eMedicine Specialties > Emergency Medicine > Genitourinary

Hydrocele: Differential Diagnoses & Workup

Author: Scott E Rudkin, MD, MBA, RDMS, FAAEM, FACEP, Associate Clinical Professor; Assistant Dean, Continuing Medical Education; Vice Chair, Director of Medical Informatics, 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: Nov 25, 2009

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. Garriga V, Serrano A, Marin A, Medrano S, Roson N, Pruna X. US of the Tunica Vaginalis Testis: Anatomic Relationships and Pathologic Conditions. Radiographics. November-December 2009;29(7):2017-2032. [Medline].

  2. [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].

  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. 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].

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

  6. Jayanthi VR. Adolescent urology. Adolesc Med Clin. Oct 2004;15(3):521-34. [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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Further Reading

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Keywords

hydrocele, hydrocele causes, hydrocele symptoms, hydrocele treatment, defect in tunica vaginalis of scrotum, communicating hydrocele, congenital hydrocele, pediatric hydroceles, indirect inguinal hernias, noncommunicating hydrocele, painless enlarged scrotum

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Contributor Information and Disclosures

Author

Scott E Rudkin, MD, MBA, RDMS, FAAEM, FACEP, Associate Clinical Professor; Assistant Dean, Continuing Medical Education; Vice Chair, Director of Medical Informatics, 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: eMedicine Salary Employment

Managing Editor

Richard H 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 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.

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

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
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