Introduction
Background
A hydrocele is a collection of serous fluid that results from a defect or irritation in the tunica vaginalis of the scrotum. Hydroceles also may arise in the spermatic cord or the canal of Nuck.
Pathophysiology
Embryologically, the processus vaginalis is a diverticulum of the peritoneal cavity. It descends with the testes into the scrotum via the inguinal canal around the 28th gestational week with gradual closure through infancy and childhood.1
Structurally, hydroceles are classified into 3 principal types.
- In a communicating (congenital) hydrocele, a patent processus vaginalis permits flow of peritoneal fluid into the scrotum. Indirect inguinal hernias are associated with this type of hydrocele.
- In a noncommunicating hydrocele, a patent processus vaginalis is present, but no communication with the peritoneal cavity occurs.
- In a hydrocele of the cord, the closure of the tunica vaginalis is defective. The distal end of the processus vaginalis closes correctly, but the mid portion of the processus remains patent. The proximal end may be open or closed in this type of hydrocele.
Adult hydroceles are usually late-onset (secondary). Late-onset hydroceles may present acutely from local injury, infections, and radiotherapy; they may present chronically from gradual fluid accumulation. Morbidity may result from chronic infection after surgical repair. Hydrocele can adversely affect fertility.
Frequency
United States
Hydrocele is estimated to affect 1% of adult men.
More than 80% of newborn boys have a patent processus vaginalis, but most close spontaneously within 18 months of age. The incidence of hydrocele is rising with the increasing survival rate of premature infants and with increasing use of the peritoneal cavity for ventriculoperitoneal (VP) shunts, dialysis, and renal transplants.
Sex
Hydrocele is a disease observed only in males.
Age
- Most hydroceles are congenital and are noted in children aged 1-2 years.
- Chronic or secondary hydroceles usually occur in men older than 40 years.
Clinical
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.
- 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.
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).
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.
- 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.
More on Hydrocele |
 Overview: Hydrocele |
| Differential Diagnoses & Workup: Hydrocele |
| Treatment & Medication: Hydrocele |
| Follow-up: Hydrocele |
| References |
| Next Page » |
References
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].
[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].
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].
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].
Blaivas M, Brannam L. Testicular ultrasound. Emerg Med Clin North Am. Aug 2004;22(3):723-48, ix. [Medline].
Jayanthi VR. Adolescent urology. Adolesc Med Clin. Oct 2004;15(3):521-34. [Medline].
Lau ST, Lee YH, Caty MG. Current management of hernias and hydroceles. Semin Pediatr Surg. Feb 2007;16(1):50-7. [Medline].
McAchran SE, Dogra V, Resnick MI. Office urologic ultrasound. Urol Clin North Am. Aug 2005;32(3):337-52, vii.
Further Reading
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
