Shuja Tahir, FRCS(Edin), FCPS (Hon)
ETIOLOGY & PATHOPHYSIOLOGY
Hydrocole is collection of fluid in persistant tunica than 40 years.
vaginalis in males. It is collection of serous fluid
resulting from a defect or irritation in the tunica Hydrocele is bilateral in 7-10% of cases. Hydrocele
vaginalis of the scrotum. Hydroceles also may arise often is associated with hernia, especially on the
in the spermatic cord in males or the canal of Nuck in right side of the body in infants and children.
FREQUENCY Most pediatric hydroceles are congenital; however,
Hydrocele is estimated to affect 1% of adult men. malignancy, infection, and circulatory compromise
More than 80% of newborn boys have a patent are possible causes of hydrocele.
processus vaginalis, but most close spontaneously
within 18 months of age. Hydrocele of the cord is associated with pathologic
closure of the distal processus vaginalis, which
Most hydroceles are congenital and are noted in allows fluid pooling in the mid portion of the
children aged 1-2 years of age. The incidence of spermatic cord.
hydrocele is rising with the increasing survival rate of
premature infants and with increasing use of the Communicating hydrocele is caused by failed
peritoneal cavity for ventriculoperitoneal (VP) closure of the processus vaginalis at the internal ring.
shunts, dialysis, and renal transplants. Hydrocele is Noncommunicating hydrocele results from
a disease observed only in males. Chronic or pathologic closure of the processus vaginalis and
secondary hydroceles usually occur in men older trapping of peritoneal fluid.
Hydrocele (trans illumination test) Hydrocele (ultrasound scan) Hydrocele (ultrasound scan)
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Adult-onset hydrocele may be secondary to orchitis closure through infancy and childhood. Hydroceles
or epididymitis. Hydrocele also can be caused by are classified into three principal types.
malignancy, tuberculosis and by tropical infections
such as filariasis. CONGENITAL
These are also called a communicating (congenital)
Testicular torsion may cause a reactive hydrocele in hydroceles. Patent processus vaginalis permits flow
20% of cases. The clinician may be mis-led by of peritoneal fluid into the scrotum. Indirect inguinal
focusing on the hydrocele, which delays the hernias are associated with this type of hydrocele.
diagnosis of torsion. Tumor, especially germ cell ACQUIRED
tumors or tumors of the testicular adnexa may cause It is also called noncommunicating hydrocele. Patent
hydrocele. Traumatic (ie, hemorrhagic) hydroceles processus vaginalis is present, but no communi-
are common. Ipsilateral hydrocele occurs in as many cation with the peritoneal cavity occurs.
as 70% of patients after renal transplantation.
Radiation therapy is associated with cases of HYDROCELE OF CORD
hydrocele. Closure of the tunica vaginalis is defective. The distal
end of the processus vaginalis closes correctly, but
Exstrophy of the bladder may lead to hydrocele. the mid portion of the processus remains patent. The
Hydrocele may arise from Ehlers-Danlos syndrome. proximal end may be open or closed in this type of
Hydrocele may result from a change in the type or hydrocele.
volume of peritoneal fluid, like in patients undergoing
peritoneal dialysis and those with a ventri- SECONDARY HYDROCELE
culoperitoneal shunt. Adult hydroceles are usually late-onset (secondary).
Late-onset hydroceles may present acutely following
PATHOPHYSIOLOGY local injury, infections, and radiotherapy; these may
Embryologically, the processus vaginalis is a present chronically from gradual fluid accumulation.
diverticulum of the peritoneal cavity. It descends with Morbidity may result from chronic infection after
the testes into the scrotum via the inguinal canal surgical repair. This type of hydrocele can adversely
around the 28th gestational week with gradual affect fertility.
ASYMPHTOMATIC SCROTAL DISCOMFORT
Most hydroceles are asymptomatic or subclinical. Sensation of heaviness, fullness, or dragging may be
Onset, duration, and severity of signs and symptoms felt by the patient. Patients occasionally report mild
are evaluated. Relevant genitourinary (GU) history, discomfort radiating along the inguinal area to the
sexual history, recent trauma, exercise, or systemic mid portion of the back.
illnesses are identified.
SCROTAL SWEELING Hydrocele usually is not painful; pain may be an
Most common presentation is a painless enlarged indication of an accompanying acute epididymal
scrotum. infection. The size may decrease with recumbency
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or increase in the upright position. Chronically erythema or scrotal discoloration is observed.
formed hydroceles appear to be larger in size than
acutely formed ones. Transillumination
A light source shined through the scrotum causes the
SYSTEMIC SYMPTOMS hydrocele to illuminate. The bowel also may
Fever, chills, nausea, or vomiting are absent in transilluminate; thus, positive transillumination
uncomplicated hydrocele. GU symptoms are absent findings are not diagnostic of hydrocele. Positive
in uncomplicated hydrocele. transillumination findings should not stop the
clinician from investigating serious causes or co-
Hydroceles are located superior and anterior to the morbid conditions that may be associated with
testis, in contrast to spermatoceles, which lie secondary hydrocele. This procedure is not reliable
superior and posterior to the testis. for final diagnosis.
The size and the palpable consistency of hydroceles Transillumination test is usually positive.
can vary with position. Hydrocele usually becomes
smaller and softer after lying down, it usually A light source shines brightly through a hydrocele.
becomes larger and tenser after prolonged standing. Transillumination is common, and diagnostic for
Systemic signs of toxicity are absent. The patient is hydrocele. Transillumination may be observed with
usually afebrile with normal vital signs. Abdominal or other etiologies of scrotal swelling (eg, hernia).
testicular tenderness is absent. No abdominal DIFFERENTIAL DIAGNOSIS
distension is present. Bowel sounds cannot be Indirect inguinal hernia
auscultated in the scrotum unless an associated Epididymitis
hernia is present. Traumatic injury to the testicle
Unless an infection causes an acute hydrocele, no
BLOOD EXAMINATION bowel.
A CBC with differential count may indicate the
existence of an inflammatory process. Urinalysis Hydrocele appears as a cystic mass within the
may detect proteinuria or pyuria. spermatic cord (hydrocele of the cord) or as mass
surrounding the testicle.
It is used to confirm the diagnosis. It may be useful to DOPPLER ULTRASOUND FLOW STUDY
identify abnormalities in the testis, complex cystic This study is recommended to assess perfusion,
masses, tumors, appendages, spermatocele, or even if an acute scrotum is clinically unlikely. This
associated hernia. In the context of pain or testicular must be performed urgently if there is suspicion of
bleeding after trauma, an imaging test can testicular torsion or of traumatic hemorrhage into a
differentiate between a hydrocele and incarcerated hydrocele or testes. Sensitivity of Doppler ultrasound
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is 86-100%; specificity is up to 100%. incomplete torsion, and following detorsion.
Specificity for torsion can be 90%, but it is decreased
Limited availability of this test within a clinically useful in the presence of scrotal fluid collections (such as
period reduces its usefulness. hydrocele, hernia, abscess and hematocele).
TESTICULAR SCINTIGRAPHY X-RAY ABDOMEN
This nuclear scan is particularly useful, especially in Abdominal x-ray findings usually are normal in
children, if testicular torsion is suspected. Decreased patients with hydrocele. If films demonstrate an
or absent flow to one testis or a testicular pole obstructive gas pattern, they may help to
indicates torsion. Sensitivity for torsion can be 90%, differentiate between incarcerated hernia and
but it is decreased with infancy, early torsion, hydrocele.
Aspiration of a hydrocele reveals a clear amber fluid. ! Ischemic testicle in children
Aspiration is not therapeutic because the fluid
generally reaccumulates quickly. Aspiration of SURGICAL TREATMENT
hydroceles is not recommended because it is Hydrocele is treated through inguinal incisions with
associated with a high rate of immediate recurrence high ligation of the patent processus vaginalis
and with a risk of introducing an infection. If an (herniotomy) and excision of the distal sac.
associated hernia is present, risk of perforating a ! Herniotomy
loop of bowel also exists. ! Eversion of sac
! Lord’s operation
Differentiating between a hydrocele and an acute Spontaneous closure is unlikely in children older
scrotum (eg, testicular torsion, strangulated hernia) than 1 year. Infants with hydrocele are observed for
is important. As many as 50% of acute scrotum 1-2 years. Surgical treatment is offered afterwards.
cases are initially misdiagnosed.
Transillumination is not diagnostic and cannot rule An extremely large hydrocele may impinge on the
out an acute scrotum. testicular blood supply. The resulting ischemia can
cause testicular atrophy and subsequent impairment
Ultrasound examination, imaging and Doppler of fertility.
evaluation of testicular blood flow is indicated when
an acute scrotum is suspected. Hemorrhage into the hydrocele can result from
ACUTE SCROTAL PROBLEMS
! Traumatic hemorrhage into a hydrocele or Incarceration or strangulation of an associated
testes hernia may occur.
! Testicular torsion with or without a secondary
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SURGICAL COMPLICATIONS later in life depends upon the etiology of the
Accidental injury to the vas deferens can occur hydrocele.
during inguinal surgery for hydrocele.
Adult-onset hydrocele is not uncommonly
Postoperative wound infections occur in 2% of associated with an underlying malignancy.
patients undergoing surgery for hydrocele.
Postoperative hemorrhagic hydrocele is not Medical/Legal Pitfalls
uncommon, but it usually resolves spontaneously. In a patient with signs and symptoms of an acute
scrotum, the presence of a hydrocele and a finding of
Direct injury to the spermatic vessels may occur. positive transilluminance does not rule out testicular
torsion. Immediate definitive tests are indicated to
PROGNOSIS rule out torsion because testicular survival is poor
The prognosis for congenital hydrocele after surgery after 4 hours of ischemia. A reasonable search for
is excellent. possible etiologies should be documented.
Most congenital cases resolve by the end of the first SPECIAL CONCERNS
year of life. Pediatric: Most cases resolve without intervention.
Geriatric: Hydroceles in this group rarely resolve
Persistent congenital hydrocele is readily corrected without surgical intervention.
surgically. The prognosis of hydrocele presenting
1. Blaivas M, Brannam L. Testicular ultrasound. Emerg Med 4. Schul MW, Keating MA. The acute pediatric scrotum. J
Clin North Am. Aug 2004;22(3):723-48, ix. [Medline]. Emerg Med. Sep-Oct 1993;11(5):565-77. [Medline].
2. Jayanthi VR. Adolescent urology. Adolesc Med Clin. Oct 5. Skoog SJ, Conlin MJ. Pediatric hernias and hydroceles.
2004;15(3):521-34. [Medline]. The urologist''s perspective. Urol Clin North Am. Feb
3. McAchran SE, Dogra V, Resnick MI. Office urologic
ultrasound. Urol Clin North Am. Aug 2005;32(3):337-52, 6. Tanagho EA, McAninch JW. Disorders of the spermatic
vii. cord. In: Smith's General Urology. 1992;620-3. [Medline].
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