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Hydrocele: Treatment
Updated: Apr 1, 2009
Treatment
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.
Surgical Therapy
Surgical therapy can be divided into 3 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.
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.
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.
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.
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.
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.
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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References
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Bloom DA, Wan J, Kay D. Disorders of the male external genitalia and inguinal canal. In: Kelalis PP, King LR, Belman AB, eds. Clinical Pediatric Urology. 3rd ed. Philadelphia, Pa: WB Saunders; 1992:1015-49.
Campbell MF, Walsh PC, Retik AB, eds. Campbell's Urology. 8th ed. W.B. Saunders Company; 2002.
Depue RH. Maternal and gestational factors affecting the risk of cryptorchidism and inguinal hernia. Int J Epidemiol. Sep 1984;13(3):311-8. [Medline].
Hutson JM, Temelcos C. Could inguinal hernia be treated medically?. Med Hypotheses. 2005;64(1):37-40. [Medline].
Kaye R. Treatment of hydroceles by injection of sclerosing agents. N Engl J Med. Oct 28 1982;307(18):1149-50. [Medline].
Lloyd DA, Rintala RJ. Inguinal hernia and hydrocele. In: O'Neill Jr J, Rowe M, Grosfeld J, Fonkalsrud E, Coran A, eds. Pediatric Surgery. 5th ed. St. Louis, Mo: Mosby-Year Book; 1998:1071-86.
Marshall FF. The management of hydroceles. AUA Update Series. Vol 1. Baltimore, Md; American Urological Association; 1982:. 2-7.
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].
Further Reading
Keywords
hydrocele, communicating hydrocele, noncommunicating hydrocele, pediatric hydrocele, patent processus vaginalis, scrotal hydrocele, postvaricocelectomy hydrocele, post-varicocelectomy hydrocele, filarial hydrocele, filariasis, iatrogenic hydrocele, posttraumatic hydrocele, post-traumatic hydrocele, reactive hydrocele
