Hydrocele in Emergency Medicine Clinical Presentation

  • Author: Scott E Rudkin, MD, MBA, RDMS, FAAEM, FACEP; Chief Editor: Erik D Schraga, MD   more...
 
Updated: Mar 30, 2012
 

History

  • Most hydroceles are asymptomatic or subclinical.
  • Evaluate the onset, duration, and severity of signs and symptoms.
  • Identify any relevant genitourinary (GU) history, sexual history, recent trauma, exercise, or systemic illnesses.
  • The usual presentation is a painless enlarged scrotum.
  • The patient may report a sensation of heaviness, fullness, or dragging.[2]
  • Patients occasionally report mild discomfort radiating along the inguinal area to the mid portion of the back.
  • Hydrocele usually is not painful; pain may be an indication of an accompanying acute epididymal infection.
  • The size may decrease with recumbency or increase in the upright position.
  • Chronically formed hydroceles appear to be larger in size than acutely formed ones.
  • Systemic symptoms such as fever, chills, nausea, or vomiting are absent in uncomplicated hydrocele.
  • GU symptoms are absent in uncomplicated hydrocele.
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Physical

  • Hydroceles are located superior and anterior to the testis, in contrast to spermatoceles, which lie superior and posterior to the testis.
  • Hydrocele is bilateral in 7-10% of cases.
  • Hydrocele often is associated with hernia, especially on the right side of the body.
  • The size and the palpable consistency of hydroceles can vary with position. Hydrocele usually becomes smaller and softer after lying down it usually becomes larger and tenser after prolonged standing.
  • Systemic signs of toxicity are absent. The patient is usually afebrile with normal vital signs.
  • Abdominal or testicular tenderness are absent; no abdominal distension is present.
  • Bowel sounds cannot be auscultated in the scrotum unless an associated hernia is present.
  • Unless an infection causes an acute hydrocele, no erythema or scrotal discoloration is observed.
  • Transillumination
    • A light source shines brightly through a hydrocele.
    • Transillumination is common, but it is not diagnostic for hydrocele. Transillumination may be observed with other etiologies of scrotal swelling (eg, hernia).
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Causes

  • Most pediatric hydroceles are congenital; however, consider malignancy, infection, and circulatory compromise as possible causes of hydrocele presenting after infancy.
  • Hydrocele of the cord is associated with pathologic closure of the distal processus vaginalis, which allows fluid pooling in the mid portion of the spermatic cord.
  • Communicating hydrocele is caused by failed closure of the processus vaginalis at the internal ring.
  • Noncommunicating hydrocele results from pathologic closure of the processus vaginalis and trapping of peritoneal fluid.[3]
  • Adult-onset hydrocele may be secondary to orchitis or epididymitis. Hydrocele also can be caused by tuberculosis and by tropical infections such as filariasis.
  • Testicular torsion may cause a reactive hydrocele in 20% of cases. The clinician may be misled by focusing on the hydrocele, which delays the diagnosis of torsion.
  • Tumor, especially germ cell tumors or tumors of the testicular adnexa may cause hydrocele.
  • Traumatic (ie, hemorrhagic) hydroceles are common.
  • Ipsilateral hydrocele occurs in as many as 70% of patients after renal transplantation.
  • Radiation therapy is associated with cases of hydrocele.
  • Exstrophy of the bladder may lead to hydrocele.
  • Hydrocele may arise from Ehlers-Danlos syndrome.
  • Hydrocele may result from a change in the type or volume of peritoneal fluid, like in patients undergoing peritoneal dialysis and those with a ventriculoperitoneal shunt.
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Contributor Information and Disclosures
Author

Scott E Rudkin, MD, MBA, RDMS, FAAEM, FACEP  Clinical Professor, Vice Chief, Department of Emergency Medicine, University of California at Irvine Medical Center

Scott E Rudkin, MD, MBA, RDMS, FAAEM, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

A Antoine Kazzi  MD, Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward A Michelson, MD  Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Richard H Sinert, DO  Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Mazen J El-Sayed, MD, to the development and writing of this article.

References

  1. Garriga V, Serrano A, Marin A, Medrano S, Roson N, Pruna X. US of the tunica vaginalis testis: anatomic relationships and pathologic conditions. Radiographics. Nov 2009;29(7):2017-32. [Medline].

  2. Bhosale PR, Patnana M, Viswanathan C, Szklaruk J. The inguinal canal: anatomy and imaging features of common and uncommon masses. Radiographics. May-Jun 2008;28(3):819-35; quiz 913. [Medline].

  3. Bayne A, Paduch D, Skoog SJ. Pressure, fluid and anatomical characteristics of abdominoscrotal hydroceles in infants. J Urol. Oct 2008;180(4 Suppl):1720-3; discussion 1723. [Medline].

  4. Rizvi SA, Ahmad I, Siddiqui MA, Zaheer S, Ahmad K. Role of color Doppler ultrasonography in evaluation of scrotal swellings: pattern of disease in 120 patients with review of literature. Urol J. Winter 2011;8(1):60-5. [Medline].

  5. [Guideline] Tekgul S, Riedmiller H, Gerharz E, Hoebeke P, Kocvara R, Nijman R, et al. Hydrocele. Guidelines on paediatric urology. European Association of Urology, European Society for Paediatric Urology. Mar 2009;[Full Text].

  6. Cimador M, Castagnetti M, De Grazia E. Management of hydrocele in adolescent patients. Nat Rev Urol. Jul 2010;7(7):379-85. [Medline].

  7. Lau ST, Lee YH, Caty MG. Current management of hernias and hydroceles. Semin Pediatr Surg. Feb 2007;16(1):50-7. [Medline].

  8. McAchran SE, Dogra V, Resnick MI. Office urologic ultrasound. Urol Clin North Am. Aug 2005;32(3):337-52, vii.

 
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