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A Mini Review on Hydrocele: The Most Common Scrotal Problem

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Tauseef Ahmad Sana Ullah

Jiangsu Provincial Center for Disease Control and Prevention Nanjing University
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Quaid-i-Azam University Chinese Academy of Sciences
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ISSN: 2313-6758 *Tauseef Ahmad1

Sana Ullah2
Ghulam Nabi3
Naseer Ullah4
Volume 2, Issue 12
Khaista Rahman5
Pages: 571-575

A Mini Review on Hydrocele: The Most Common

Scrotal Problem

1. Department of Abnormal collection of serous fluid between the visceral and parietal layers
Microbiology, Hazara of the tunica vaginalis is termed as hydrocele. It is the commonest reason for
University, Mansehra, painless scrotal swelling and affects about 1% of men, mostly above forty
Khyber Pakhtunkhwa, years of age, and 4.7% neonates. Normally it is idiopathic in origin, yet
Islamic Republic of infection, variococelectomy, inguinal surgery, a patent processus vaginalis
Pakistan. and trauma are linked with its consequent expansion. Surgical removal of
hydrocele is still considered as the gold standard of care. Cases have been
2, 3, & 4. Department of reported with high success rates, 85%-96%, after using aspiration and
Animal Sciences, Quaid-i- sclerotherapy in combination. This article reviews some aspect of treatment
Azam University, and complication of Hydrocele.
Islamabad, Islamic
Republic of Pakistan.

5. Department of Keywords: Vaginalis, Hydrocele, Variococelectomy, Surgery,

Biotechnology, Quaid-i- Sclerotherapy,
Azam University,
Islamabad, Islamic
Republic of Pakistan.

Email for correspondence:

Tauseef.ahmad@hu.edu.pk

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A Mini Review on Hydrocele: The Most Common Scrotal Problem
INTRODUCTION
Acute scrotal pain in children is considered as one of
the main diagnostic and therapeutic challenges (Klin et
al., 2001). Sighting scrotal mass by parents, physician
or by patient itself can emotionally be a distressing
occasion. Even an experienced treating physician met
an astounding list of promises as to be the cause and
origin of the mass (Schul and Keating, 1993). It might
be a simple hydrocele in infants but in adolescent it
may be a varicocele or a testicular neoplasm. To solve
this investigative dilemma, a systematic approach is
applied, based on the presence of different symptoms,
physical findings, location of the mass and anatomic
content of the spermtic cord and scrotum (Skoog, 1997).
An acute scrotum may be due to a number of diseases.
Physical examination and a good history are still
considered a paramount in appraisal. Testicular
radionuclide scanning and scrotal ultrasonography are
important in diagnostic armamentarium and should be
employed if possible. Unluckily the expertise and
equipment required for these beneficial examinations
are not readily available. In case these tests are not
possible or cannot be done swiftly and promptly, then
treatment should be initiated without further delay.
Lesions causing an acute scrotum should be
expeditiously treated, as cautious treatment may
reduce patients’ morbidity, discomfort, distress and
even mortality to a greater extent. Moreover testicular
salvage mostly depends on early and proper
management (Witherington, 1987).
An immediate action is required, by clinical
appearance of a painful scrotal mass as torsion of the
spermatic cord is a urologic emergency (Sidler et al.,
1997). A clinical statement that an aching scrotal mass
is torsion till it is proven else must be heeded (Macrozzi
and Suner, 2001). There are many such conditions that
might present scrotal swelling such as torsion of
testicular appendages, spermatic cord torsion, orchitis,
epididymitis, varicocele, trauma, incarcerated scrotal
hernia, tumor, and testicular pain in vasculitis
syndrome like Schoenlein-Hennoch purpura and
hydrocele (Ringert, 1998).
An article by Kass and Lundak (1997) covers the
diagnosis, treatment and evaluation of painful scrotal
masses in detail. A hydrocele is a fluid collection in the
space between the layers (parietal and visceral) of the
tunica vaginalis (Leung et al., 1984). Because of passing
fluid from peritoneal space into the scrotum through a
patent processus vaginalis leads to a communication
Ahmad et al.,
hydrocele. Simple or non-cumminating hydrocele has
no connection like the earlier one. The occurrence rate
of hydrocele is 1 % in men, mostly over the age of forty,
and 4.7% in neonates (Osifo and Osaigbovo, 2008).
At birth or within one year of birth, congenital
hydroceles are present or usually caused due to
incomplete or late closure of processus vaginalis
(Caterino et al., 2014). After a year of life, hydroceles
occur due to venous and lymphatic obstruction due to
infection or trauma (Cimador et al., 2010). However,
most hydroceles have no recognizable cause as in a
study, conducted on children having age of more than
a year having new-onset hydrocele, a clear cause was
observed in only twenty patients out of three hundreds
and two (Ouakadi et al., 1988; Christensen et al., 2006).
In northern America, the common catching causes of
hydroceles are viruses and epididymitis while filariasis
is a major cause of hydroceles worldwide. There are
certain other conditions as well which leads to
hydroceles such as torsion of the testicle or testicular
appendages, recent scrotal surgery or trauma (Dubois
and Dodat, 1998). Testicular cancer may also be
considered, especially in men with onset of hydrocele
in his 3rd or 4th decade of life. Approximately in ten out
of hundred cases, testicular tumours are accompanied
by a hydrocele making testicle vague and prevent a
detailed examination of the case.
Hydroceles may differ in size but most of the cases are
asymptomatic. Acquired hydroceles are usually
developed gradually and are not that much alarming.
Larger hydroceles may result in chronic pain in the
scrotum or lower back and can cause injury to the
scrotal contents such as the testicle (Kiddoo et al., 2004;
Swartz et al., 2007). Communicating hydrocele
(discussed before) may be of small size each morning
but grow bigger all over the day as the patient is
upright. The marked feature on physical examination
is a smooth, tense, scrotal mass that trans-illuminates
easily. This can help distinguishing a hydrocele from a
hernia or a mass, solid in nature. Communicating
hydrocele might be present with indirect inguinal
hernia (Chiang et al., 2014). To assess the mass, the
whole surface of testes should be palpated (Walper and
Llans, 2010).
If a thorough examination of the scrotal structures is
prohibited by a size of the hydrocele or it does not
trans-illuminate fully, then ultrasound can exclude
testicular tumour as cause (Krone and Caroll, 1985;
572 | P a g e
A Mini Review on Hydrocele: The Most Common Scrotal Problem
Coley, 2006; Sakellaris and Charissis, 2008). If the
patient is symptomatic or its history along with his
physical check-up advocates a causative process, then
imaging must be ordered too (Caldamone et al., 1984;
Rifkin, 1987). The ultrasound can display an inguinal
hernia, accompanied by a communicating hydrocele
(Lewis et al., 1995; Liaqat et al., 2014).
Non-communicating hydroceles are often resolved by
two years of age in infants while it is resolved within
six months in boys (older than one year with onset of
hydroceles) in approximately 75% cases (Christensen
et al., 2006). Alert wait is suitable for this population. In
adults, hydroceles do not need treatment, if there is
normal testicle or the patient remains asymptomatic.
Conversely symptomatic or communicating
hydroceles require proper treatment. Non-
communicating hydroceles can be treated through
surgical resection through an inguinal method or
through aspiration and sclerotherapy (Tammela et al.,
1992).
Sclerotherapy along with various agents such as
polidocanol, phenol and thanolamine oleate, and
aspiration is well documented. It is considered as safe
and effective having a success rate of 58 % to 98 %
(Dehlin et al., 1997). A mass literature is also present,
reporting complication of sclerotherapy and aspiration
up to 50% (Levine and Dewolf, 1988; Rencken et al.,
1990; Miskowiak and Christensen, 1998; Agrawal et al.,
2009; Shan et al., 2011). A small non-randomized trial
showed surgical resection as somewhat more effective
than sclerotherapy and aspiration but was also having
a higher rate of complications and was more costly
(Beiko et al., 2003).
Communicating hydroceles are treated surgically
through resection and correction (like indirect inguinal
hernia) of the anatomic defect, which cause insistent
association with the peritoneal cavity (Cavusoglu et al.,
2005). A case of patient with recurring complex
hydrocele and effective treatment utilizing a
combination of thrombolytic therapy, catheter
drainage and subsequent alcohol ablation is also been
reported (Metcafe et al., 2014).
CONCLUSION
Ahmad et al.,
Acute scrotal pain is considered as one of the main
diagnostic and therapeutic challenges. The physical
examination and history cannot identify reliably, who
may be conservatively managed. Colour Doppler
ultrasound is a convenient aide for evaluation of acute
scrotum when physical findings are vague, yet it can
also be misleading. There are many such conditions
that might present scrotal swelling. Hydrocele is of
these conditions. A hydrocele is a collection of fluid in
the layers namely parietal and visceral layer of the
tunica vaginalis, due to fluid passage from peritoneal
space into the scrotum. Hydroceles can be treated
through surgical resection with an inguinal method, a
combination of thrombolytic therapy, catheter
drainage and subsequent alcohol ablation, or through
sclerotherapy (along with various agents such as
polidocanol, phenol and thanolamine oleate) and
aspiration.
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