Trip Answers

Question answered:18/02/08

We searched the NLH Library and the TRIP and Medline databases but found no guidelines on the management of hydrocele. However, an e-Medicine article gives discusses the presentation, investigation and management of this condition.

 

“Hydroceles typically manifest as a soft nontender fullness within the hemiscrotum. The testis generally is palpable along the posterior aspect of the fluid collection. When the scrotum is investigated with a focused beam of light, the scrotum transilluminates, revealing a homogenous glow, without internal shadows.
The inability to clearly delineate or palpate the testicular structures; the presence of tenderness, fever, or any gastrointestinal symptoms (eg, vomiting, constipation, diarrhea), or the appearance of internal shadows on transillumination should raise the suggestion of a different diagnosis or some additional underlying pathology. A scrotal ultrasound is the next logical step.

 

Indications for intervention include the following:

 

• Inability to distinguish from an inguinal hernia
• Failure to resolve spontaneously after an appropriate interval of observation
• Inability to clearly examine testis
• Association of hydroceles with suggestive pathology (eg, torsion, tumor)
• Pain or discomfort
• Male infertility
• Patient desire

 

Lab Studies
General

 

Few laboratory tests, if any, are warranted specifically for simple hydroceles, communicating or noncommunicating. Concomitant medical conditions may be indications for preoperative laboratory studies…”

 

Please refer to the full text of the article for investigations and differential diagnoses.

 

Lee, the author adds:

 

“Diagnostic Procedures
No interventional or invasive diagnostic procedures are recommended in the evaluation of hydroceles. Specifically, diagnostic aspirations should be avoided.” [1]

 

A second e-Medicine article discusses transillumination and hydrocele aspiration:

 

• “Transillumination
o A light source shined through the scrotum causes the hydrocele to illuminate.
o The bowel also may transilluminate; thus, positive transillumination findings are not diagnostic of hydrocele. Positive transillumination findings should not stop the clinician from investigating serious causes or comorbid conditions that may be associated with secondary hydrocele.
o This procedure is not reliable for final diagnosis

 

• Hydrocele aspiration
o Aspiration of a hydrocele reveals a clear amber fluid.
o Aspiration is not therapeutic because the fluid generally reaccumulates quickly.
o Aspiration of hydroceles is not recommended because it is associated with a high rate of immediate recurrence and with a risk of introducing an infection. If an associated hernia is present, risk of perforating a loop of bowel also exists.” [2]

 

A third source, GPNotebook notes in its entry on treatment of hydrocele:

 

“Hydrocoeles that present in early childhood are managed as a patent processus vaginalis with operation indicated only if they persist after the first year. The procedure is as for an inguinal hernia - open the sac, inspect the testis for abnormalities, ligate and divide the patent processus.
In adults, primary hydrocoeles may be treated:
• conservatively - reassure the patient and provide a scrotal support.
• by aspiration - use a sterile needle and syringe. Clear, pale yellow fluid should be drained; fluid that is bloodstained suggests trauma or other underlying pathology. Following aspiration, the testis should be palpable. A sclerosant such as phenol may then be injected to stop fluid from reaccumulating, otherwise, periodic aspiration may be necessary. A hydrocoele should not be tapped if there is any suspicion of tumour - in the case of a tumour, aspiration may result in spread of malignant cells.
• by operation - if the diagnosis is in doubt, the hydrocoele is large, or fluid repeatedly reaccumulates after drainage. Once the fluid has been removed, the testis is examined for abnormalities.
In secondary hydrocoeles, treatment is of the underlying condition.” [3]

 

Finally, a patient information leaflet on hydrocele adds:

 

“Do I need any tests?
Usually not. A doctor will want to check that the testes are healthy. If the hydrocele is large, and the doctor cannot feel the testis, the fluid can be drained with a needle and syringe. (This is helped by injecting local anaesthetic into the overlying skin to make the procedure painless.) Once the fluid is removed, the testes can be examined more easily. Sometimes an ultrasound scan of the testes will be advised. This can check the testes to make sure there is no underlying cause for the hydrocele.

 

What are the treatments for hydrocele?
Leave alone. If the hydrocele causes no symptoms one option is simply to leave it alone. If it becomes larger or troublesome, you can always change your mind.

 

Drainage. The fluid can be drained easily with a needle and syringe. However, it is common for the sac of the hydrocele to refill with fluid within a few months. Draining every now and then may be an option if you are an older person and not fit for surgery, or if you do not want an operation.

 
Surgery. Hydroceles can usually be cured with a relatively simple surgical operation.” [4]

 

References
1. Lee S. Hydrocele. E-Medicine. June 2006. (http://www.emedicine.com/MED/topic2778.htm)
2. Rudkin S and Antonin Kazzi A. Hydrocele. E-Medicine. June 2006 (http://www.emedicine.com/emerg/topic256.htm)
3. GPNotebook. Hydrocoeles – treatment. http://www.gpnotebook.co.uk/simplepage.cfm?ID=1892679703&linkID=18406&cook=yes
4. Patient UK. Hycrocele. June 2002. (http://www.patient.co.uk/showdoc/23068886/)

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