Hydrocele

Definition/diagnostic criteria A hydrocele is defined as an accumulation of serous fluid within the tunica vaginalis of the testis or along the spermatic cord. It is characterised by painless, unilateral scrotal swelling. Hydroceles can be congenital, appearing in infancy, or acquired, developing secondary to trauma, infection, or neoplasm.

Epidemiology Hydroceles are common in newborns, with a prevalence of about 1-2%. The prevalence in adult men increases with age, primarily affecting those over 40 years old. Congenital hydroceles often resolve spontaneously within the first year of life. However, the incidence of acquired hydrocele increases with age, particularly in men over 40 years old.

Diagnosis
Clinical features: The primary symptom of a hydrocele is a painless, swollen testicle, which may be accompanied by a feeling of heaviness. The swelling may fluctuate in size and is typically non-tender upon palpation. Transillumination of the scrotum can distinguish hydrocele from other scrotal masses by demonstrating a characteristic glow.

Investigations: Ultrasound of the scrotum is the primary imaging modality used to confirm the diagnosis of hydrocele and to differentiate it from other scrotal abnormalities such as testicular tumours or epididymitis. Ultrasound findings typically show an anechoic or hypoechoic fluid collection surrounding the testicle.

Treatment The treatment of hydrocele depends on the patient’s age, the severity of symptoms, and the presence of any underlying pathology.

  • Observation: Asymptomatic hydroceles in infants and adults without discomfort may only require observation, as they often resolve spontaneously, especially in infants. Referral is required in children if the hydrocele has not resolved by the age of one.
  • Surgical treatment: Indications for surgery include discomfort, cosmetic reasons, or suspicion of underlying pathology. The common surgical procedures are:
    – Hydrocelectomy: Removal of the hydrocele sac, typically performed via a scrotal incision.
    – Sclerotherapy: Injection of a sclerosing agent to induce fibrosis and obliteration of the hydrocele sac. This is less commonly used due to higher recurrence rates compared to surgery.
    – Aspiration is occasionally used in older men who are unfit for surgery
  • Antibiotic treatment: In cases of infected hydrocele or associated epididymo-orchitis, appropriate antibiotic therapy should be initiated based on culture and sensitivity results.

Prognosis The prognosis for hydrocele is generally excellent. Surgical treatment has high success rates with low recurrence. However, complications such as infection, haematoma, or damage to surrounding structures including the testis or spermatic cord can occur. Long-term outcomes are typically favourable, and recurrence rates after surgery are low.

References

  • British Association of Urological Surgeons. Repair of a scrotal hydrocele. 2020
  • NICE CKS. Scrotal pain and swelling. 2023

Published: 1st August 2022 Updated: 29th January 2024

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Pulse Reference is based on the best-selling book Symptom Sorter. The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse. This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.