 3 main methods of scrotal hydrocelectomy to consider include excision, plication, and internal drainage.
  • Complications of hydrocelectomy include scrotal edema, wound infection, and hematoma.
• Aspiration and sclerotherapy is an alternative for patients not wanting surgery.
  • The procedure is noninvasive, but may need to be repeated multiple times to achieve a lasting cure.
  • Sclerosing agents are used to adhere parietal and visceral layers of the tunica vaginalis together and include phenol, antazoline, ethanolamine oleate, sodium tetradecyl sulfate (STDS), tetracycline, and purified mineral talc.