Approach

Hydroceles predominantly occur in males and are rare in females. Treatment depends on the age of the patient and the degree of discomfort or complications caused by the hydrocele.

Children ≤2 years of age

Many hydroceles resolve spontaneously before the age of 2 years and so observation is usually appropriate. Although, European guidelines suggest surgical correction may be indicated after 12 months, the clinical impression is that some cases will resolve and it is safe to wait for 2 years, unless there is bowel palpable in the groin and provided the testis has been evaluated and there is no evidence of underlying pathology.​[19] However, if there is an inguinal component or abdominal contents are in the hydrocele sac, spontaneous resolution is unlikely and surgery is recommended.

Children 2-11 years of age

Open repair

  • Surgical repair is indicated for the persistence of a hydrocele beyond 2 years of age. The surgical approach involves open repair with an inguinal exploration, careful dissection of the hernia sac (processus vaginalis) from the cord structures, and a high ligation of the sac at the internal ring. Although there is no need to fix the distal hydrocele sac, if it remains tense, then it is best to incise it widely and sew it back upon itself to allow better drainage.[17] In hydrocele of the spermatic cord, the cystic mass is excised or unroofed.[19]

Laparoscopic exploration

  • Contralateral symptomatic hydrocele may be present in 3% to 5 % of patients.[26] While a contralateral open inguinal exploration may be used to investigate a contralateral patent processus vaginalis, endoscopy of the contralateral side through the ipsilateral hydrocele sac can be easily performed and obviates open exploration when the processus is closed.[26]

Bilateral repair

  • This is indicated for patients with an open contralateral internal ring, inguinal or scrotal pathology, or increased intraperitoneal fluid (e.g., following ventriculo-peritoneal shunts, peritoneal dialysis, or ascites).

Abdominoscrotal hydroceles

  • These require surgery with an abdominal incision, and the entire abdominal component should be removed. By opening a large window in the abdominal portion of the hydrocele, the fluid may well drain continuously into the peritoneum where it will be reabsorbed.

  • A novel method involving laparoscopic marsupialisation of the abdominal component followed by hydrocelectomy by an inguinal incision has also been reported as successful.[31]

Adolescents 12-18 years of age

Adolescents most commonly have non-communicating hydroceles. In most cases they are idiopathic. The testis should always be examined, as rarely testicular pathology can lead to a reactive hydrocele. A review classified the treatment options for adolescent hydrocele.[20]

Idiopathic hydrocele

  • In most cases, observation is appropriate. If the hydrocele gets very large and uncomfortable, surgery may be considered. Aspiration is possible, but the long-term success rate seems to be poor.[32]

  • When treatment is needed, surgical repair is the definitive management. There are different methods for performing surgical hydrocelectomy in adolescents, such as excision of the hydrocele or plication of the hydrocele wall and internal drainage.[20]

Hydrocele after varicocelectomy

  • The incidence of post-varicocelectomy hydrocele has decreased due to technical improvements such as microsurgical methods or sclerotherapy of internal spermatic veins. However, if hydrocele occurs after varicocelectomy conservative management should be chosen for the initial approach.

  • Surgery should be second line for those who do not benefit from conservative management.

Filarial-related hydrocele

  • Complete excision of the tunica vaginalis is appropriate treatment.

Adults

In adults, once the underlying pathology has been excluded by examination, hydroceles can be managed conservatively with reassurance and scrotal support. Surgery may be appropriate if the hydrocele is large and uncomfortable. During surgery, the sac is usually everted and sewn in that position. For hydroceles with large, thick-walled, or multilocular sacs, excision of the hydrocele sac is more appropriate. With either approach, extreme care must be taken to avoid injury to the vas deferens in younger patients to avoid loss of fertility.

For symptomatic patients who are unsuitable for or unwilling to have surgery and when fertility is not an issue, aspiration of the hydrocele followed by sclerotherapy can be considered.[32]​ In general, it is considered second-line treatment. A small amount of local anaesthetic is injected into the skin of the scrotum. A needle is passed into the hydrocele through the anaesthetised area and the fluid is removed. After the removal of fluid, a sclerosing agent such as tetracycline, polidocanol, or 95% alcohol may be instilled. A success rate up to 90% was reported by 1 to 4 injections of polidocanol with a complication rate of 30%.[33] The sclerosant may be drained or allowed to be reabsorbed. However, postoperative pain and recurrence are 2 major complications associated with the sclerosing technique. Recurrent hydroceles tend to be multilocular (hydroceles that have multiple compartments).[29] One study has shown that aspiration, up to 3 times, without injecting a sclerosing agent has a success rate of 60% in patients with hydroceles after a varicocelectomy.[34] A review indicated that observation with or without hydrocele aspiration should be the initial management and surgery should be considered as a second-line procedure.[20]

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