Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

children

1st line – observation

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ONGOING
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children
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≤2 years old
1st line – 

observation

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]​

1st line – surgery

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children
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2-11 years old
1st line – 

surgery

Elective surgical repair is indicated for persistence of a hydrocele beyond 2 years of age to avoid complications such as incarcerated inguinal hernia.

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.[15]

Many clinicians perform laparoscopy via the ipsilateral hydrocele sac to investigate whether there is a contralateral patent processus vaginalis.

Bilateral repair is indicated for patients with an open contralateral internal ring, inguinal or scrotal pathology, or increased intraperitoneal fluid (ventriculoperitoneal shunt, peritoneal dialysis).

adolescents

1st line – surgery

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adolescents
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idiopathic
1st line – 

surgery

In most cases, observation is appropriate. If the hydrocele gets very large and uncomfortable, 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]

1st line – observation +/- aspiration

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adolescents
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post-varicocelectomy
1st line – 

observation +/- aspiration

Post-varicocelectomy hydroceles should be observed with or without aspiration.[20]

2nd line – surgery

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adolescents
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post-varicocelectomy
2nd line – 

surgery

Surgery should be second line for those who do not benefit from conservative management. It is the best therapy for large, persistent post-varicocelectomy hydroceles.

1st line – surgery

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adolescents
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filarial-related hydrocele
1st line – 

surgery

Complete excision of tunica vaginalis is appropriate treatment.

adults

1st line – observation

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ONGOING
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adults
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without discomfort or infection
1st line – 

observation

In adults, once underlying pathology has been excluded, hydroceles can be managed conservatively with reassurance and scrotal support.

1st line – surgery or aspiration and sclerotherapy

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ONGOING
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adults
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with discomfort or infection
1st line – 

surgery or aspiration and sclerotherapy

Surgery may be appropriate if the hydrocele is large or uncomfortable (dragging sensation) or becomes infected.

Excision of the hydrocele sac is appropriate for hydroceles with thick-walled sacs and multiloculated sacs.

Extreme care must be taken to avoid injury to the vas deferens in younger patients to avoid loss of fertility.

Aspiration and sclerotherapy may be an alternative for adult patients who are poor surgical candidates or unwilling to have surgery and fertility is not an issue.[32]​ Repeated aspirations without injecting a sclerosing agent have a success rate of 60% in patients with a hydrocele post-varicocelectomy.[34]

A small amount 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] Sclerosant may be drained or allowed to be re-absorbed.

Post-operative pain and recurrence are 2 major complications. Recurrent hydroceles tend to be multiloculated.[27]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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