Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Hydrocele Treatment & Management

  • Author: Steven L Lee, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 08, 2015
 

Medical Therapy

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.

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%.[8]

Next

Surgical Therapy

Surgical therapy can be divided into three approaches. The first is an inguinal approach with ligation of the processus vaginalis high within the internal inguinal ring and 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.[9]

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.[9]

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.[10]

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

The third, 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.

Previous
Next

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.

Previous
Next

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 almost always transient.

Previous
Next

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 collodion, Dermabond, or occlusive dressing. No activity restrictions are required, and nonnarcotic analgesics are used minimally.

Patients undergoing scrotal approaches benefit from supportive dressings, such as fluff 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.

Previous
Next

Follow-up

At least one postoperative follow-up visit is recommended. For small infants, 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.

Previous
Next

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.
Previous
Next

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.

Previous
Next

Future and Controversies

Recently, 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.

Previous
 
Contributor Information and Disclosures
Author

Steven L Lee, MD Chief of Pediatric Surgery, Harbor-UCLA Medical Center; Associate Clinical Professor of Surgery and Pediatrics; University of California, Los Angeles, David Geffen School of Medicine

Steven L Lee, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, International Pediatric Endosurgery Group, Pacific Association of Pediatric Surgery, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey J Du Bois, MD Chief of Children's Surgical Services, Division of Pediatric Surgery, Kaiser Permanente, Women and Children's Center, Roseville Medical Center

Jeffrey J Du Bois, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, California Medical Association

Disclosure: Nothing to disclose.

Shant Shekherdimian, MD, MPH Resident Physician, Department of Pediatric Surgery, Hospital for Sick Children; Toronto, Ontario, Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, SWOG

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Additional Contributors

Edmund S Sabanegh, Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh, Jr, MD is a member of the following medical societies: American Medical Association, American Society of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG

Disclosure: Nothing to disclose.

References
  1. Chang YT, Lee JY, Wang JY, Chiou CS, Chang CC. Hydrocele of the spermatic cord in infants and children: its particular characteristics. Urology. 2010 Jul. 76(1):82-6. [Medline].

  2. Manjunatha Y, Beeregowda Y, Bhaskaran A. Hydrocele of the canal of Nuck: imaging findings. Acta Radiol Short Rep. 2012. 1(3):[Medline]. [Full Text].

  3. Heer J, McPheeters R, Atwell AE. Hydrocele of the Canal of Nuck. West J Emerg Med. 2015 Sep. 16 (5):786-7. [Medline]. [Full Text].

  4. Kono R, Terasaki H, Murakami N, Tanaka M, Takeda J, Abe T. Hydrocele of the canal of Nuck: a case report with magnetic resonance hydrography findings. Surg Case Rep. 2015 Dec. 1:86. [Medline]. [Full Text].

  5. Otabil KB, Tenkorang SB. Filarial hydrocele: a neglected condition of a neglected tropical disease. J Infect Dev Ctries. 2015 Mar 18. 9 (5):456-62. [Medline]. [Full Text].

  6. Clarnette TD, Hutson JM. The genitofemoral nerve may link testicular inguinoscrotal descent with congenital inguinal hernia. Aust N Z J Surg. 1996 Sep. 66(9):612-7. [Medline].

  7. Clarke S. Pediatric inguinal hernia and hydrocele: an evidence-based review in the era of minimal access surgery. J Laparoendosc Adv Surg Tech A. 2010 Apr. 20(3):305-9. [Medline].

  8. Lund L, Kloster A, Cao T. The long-term efficacy of hydrocele treatment with aspiration and sclerotherapy with polidocanol compared to placebo: a prospective, double-blind, randomized study. J Urol. 2014 May. 191(5):1347-50. [Medline].

  9. Saka R, Okuyama H, Sasaki T, Nose S, Yoneyama C, Tsukada R. Laparoscopic treatment of pediatric hydrocele and the evaluation of the internal inguinal ring. J Laparoendosc Adv Surg Tech A. 2014 Sep. 24(9):664-8. [Medline].

  10. Peng Y, Li C, Lin W, Xu L. Application of a Laparoscopic, Single-port, Double-needle Technique for Pediatric Hydroceles With Multiple Peritoneal Folds: A Trial From a Single-center 5-Year Experience. Urology. 2015 Jun. 85 (6):1466-70. [Medline].

  11. Glick PL, Boulanger SC. Inguinal hernia and hydrocele. Coran AG, Adzick NS, Krummel TM, et al, Eds. Pediatric Surgery. 7th ed. Philadelphia PA: Saunders; 2012. 985-1002.

  12. Sagar J, Kumar S, Mondal D, Shah DK. Idiopathic infected hydrocele in a toddler: a case report with review. ScientificWorldJournal. 2006. 6:2396-8. [Medline].

 
Previous
Next
 
Hydrocele that extended retrograde into the abdominal compartment.
Hydrocele. Small patent processus vaginalis (indicated by the bubbles) as viewed laparoscopically.
Young girl with groin bulge, which, at surgery, was a hydrocele of along the canal of Nuck.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.