Hydrocele in Emergency Medicine 

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

Overview

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. 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]

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.[2]

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.[3]

Epidemiology

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]

 

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.

 

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.

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.

 

DDx

 

Workup

Laboratory Studies

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

Imaging Studies

Inguinal-scrotal imaging ultrasound is indicated to confirm the diagnosis. It may be useful to identify abnormalities in the testis, complex cystic masses, tumors, appendages, spermatocele, or associated hernia. In the context of pain or testicular bleeding after trauma, an imaging test can differentiate between a hydrocele and incarcerated bowel. Hydrocele appears as a cystic mass within the spermatic cord (hydrocele of the cord) or as mass surrounding the testicle.[7, 8]

Doppler ultrasound flow study[9] is recommended to assess perfusion, even if an acute scrotum is clinically unlikely. This must be performed emergently if there is suspicion of testicular torsion or of traumatic hemorrhage into a hydrocele or testes. Sensitivity of Doppler ultrasound is 86-100%; specificity is up to 100%. Limited availability of this test within a clinically useful period reduces its usefulness.

Testicular scintigraphy is a nuclear scan that is particularly useful, especially in children, if testicular torsion is suspected. Decreased or absent flow to one testis or a testicular pole indicates torsion. Sensitivity for torsion can be 90%, but it is decreased with infancy, early torsion, incomplete torsion, and following detorsion. Specificity for torsion can be 90%, but it is decreased in the presence of scrotal fluid collections (eg, hydrocele, hernia, abscess, hematocele).

Abdominal radiographic findings usually are normal in patients with hydrocele. If films demonstrate an obstructive gas pattern, they may help differentiate between incarcerated hernia and hydrocele.

Procedures

Transillumination is a a light source that is shined through the scrotum and causes the hydrocele to illuminate. The bowel also may transilluminate; thus, positive transillumination findings are not diagnostic of hydrocele. Positive transillumination findings should not stop the clinician from investigating serious causes or comorbid conditions that may be associated with secondary hydrocele. This procedure is not reliable for final diagnosis

Hydrocele aspiration reveals a clear amber fluid. Aspiration is not therapeutic, because the fluid generally reaccumulates quickly. Aspiration of hydroceles is not recommended, because it is associated with a high rate of immediate recurrence and with a risk of introducing an infection. If an associated hernia is present, risk of perforating a loop of bowel also exists.

 

Treatment

Emergency Department Care

Differentiating between a hydrocele and an acute scrotum (eg, testicular torsion, strangulated hernia) is important.[10]

As many as 50% of acute scrotum cases are initially misdiagnosed.

Transillumination is not diagnostic and cannot rule out an acute scrotum.

Ultrasound anatomic imaging with Doppler evaluation of testicular blood flow is indicated when an acute scrotum is suspected, as follows:

  • A traumatic hemorrhage into a hydrocele or testes

  • A testicular torsion with or without a secondary hydrocele

  • An ischemic testicle

In children, hydrocele is treated through inguinal incisions with high ligation of the patent processus vaginalis and excision of the distal sac.[10]

Consultations

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.

Medical Care

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%.[11, 12, 13, 14, 15, 16]

 

Follow-up

Further Outpatient Care

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.

Complications

An extremely large hydrocele may impinge on the testicular blood supply. The resulting ischemia can cause testicular atrophy and subsequent impairment of fertility.

Hemorrhage into the hydrocele can result from testicular trauma.

Incarceration or strangulation of an associated hernia may occur.

Surgical complications include the following:

  • Accidental injury to the vas deferens can occur during inguinal surgery for hydrocele.

  • Postoperative wound infections occur in 2% of patients undergoing surgery for hydrocele.

  • Postoperative hemorrhagic hydrocele is not uncommon, but it usually resolves spontaneously.

  • Direct injury to the spermatic vessels may occur.

Prognosis

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.[11]

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%).[12]

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.[13]

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.

Patient Education

Emphasize the importance of timely follow-up care.

For patient education resources, see the Men's Health Center, as well as Understanding the Male Anatomy.