Hydrocele Treatment & Management

In pediatric patients, communicating hydroceles are surgically managed if they persist beyond the first year or two of life. Additionally, large noncommunicating hydroceles may also warrant surgical management. 

Abdominoscrotal hydroceles (and canal of Nuck hydroceles) require an inguinal approach so that the abdominal extent can be managed. Surgical excision has been considered appropriate for these entities, although excision of the intra-abdominal component can be quite challenging. A combined laparoscopic-inguinal approach may allow more complete determination of resection. ^[24]

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 can be divided into three approaches: inguinal, scrotal, and sclerotherapy. For more information on surgery in children, see Pediatric Hydrocele and Hernia Surgery.

Inguinal

The inguinal approach, with ligation of the processus vaginalis high within the internal inguinal ring, 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.

In a study by Saka et al, 69 patients with hydrocele underwent either laparoscopic percutaneous extraperitoneal closure (40 patients) or open repair (29 patients), and the safety and efficacy of the two approaches were compared. There were no significant differences in length of operation, anesthesia, or complications for the two procedures; and no recurrences were observed for either procedure. ^[25]

In addition, the authors reported on the features of the internal inguinal ring (IIR) found in cases of hydrocele and in cases of inguinal hernia treated during the study period. In the cases of hydrocele, 59.1% of the IIRs were narrow patent processus vaginalis (PPV) with a peritoneal veil; for patients with inguinal hernia, 92% of the IIRs were widely opened PPV. ^[25]

Peng et al reported the successful use of minilaparoscopic procedures in 125 boys (age range, 12-68 months) with multiple peritoneal folds in the hydrocele sac orifice. Modified single-port, double-needle, minilaparoscopic surgery in which an Endo Close needle was used to spread the peritoneal folds and facilitate circular extraperitoneal suturing produced outcomes comparable to those with a two-port laparoscopic procedure, during which a 3-mm grasping forceps was used to grasp the folds around the internal inguinal ring. The authors suggest that the modified single-port technique is safe, effective, and more cosmetically appealing for the management of complicated pediatric hydroceles. ^[26]

Wang et al reported success with single-site laparoscopic percutaneous extraperitoneal closure of the internal ring in 483 children with hydrocele. Their technique, which uses an epidural and spinal needle, required a median operation time of 18 minutes (range, 10-30 min) and no patient developed intraoperative or postoperative complications. ^[27]

Scrotal

The scrotal approach, with excision or eversion and suturing of the tunica vaginalis, is recommended for chronic noncommunicating hydroceles. This approach should be avoided if there is any suspicion for underlying malignancy.

In contrast, Alp et al report that the scrotal approach is an effective alternative for the treatment of communicating hydrocele in pediatric patients. In their study of 43 boys (46 testicular units) treated with the classic inguinal approach and 27 boys (30 testicular units) treated with a scrotal approach, operative time was significantly lower in the scrotal group (P < 0.0001), the early minor complication rate did not differ between the two groups, no major complications noted, and none of the patients had hydrocele recurrence after a mean follow-up of 6 months. ^[28]

Sclerotherapy

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.

A review by Taylor et al of aspiration and sclerotherapy treatment for hydroceles in aging men concluded that sodium tetradecyl sulphate (STDS) is the sclerosing agent with the best cure rate after a single injection and rates of adverse effects. Cure rates with STDS were 76% after a single aspiration and injection and 94% after multiple treatments. Patient satisfaction rates at a mean of 40 months were 95%. Complication rates were generally low and much lower than those seen with surgical repair. ^[29]

Lund et al, in a study of 76 patients with hydrocele testis, found that aspiration and sclerotherapy with polidocanol is an effective treatment with a low recurrence rate. In this prospective, double-blind, randomized study, 36 patients given polidocanol (group 1) were compared with 41 patients given placebo (group 2). Recurrence after the first treatment was seen in 16 (44%) of the polidocanol patients and in 32 (78%) of the placebo patients. Recurrence after re-treatment with polidocanol in both groups was seen in four patients (25%) in group 1 and in 14 patients (44%) in the former placebo group. The overall success rate of treatment in group 1 was 89%. ^[30]

Jahnson et al reported that in patients undergoing sclerotherapy, adjuvant treatment with an antibiotic and a nonsteroidal anti-inflammatory drug resulted in an increased cure rate and a lower incidence of subclinical epididymitis/swelling (SES). In their prospective observational study of 191 men who underwent polidocanol sclerotherapy for hydrocoele/spermatocoele, the patients who received anti‐inflammatory medication after the procedure had a decreased rate of SES (5% vs 26%) and an increased cure rate (96% vs 88%), compared with those who did not receive anti-inflammatory medication. The usual regimen in the treatment group was trimethoprim 160 mg (occasionally ciprofloxacin 500 mg) twice daily and diclofenac 50 mg three times daily for 10 days. ^[31]

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 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 is almost always transient.

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 tissue adhesive or occlusive dressing. No activity restrictions are required, and nonnarcotic analgesics are used minimally.

Patients undergoing scrotal approaches benefit from supportive 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.

At least one postoperative follow-up visit is recommended. For small infants, patients with 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 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 can occur. 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 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.

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. ^[32]

The Ilioinguinal/genitofemoral nerves may be entrapped or divided during inguinal approaches. The injury may be temporary or permanent.

Postoperative wound infections are quite uncommon, particularly in children. Wound infections should be managed with antibiotics and, if necessary, opening the wound.

Inguinal repairs of communicating hydroceles are exceedingly successful, with a less than 1% recurrence rate. If a unilateral approach is completed, the small but recognized risk for a metachronous hydrocele or inguinal hernia developing remains, but the rate is likely less than 10%. Likewise, recurrence after tunica excision is also uncommon.

Many surgeons have begun to advocate routine diagnostic laparoscopy of the contralateral groin in patients (particularly children) with unilateral hernias. The premise is that this will permit identification and repair of unsuspected contralateral hernias prior to clinical recognition. However, many more patent processus are being ligated than true hernias are being repaired. Whether an increased use of this technique will reduce the incidence of hydroceles in older children or adults remains to be seen. Furthermore, whether utilization of this intraoperative modality is of any utility in inguinal hydrocele repairs is open for debate.

Medical management, or, more importantly, prevention of patent processus vaginalis, has been theorized as possible after full elucidation of the intricate molecular processes that control fetal cell migration, proliferation, and adherence. Although the idea of preventing hydroceles or indirect hernias is interesting, it is far from being applicable in clinical medicine.

In 2000, the World Health Organization (WHO) launched the Global Program to Eliminate Lymphatic Filariasis (GPELF), with a goal of eliminating lymphatic filariasis by 2030. In 2018, three of nine countries participating in the program in Southeast Asia had eliminated LF and Bangladesh was in reach of its elimination goal.  In 2020, the program had thus far prevented or cured 74.9 million infections, resulting in a 84.2% reduction of lymphodema and hydrocele. ^[33]