OVERVIEW: What every practitioner needs to know

Are you sure your patient has a hydrocele? What are the typical findings for this disease?

Hydrocele is an accumulation of fluid within the processus vaginalis/tunica vaginalis. In scrotal hydroceles, the processus vaginalis is contiguous with the tunica vaginalis. Hydroceles can be classified as communicating, noncommunicating, or hydrocele of the cord. Hydroceles can rarely occur in the groin (canal of Tuck) in female children. Hydroceles, by themselves, pose little clinical consequence but can be associated with pathologic conditions such as testicular malignancy and thus require an appropriate work-up. Children with a communicating hydrocele (a patent processus vaginalis) are at risk for a hernia.

In children, hydroceles are often identified incidentally and often present as a painless scrotal swelling. The diagnosis of a hydrocele can be confirmed by transillumination of the scrotum. If the scrotum does not transilluminate and/or the testes cannot be fully palpated, a scrotal ultrasonogram is indicated to ensure that the swelling is indeed a hydrocele and that there is no underlying testicular pathologic condition.

What other disease/condition shares some of these symptoms?

Testicular tumors, trauma, epididymitis, orchitis, testicular torsion can result in a hydrocele, and in an infant a fever may lead to a reactive hydrocele. A hydrocele is an infrequent complication of varicocele repair.

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What caused this disease to develop at this time?

Most pediatric hydroceles are congenital. Embryologically, the processus vaginalis is an outpouching of the peritoneal cavity. It descends with the testes into the scrotum through the inguinal canal and typically closes thereafter. Peritoneal fluid that surrounds the testis at the time of its descent may become trapped with closure of the processus vaginalis.

A hydrocele of the cord occurs when the patent processus vaginalis obliterates above the testis. Communicating hydroceles are caused by failure of closure of the processus vaginalis at the internal ring, and noncommunicating hydrocele results from peritoneal fluid being trapped within the closed processus vaginalis. Because the fluid is often reabsorbed, surgical intervention for a noncommunicating hydrocele is not routinely performed in an infant. A sudden onset of hydrocele in older children could signify an epididymitis/orchitis or arise secondary to scrotal trauma.

History from a parent or patient reveals a painless enlarged scrotum. The patient may report a feeling of fullness or heaviness. If the patient does report pain, it may be an indicator of an accompanying epididymal infection or trauma, or if the pain is severe, testicular torsion.

Physical examination reveals smooth, symmetrical enlargement of one side of the scrotum (bilateral 7%-10% of the time). If the hydrocele is large and tense, it may be difficult to palpate the ipsilateral testis. The size and consistency of hydrocele may vary depending on whether it is communicating or noncommunicating.

Communicating hydroceles vary with position; they are smaller in the supine position and increase in size when the patient stands. A Valsalva maneuver can increase the size of a communicating hydrocele. Communicating hydroceles are frequently associated with hernias, which can be elicited or palpated on examination. Unless the cause of the hydrocele is the result of an intrascrotal infectious process, erythema or discoloration is not observed.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Laboratory tests are not indicated for the evaluation of simple hydroceles. If there is a suspected infectious cause such as epididymitis and/or orchitis(scrotal pain, scrotal wall erythema or induration, tenderness of the epididymis and/or testis on palpation), a urinalysis and urine culture should be performed. If testicular tumor is in the differential diagnosis, as reflected by a palpable mass within the testis or identified on ultrasonography, a serum alpha fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase levels should be obtained.

Would imaging studies be helpful? If so, which ones?

Transillumination is usually the first test of choice to evaluate for hydrocele. Transillumination is performed by using a flashlight, penlight or even an otoscope and placing it posterior to the scrotum with the light in the room dimmed. If there is a hydrocele the light will shine through and light up the scrotum.

Inability to fully examine the testis, or the presence of other signs and symptoms such as fever, scrotal pain, erythema or swelling, abdominal pain or incomplete transillumination are indications for scrotal ultrasonography.

If testicular torsion is suspect (history of acute onset of scrotal pain, localized to the testis, nausea/vomiting, transverse lie to the testis, absence of cremasteric reflexes), a duplex scrotal ultrasonogram should be obtained.

If you are able to confirm that the patient has a hydrocele, what treatment should be initiated?

In the newborn presenting with a hydrocele, the first determination is whether or not the hydrocele is communicating. If no communication can be demonstrated by compressing the hydrocele and seeing the hydrocele diminish in size as a result of due to the hydrocele fluid returning to the abdominal cavity and by history (a lack of change in size of the hydrocele over the course of the day, typically smaller in the morning on awakening and increasing in size during the course of the day while the patient is upright), observation is indicated because the majority of noncommunicating hydroceles will reabsorb by the first year of life.

If the hydrocele does not reabsorb by the first year of life, inguinal exploration is indicated to ensure that there is no communication and the hydrocele is drained at the time. If the infant has a communicating hydrocele, surgical intervention is indicated because of the risk of a potential inguinal hernia. If there is a coexistent inguinal hernia, surgical intervention at a younger age is indicated to prevent incarceration of the hernia.

In younger boys presenting with a new onset of a hydrocele, an inguinal approach is also indicated because of the possibility of an associated patent processus. In adolescent boys presenting with an asymptomatic hydrocele with a normal testis on examination (or ultrasonography), the cause is more likely posttraumatic, and a scrotal approach may be performed. In the adolescent male patient, the hydrocele is most likely related to scrotal trauma and a resultant imbalance between the production and resorption of fluid from the tunica.

Needle aspiration of a hydrocele is not indicated in small male patients because of the potential for an associated patent processus vaginalis and risk for inguinal hernia. In adolescents it is not routinely performed because of the risk of recurrence (aspiration does not prevent the imbalance between production and resorption of fluid) and the risk of the hydrocele fluid becoming infected and/or a septated hydrocele developing from the trauma created from the aspiration.

What are the adverse effects associated with each treatment option?

Hydrocelelectomy is a very safe outpatient procedure with few adverse effects associated. The overall complication rate ranges from 1.7%-8%. When performed through the inguinal approach, there is a low risk of injury to the testicular vessels and/or vas deferens. Wound infection and hematoma are also uncommon.

A recurrent hydrocele occurs infrequently after both scrotal and inguinal approaches. There is a less than 5% risk of recurrence of the hydrocele. Surgical treatment of a recurrent hydrocele is recommended if it does not resolve within a year. If a recurrent hydrocele occurs it can be treated through a scrotal incision; the sac is opened, the fluid drained, and the sac is everted and approximated posterior to the testis to prevent reaccumulation of fluid.

Other risks include secondary cryptorchidism due to excessive scar formation and ascent of the testis with growth.

What are the possible outcomes of hydroceles?

Hydroceles can improve with only observation in many patients. If repair is indicated, the surgery has a great success rate, with less than a 1% recurrence. Overall, diagnosis of hydrocele has an excellent prognosis.

What causes this disease and how frequent is it?

Patent processus vaginalis is found in 80%-90% of term male infants at birth but most close spontaneously within 18 months of age. Why all cases of patent processus vaginalis do not develop into a hernia or hydrocele is not understood.

In children, a variety of conditions are associated with an increased risk of hernia and hydrocele, including undescended testis, hypospadias, ambiguous genitals, epispadias and bladder exstrophy, ventriculoperitoneal shunt, liver disease with ascites, continuous ambulatory dialysis, prematurity, low birth weight, family history of hernia/hydrocele, hydrops, meconium peritonitis, chylous ascites, cystic fibrosis, connective tissue diseases, and mucopolysaccharidosis.

A hydrocele may also occur from trauma to lymphatic vessels at the time of a varicocele repair.

In the adult population, filariasis, a parasitic infection, accounts for the most cases of hydroceles worldwide. In the adult man in the United States, most of the cases are iatrogenic after laparoscopic or transplantation or may be related to scrotal trauma. In children with such conditions, a genital examination should be performed.

How do these pathogens/genes/exposures cause the disease?

If hydrocele arises secondary to infection of the epididymis, the likely pathogen is Escherichia coli in children. In adults, epididymitis is usually secondary to Chlymadia trachomatis or Neisseria gonorroheae. In other parts of the world, filariasis infection and tuberculosis can cause hydrocele.

How can a hydrocele be prevented?

The majority of hydroceles in children are congenital and thus cannot be prevented.

What is the evidence?

Kapur, P, Caty, MG, Glick, PL. “Pediatric hernias and hydroceles”. Pediatr Clin North Am. vol. 45. 1998. pp. 773-89.

Wilson, JM, Aaronson, DS, Schrader, R. “Hydrocele in the pediatric patient: inguinal or scrotal approach”. J Urol. vol. 180. 2008. pp. 1724-7, discussion 1727.