Hydrocele

A hydrocele is accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis.

Hydroceles are divided clinically into:

Communicating hydrocele

Persistent processus vaginalis allows peritoneal fluid to enter the scrotum.

Common in children.

Noncommunicating hydrocele

Processus vaginalis is closed and fluid remains confined around the testis.

Secondary hydrocele

Occurs because of:

• Epididymo orchitis
• Testicular tumour
• Trauma
• Torsion
• Previous surgery

A newly developed adult hydrocele should not be accepted as idiopathic until the testis has been adequately examined.

Presentation is usually:

• Painless scrotal swelling
• Heaviness

A communicating paediatric hydrocele may change in size during the day.

Examine whether:

• Testis can be palpated separately
• Swelling transilluminates
• Swelling is reducible
• Inguinal hernia is present

Pain, fever or an acute presentation suggests another diagnosis.

Diagnosis is primarily clinical.

Use scrotal ultrasound when:

• Testis cannot be palpated
• Adult hydrocele is new
• Testicular tumour is possible
• Pain exists
• Diagnosis is uncertain

In infants, many noncommunicating hydroceles resolve spontaneously.

Observe during the first 12 to 18 months when no hernia or other pathology is present.

Operate earlier for:

• Communicating hydrocele
• Associated inguinal hernia
• Very large symptomatic hydrocele
• Persistence beyond expected spontaneous closure

Paediatric treatment is high ligation of the patent processus vaginalis through an inguinal approach.

Adult hydrocele

Observe if:

• Small
• Painless
• Underlying testis normal

Operate when:

• Large
• Painful
• Functionally inconvenient
• Cosmetically unacceptable

Procedures include:

Lord plication

Suitable for thin walled hydroceles.

Jaboulay eversion

Opens and everts the tunica vaginalis.

Large thickened sacs may require partial excision.

Aspiration alone has a high recurrence rate and is reserved mainly for patients unsuitable for surgery, sometimes combined with sclerotherapy.