Approach Considerations
Simple hydroceles are diagnosed on clinical grounds. Clinical findings that should raise the suggestion of a different diagnosis or some additional underlying pathology include the following:
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Inability to clearly delineate or palpate the testicular structure
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Local tenderness, fever, or any gastrointestinal symptoms (eg, vomiting, constipation, diarrhea)
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Internal shadows on transillumination
Scrotal ultrasonography is the next logical step in such cases.
Laboratory Studies
Few laboratory tests, if any, are warranted specifically for simple hydroceles, communicating or noncommunicating. Concomitant medical conditions may be indications for preoperative laboratory studies. Laboratory studies may be indicated to exclude other surgical or medical conditions that may be in the differential diagnosis.
Inguinal hernia
While laboratory studies are not warranted in routine inguinal herniorrhaphy, a possible incarcerated inguinal hernia may be difficult to distinguish from a hydrocele.
Findings that may favor urgent exploration in this setting include the following:
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Failure to clearly transilluminate
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Palpable bowel at the internal ring during the rectal examination
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An elevated white blood cell count
Testicular tumor
Approximately 10% of patients with testicular teratomas may present with a cystic mass that may transilluminate during the physical examination. Similarly, adults with testicular tumors may present with new-onset scrotal swelling. If this diagnosis is considered, measuring serum alpha-fetoprotein and human chorionic gonadotropin (hCG) levels is indicated to exclude malignant teratomas or other germ cell tumors.
Epididymitis/orchitis
Occasionally, a reactive hydrocele occurs in association with underlying testicular infection. Urinalysis and urine culture may be beneficial. Although urinalysis and/or culture results are positive in only 30% of such cases, a positive culture result may be useful in guiding antimicrobial treatment. Symptoms are treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and scrotal elevation.
Imaging Studies
The radiographic evaluation of hydroceles is controversial. Communicating hydroceles in patients (infants in particular) with a classic presentation and palpable testicle do not require radiographic studies. However, findings from radiographic or ultrasonographic studies can help evaluate for other underlying processes, such as a tumor or torsion, and can be useful in the setting of a non-communicating hydrocele or inability to palpate the testicle, acute onset of swelling/pain, or other atypical findings on presentation or examination.
Ultrasonography
Ultrasonography provides excellent detail of the testicular parenchyma. Spermatoceles can be clearly distinguished from hydroceles on sonograms. If a testicular tumor is a diagnostic consideration, ultrasonography is an excellent screening study.
In addition, testicular atrophy suggesting chronic torsion and a reactive hydrocele can be seen on sonograms. Failure to clearly delineate testicular anatomy with palpation indicates the need for further diagnostic imaging such as ultrasonography.
In female patients, hydrocele along the canal of Nuck typically appears on ultrasonography as a fluid-containing lesion in the inguinal area that is well defined, thin walled, and sausage-shaped, with or without internal septations. [22]
Duplex ultrasonography
Duplex studies may provide substantial information regarding testicular blood flow when a hydrocele may be associated with chronic torsion.
Additionally, epididymitis associated with a reactive hydrocele can be distinguished based on findings from duplex scanning, as evidenced by increased epididymal flow.
Finally, duplex studies may help identify Valsalva-augmented regurgitant flow in patients with varicoceles.
Plain abdominal radiography
Plain radiography may be useful for distinguishing an acute hydrocele from an incarcerated hernia. Gas overlying the groin may indicate an incarcerated hernia.
Computed tomography
Imaging studies for abdominoscrotal hydroceles typically include computed tomography (CT) to determine the true extent of the intra-abdominal component.
Histologic Findings
If a hernia is identified along with the hydrocele, the sac may be removed following high ligation and sent for pathologic analysis. In this case, the histology findings are consistent with peritoneal lining. [23]
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Hydrocele that extended retrograde into the abdominal compartment.
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Hydrocele. Small patent processus vaginalis (indicated by the bubbles) as viewed laparoscopically.
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Young girl with groin bulge, which, at surgery, was a hydrocele of along the canal of Nuck.
