eMedicine Specialties > Emergency Medicine > Genitourinary

Hydrocele: Differential Diagnoses & Workup

Author: Scott E Rudkin, MD, MBA, RDMS, FAAEM, FACEP, Vice Chair of Emergency Medicine, Assistant Dean of CME, Co-Director of Medical Informatics, Assistant Program Director, Associate Clinical Professor, Department of Emergency Medicine, University of California at Irvine Medical Center
Coauthor(s): A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
Contributor Information and Disclosures

Updated: Sep 30, 2008

Differential Diagnoses

Orchitis
Testicular Torsion

Other Problems to Be Considered

Indirect inguinal hernia
Epididymitis
Traumatic injury to the testicle

Workup

Laboratory Studies

  • A CBC with differential may indicate the existence of an inflammatory process.
  • Urinalysis may detect proteinuria or pyuria.

Imaging Studies

  • Inguinal-scrotal imaging ultrasound
    • This study is indicated to confirm the diagnosis.
    • May be useful to identify abnormalities in the testis, complex cystic masses, tumors, appendages, spermatocele, or associated hernia.
    • In the context of pain or testicular bleeding after trauma, an imaging test can differentiate between a hydrocele and incarcerated bowel. Hydrocele appears as a cystic mass within the spermatic cord (hydrocele of the cord) or as mass surrounding the testicle.
  • Doppler ultrasound flow study
    • This study is recommended to assess perfusion, even if an acute scrotum is clinically unlikely.
    • This must be performed emergently if there is suspicion of testicular torsion or of traumatic hemorrhage into a hydrocele or testes.
    • Sensitivity of Doppler ultrasound is 86-100%; specificity is up to 100%.
    • Limited availability of this test within a clinically useful period reduces its usefulness.
  • Testicular scintigraphy
    • This nuclear scan is particularly useful, especially in children, if testicular torsion is suspected.
    • Decreased or absent flow to one testis or a testicular pole indicates torsion.
    • Sensitivity for torsion can be 90%, but it is decreased with infancy, early torsion, incomplete torsion, and following detorsion.
    • Specificity for torsion can be 90%, but it is decreased in the presence of scrotal fluid collections (eg, hydrocele, hernia, abscess, hematocele).
  • Abdominal x-ray findings usually are normal in patients with hydrocele. If films demonstrate an obstructive gas pattern, they may help to differentiate between incarcerated hernia and hydrocele.

Procedures

  • Transillumination
    • A light source shined through the scrotum causes the hydrocele to illuminate.
    • The bowel also may transilluminate; thus, positive transillumination findings are not diagnostic of hydrocele. Positive transillumination findings should not stop the clinician from investigating serious causes or comorbid conditions that may be associated with secondary hydrocele.
    • This procedure is not reliable for final diagnosis
  • Hydrocele aspiration
    • Aspiration of a hydrocele reveals a clear amber fluid.
    • Aspiration is not therapeutic because the fluid generally reaccumulates quickly.
    • Aspiration of hydroceles is not recommended because it is associated with a high rate of immediate recurrence and with a risk of introducing an infection. If an associated hernia is present, risk of perforating a loop of bowel also exists.

More on Hydrocele

Overview: Hydrocele
Differential Diagnoses & Workup: Hydrocele
Treatment & Medication: Hydrocele
Follow-up: Hydrocele
References
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References

  1. 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].

  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. Blaivas M, Brannam L. Testicular ultrasound. Emerg Med Clin North Am. Aug 2004;22(3):723-48, ix. [Medline].

  4. Jayanthi VR. Adolescent urology. Adolesc Med Clin. Oct 2004;15(3):521-34. [Medline].

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

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

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Further Reading

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Keywords

defect in tunica vaginalis of scrotum, irritation in tunica vaginalis of scrotum, communicating hydrocele, congenital hydrocele, pediatric hydroceles, indirect inguinal hernias, noncommunicating hydrocele, hydrocele of the cord, late-onset hydroceles, adult hydroceles, ventriculoperitoneal shunts, VP shunts, peritoneal dialysis, renal transplants, chronic hydroceles, secondary hydroceles, painless enlarged scrotum, transillumination, orchitis, epididymitis, tuberculosis, filariasis, testicular torsion, germ cell tumors, tumors of the testicular adnexa, traumatic hydroceles, hemorrhagic hydroceles, exstrophy of the bladder, Ehlers-Danlos syndrome

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Contributor Information and Disclosures

Author

Scott E Rudkin, MD, MBA, RDMS, FAAEM, FACEP, Vice Chair of Emergency Medicine, Assistant Dean of CME, Co-Director of Medical Informatics, Assistant Program Director, Associate Clinical Professor, 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, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard Sinert, DO, Associate 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 Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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