Hydrocele in Emergency Medicine Clinical Presentation

Updated: Mar 23, 2016
  • Author: Scott E Rudkin, MD, MBA, RDMS, FAAEM, FACEP; Chief Editor: Erik D Schraga, MD  more...
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Presentation

History

Most hydroceles are asymptomatic or subclinical. Evaluate the onset, duration, and severity of signs and symptoms, and 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. [4]  Occasionally, patients 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. Systemic symptoms such as fever, chills, nausea, or vomiting are absent in uncomplicated hydrocele. GU symptoms are absent in uncomplicated hydrocele.

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.

 

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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 and 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, and 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 and testicular tenderness are absent, and there is no abdominal distention. 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 is common, but it is not diagnostic for hydrocele. Transillumination may be observed with other etiologies of scrotal swelling (eg, hernia). A light source shines brightly through a hydrocele.

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Causes

Most adult hydroceles are idiopathic in origin, but inguinal surgery, varicocelectomy, infection, and trauma, for example, can result in development of a hydrocele. [5]

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. [6]

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, and 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, such as in patients undergoing peritoneal dialysis and those with a ventriculoperitoneal shunt.

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