Approach
Hydroceles are relatively straightforward to diagnose. History and physical exam should be diagnostic and other tests are rarely needed. Hydroceles predominantly occur in males and are rare in females.
History
Patients almost always present with scrotal swelling, the size of which varies during the day. It is usually smaller in the morning and enlarges with any increase in intra-abdominal pressure (e.g., coughing, straining, crying). If the swelling involves the inguinal area as well as the scrotum, and in children is accompanied by vomiting, irritability, and significant feeding problems, these may be the symptoms of incarcerated inguinal hernia.[7] Communicating hydrocele is common in children. In adults noncommunicating hydroceles are much more common and present with scrotal swelling and a vague sensation of heaviness. Noncommunicating hydrocele may occur after trauma, testicular infection, or testicular torsion.[20]
Physical exam
A scrotal mass that is not tender will usually be demonstrated on physical exam. The mass is likely to be soft if the communication is large or tense if it is small. It may be restricted to the scrotum or it may extend into the inguinal canal. Female patients with hydrocele of the canal of Nuck present with inguinal swelling. In communicating hydroceles, gentle pressure on the fluid will allow it to be reduced into the abdomen.[7][8] An inguinal bulge that cannot be reduced is an important indication for incarcerated (fixed within the sac) inguinal hernia.
Palpation of the testis is important in order to diagnose any acute testicular pathology. However, in cases of tense hydroceles or thick sacs, the testis may not be palpable. Increasing abdominal pressure by maneuvers such as standing, straining or raising the arms, if age appropriate, helps the hydrocele to be palpated if it is small at the time of examination.
Transillumination is an important tool in physical examination of hydroceles. In nearly all hydroceles, the fluid will be transilluminated when the scrotum is investigated with a focused beam of light. Omentum or bowel in the scrotum prevents transillumination. If there is bowel in the scrotum, septations may be seen.
If the hydrocele cannot be demonstrated on physical examination, even though the history is clear, the family should be requested to take photographs of the patient's scrotum at home when it is distended.
Imaging
History and a physical exam are usually sufficient for diagnosis. The inability to palpate the testis or suggestion of underlying pathology (e.g., fever, GI symptoms such as vomiting, diarrhea, or constipation, shadow on transillumination) should raise the suggestion of a different diagnosis or some additional underlying pathology and requires the use of scrotal ultrasound. Ultrasound has nearly 100% sensitivity in detecting intrascrotal lesions.[7][19][27] Ultrasound of the inguinal area may also be helpful in rare cases of female hydroceles.
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