Hydrocoele

1 What is Hydrocoele?

Hydrocoele occurs when there is abnormal accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis that surround the testicle.

In adults and adolescents, hydrocoele is an acquired condition. Its etiology is largely unknown but it is speculated that there is imbalance between fluid production and absorption in the serous membranes of the tunica.

Clinically. most hydrocoeles are asymptomatic, presenting as painless scrotal swellings. No intervention is necessary unless the hydrocoele reaches a critical size that leads to awkwardness or pain in walking, in which case drainage can be done in general practice settings.

Most often than not, the problem will be settled. Thus said, hydrocoeles can be recurrent despite recurrent drainage, where pathological conditions like hypoproteinemia, filarial infections, or pelvic cavity malignancies have to be excluded.

If the cause of recurrent hydrocoele remains idiopathic, surgical procedures like sclerotherapy or hydrocoelectomy can be considered as definitive treatment.

2 Symptoms

The main symptom of a hydrocele is swelling in the scrotum.

A hydrocoele can occur on one side or on both sides of the scrotum but most commonly occur on the right side.

Apart from the scrotal swelling associated with a hydrocoele, other signs characteristic of the condition include:

  • A bluish discoloration of the skin if the hydrocoele is large.
  • Fluctuation in the size of the swelling (mainly in infants).
  • The area of the hydrocoele is clearly defined.
  • Hydrocoeles are not painful but may cause discomfort if they are large.
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3 Causes

The causes of hydroceles include:

  • In children, most hydroceles are of the communicating type, in which patency of the processus vaginalis allows peritoneal fluid to flow into the scrotum, particularly during Valsalva maneuvers.
  • In the adult population, filariasis, a parasitic infection caused by Wuchereria bancrofti, accounts for most causes of hydroceles worldwide, affecting more than 120 million people in more than 73 countries. However, this condition is virtually nonexistent in the United States, where iatrogenic causes of hydroceles predominate.
  • Following laparoscopic or transplant surgery in males, inadequate irrigation fluid aspiration may cause hydroceles in patients with a patent processus vaginalis or a small hernia. Careful aspiration of fluid at the end of laparoscopic procedures helps prevent this complication.
  • In noncommunicating hydroceles, for both children and adults, the balance between fluid production within the tunica and the fluid absorption is altered.
  • A few studies have attempted to show a link between certain molecular derangements and an increased incidence of patent processus vaginales (and therefore hydroceles and indirect hernias). Two such examples include increases in maternal estrogen concentrations during pregnancy and abnormalities in the calcitonin gene-related peptide (CGRP) released by the genitofemoral nerve.

4 Making a Diagnosis

Diagnosis of hydrocoele is on the basis of history and physical examination. Hydroceles predominantly occur in males and are rare in females.

History

Patients almost always present with scrotal swelling, the size of which varies during the day. It is usually smaller in the morning and enlarges with any increase in intra-abdominal pressure (e.g. coughing, straining, and crying).

If the swelling involves the inguinal area as well as the scrotum, and in children is accompanied by vomiting, irritability, and significant feeding problems, these may be the symptoms of incarcerated inguinal hernia. Communicating hydrocele is common in children.

In adults, non-communicating hydroceles are much more common and present with scrotal swelling and a vague sensation of heaviness. Non-communicating hydrocele may occur after trauma, testicular infection, or testicular torsion.

Physical examination

A scrotal mass that is not tender will usually be demonstrated on physical examination. The mass is likely to be soft if the communication is large or tense if it is small. It may be restricted to the scrotum or it may extend into the inguinal canal.

Female patients with hydrocele of the canal of Nuck present with inguinal swelling.

In communicating hydroceles, gentle pressure on the fluid will allow it to be reduced into the abdomen. An inguinal bulge that cannot be reduced is an important indication for incarcerated (fixed within the sac) inguinal hernia.

Palpation of the testis is important in order to diagnose any acute testicular pathology. However, in cases of tense hydroceles or thick sacs, the testis may not be palpable. Increasing abdominal pressure by manoeuvres such as crying or raising the arms helps the hydrocele to be palpated if it is small at the time of examination.

Transillumination is an important tool in physical examination of hydroceles. In nearly all hydroceles, the fluid will be transilluminated when the scrotum is investigated with a focused beam of light. Omentum or bowel in the scrotum prevents transillumination. If there is bowel in the scrotum, septations may be seen.

If the hydrocele cannot be demonstrated on physical examination, even though the history is clear, the family should be requested to take photographs of the patient's scrotum at home when it is distended.

Imaging

History and a physical examination are usually sufficient for diagnosis.

The inability to palpate the testis or suggestion of underlying pathology (e.g. fever, gastrointestinal symptoms such as vomiting, diarrhoea or constipation, shadow on transillumination) should raise the suggestion of a different diagnosis or some additional underlying pathology and requires the use of scrotal ultrasound.

Ultrasound has nearly 100% sensitivity in detecting intrascrotal lesions. Ultrasound of the inguinal area may also be helpful in rare cases of female hydroceles.

5 Treatment

Most hydroceles resolve without medical treatment. However, if the condition causes discomfort or becomes very large, treatment may be necessary.

There are two methods of treatment: aspiration and hydrocelectomy (surgery).

In aspiration, a needle is used to drain the fluid. Aspiration is not the most common treatment for hydroceles, but it may be performed when surgery is too risky.

In some cases, medication is injected after the procedure to close the sac and help prevent hydroceles from recurring. However, this treatment increases the risk for infection and hydroceles sometimes recurs even with this procedure. Fibrosis (abnormal hardening of tissue) is another possible complication with aspiration.

Hydrocelectomy is a minor surgical procedure in which the fluid and sac are removed. It is performed on an outpatient basis, takes about an hour, and the patient usually goes home the same day. After the patient is given general or spinal anesthesia, a small cut is made in the scrotum or lower abdomen. The doctor drains the fluid, removes the sac, and then uses stitches to keep the muscle wall strong as it heals and help prevent hernia or another hydrocele.

After surgery, some patients experience pain or discomfort. Pain-reducing medications may be prescribed, usually for about one week. Applying an ice pack to the affected area can also be helpful. In some cases, a scrotal drainage tube, scrotal support, and/or heavy bandages are necessary for a period of time following surgery.

In children, sponge baths rather than tub baths are recommended during the healing process. Straddle toys (e.g. rocking horses, bicycles), playing sports, and participating in gym classes should be avoided for about three weeks.

Complications of hydrocelectomy include blood clots, infection, and injury to the scrotal area. While hydroceles are not known to cause infertility, this can rarely result from surgery.

In most cases, surgery to correct a hydrocele in infant boys is not performed until the child is 12–18 months of age.

6 Prevention

Because the condition develops before birth, hydroceles cannot be prevented in newborn infants. However, proper prenatal care can help prevent premature births and reduce the risk for hydroceles in baby boys.

Adult males can take steps to protect the genital area from injury—for example, wearing a protective athletic cup and following safety rules when playing sports.

Healthy lifestyle choices, such as exercising and eating right and avoiding sexually transmitted infections (STDs) are also recommended to help prevent hydrocele.

7 Risks and Complications

There are several risks and complications associated with hydrocoele.

Rupture usually occurs as a result of trauma but may be spontaneous. On rare occasions, cure results after the fluid has been absorbed.

  • Herniation of the hydrocele sac through the dartos muscle sometimes occurs in long-standing cases.
  • Transformation into a haematocele occurs if there is spontaneous bleeding into the sac or as a result of trauma.
  • Acute haemorrhage into the tunica vaginalis sometimes results from testicular trauma and it may be difficult without exploration to decide whether the testis has been ruptured.
  • If the haematocele is not drained, a clotted haematocele usually results.
  • The sac may calcify.
  • Clotted hydrocele may result from a slow spontaneous ooze of blood into the tunica vaginalis. It is usually painless and by the time the patient seeks help, it may be difficult to be sure that the swelling is not due to a testicular tumor. Indeed, a tumor may present as a haematocele.
  • Occasionally, severe infection can be introduced by aspiration. Simple aspiration, however, often may be used as a temporary measure in those cases where surgery is contraindicated or must be postponed.
  • Post herniorrhaphy hydrocele is a relatively rare complication of inguinal hernia repair. It is possibly due to interruption to the lymphatics draining the scrotal contents.
  • Infection which may lead to pyocele.
  • Atrophy of testis in long standing cases.

Complications are often diagnosed post operatively which can be differentiated through duplex ultrasound scanning, observed not only until 24 to 48 hours for early complications such as drainage, infection, formation of haematocele, rupture etc. but also for 1 to 6 weeks during follow-up on out-patient basis.

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