Hydrocele in Emergency Medicine

Updated: Nov 05, 2021
  • Author: Scott E Rudkin, MD, MBA, RDMS, FAAEM, FACEP; Chief Editor: Erik D Schraga, MD  more...
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Practice Essentials

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. A communicating hydrocele is similar to a hernia except that the sac connecting the abdomen to the scrotum or labia majora contains only fluid rather than abdominal contents. A noncommunicating hydrocele is a collection of scrotal fluid that is isolated from the abdomen. Noncommunicating hydroceles are the most common type of hydrocele globally, affecting more than 30 million men and boys. [1]

Hydroceles can be primary and secondary. In primary hydrocele, the processus vaginalis of the spermatic cord fuses at term or within 1-2 years after birth, obliterating the communication between the abdomen and the scrotum. There are 4 types of primary hydrocele: (1) congenital hydrocele, which occurs when the processus vaginalis is patent and communicates with the peritoneal cavity; (2) infantile hydrocele, in which the processus vaginalis gets obliterated at the level of the deep inguinal ring; (3) encysted hydrocele of the cord, in which both the proximal and the distal portions of the processus vaginalis get obliterated; and (4) vaginal hydrocele, in which the processus vaginalis remains patent only around the testes. Secondary hydrocele usually occurs as a result of an underlying condition, such as infection (filariasis, tuberculosis of the epididymis, syphilis), injury (trauma, post-herniorrhaphy hydrocele), or malignancy. [2]


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. [3]  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.


Most adult hydroceles are idiopathic in origin, but inguinal surgery, varicocelectomy, infection, and trauma, for example, can result in development of a hydrocele. [4]

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. [5]

Adult-onset hydrocele may be secondary to orchitis or epididymitis. Hydrocele also can be caused by tuberculosis and by tropical infections such as lymphatic filariasis (LF).

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.

Other causes of hydrocele include radiation therapy, exstrophy of the bladder, Ehlers-Danlos syndrome, and a change in the type or volume of peritoneal fluid, such as in patients undergoing peritoneal dialysis and those with a ventriculoperitoneal shunt.


A CBC with differential may indicate the existence of an inflammatory process. Urinalysis may detect proteinuria or pyuria.

Doppler ultrasound flow study is recommended to assess perfusion, even if an acute scrotum is clinically unlikely. [6]  

Testicular scintigraphy is a nuclear scan that is particularly useful, especially in children, if testicular torsion is suspected. 

Abdominal radiographic findings usually are normal in patients with hydrocele. 


Surgical removal of hydroceles is the gold standard of care. However, high success rates (85-96%) have been reported with a combination of aspiration and sclerotherapy. Reports of effective agents include polidcocanol, phenol, tetracycline ethanolamine oleate, sodium tetradecyl sulfate (STS), and alcohol. Complication rates have been reported to be as high as 50%. [7, 8, 9, 10, 11, 12]

Immediately consult a urologist if testicular torsion is found or suspected. A urologic follow-up examination is required if any testicular pathology is involved. A general surgery evaluation is indicated for patients with a tense hydrocele that threatens to embarrass scrotal circulation. Surgical evaluation is also indicated for hydrocele producing a large and bulky mass that is unsightly or uncomfortable.

Arrange for quarterly follow-up examinations until a decision for or against surgery is made. Spontaneous closure is unlikely in children older than 1 year. Observe infants with hydrocele for 1-2 years or until definite communication is demonstrated. Watch for a concomitant hernia.





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. [13]

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.

Primary new-onset hydroceles presenting in late childhood and pre-adolescence are often noncommunicating and resemble the adult-type hydrocele pathology. [14]



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.

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.

Noncommunicating hydroceles are the most common type of hydrocele globally, affecting more than 30 million men and boys [1]

In endemic areas of lymphatic filariasis, hydrocele rates vary and can reach as high as 50%.  

The World Health Organization (WHO) launched a program for global elimination of lymphatic filariasis in Southeast Asia.  In 2021 it was reported  that approximately 1 million lymphoedema patients and 0.5 million hydrocele patients were receiving treatment. [15]



The prognosis for congenital hydrocele is excellent.

Most congenital cases resolve by the end of the first year of life.

Persistent congenital hydrocele is readily corrected surgically. One study assessed the safety and efficacy of laparoscopic percutaneous extraperitoneal closure (LPEC) for hydrocele in comparison with that of open repair (OR). LPEC was found to be a safe and effective procedure for treating hydrocele. Among a total of 69 patients, 40 underwent LPEC, and 29 underwent OR. There were no significant differences in the length of operation/anesthesia and complications. No recurrences were observed in either group. [7]

Polidocanol was shown, in a Danish study, to be an effective treatment for hydrocele testis in 77 men, 36 of whom were initially given polidocanol and 41 of whom were initially given placebo. Depending on hydrocele testis size (< 100 ml, 100-200 ml, and >200 ml), the patients were treated with 1, 3 or 4 ml polidocanol after aspiration. The overall success rate of treatment in the polidocanol group was 89%. Recurrence after the first treatment was seen in 16 (44%) patients from the treated group and in 32 (78%) from the placebo group. Both groups were then given polidocanol after recurrence. Recurrence after re-treatment with polidocanol in the treated group was 4 out of 14 patients (25%); in the former placebo group, recurrence after re-treatment with polidocanol was 14 out of 32 (44%). [8]

Hydrocele aspiration and sclerotherapy with doxycycline was successful in correcting 84% of simple nonseptated hydroceles with a single treatment. According to the authors of this study, this success rate is similar to the reported success rate for hydrocelectomy. In this study, 29 patients (mean age, 52.8 years) presenting with 32 nonseptated hydroceles underwent hydrocele aspiration and sclerotherapy with doxycycline. Of the hydroceles, 27 (84%) were successfully treated with a single aspiration and sclerotherapy procedure. Of those patients in whom hydrocele aspiration and sclerotherapy failed, 1 had hydrocele successfully resolved with a second aspiration and sclerotherapy treatment, 3 did not have success with a second procedure and underwent hydrocelectomy, and 1 wanted immediate surgical correction. [9]

The prognosis of hydrocele presenting later in life depends upon the etiology of the hydrocele. Adult-onset hydrocele is not uncommonly associated with an underlying malignancy.