A hydrocele is a collection of serous fluid that results from a defect or irritation in the tunica vaginalis of the scrotum.

Hydroceles also may arise in the spermatic cord or the canal of Nuck

Embryologically, the processus vaginalis is a diverticulum of the peritoneal cavity. It descends with the testes into the scrotum via the inguinal canal around the 28th gestational week with gradual closure through infancy and childhood

In a communicating (congenital) hydrocele, a patent processus vaginalis permits flow of peritoneal fluid into the scrotum. Associated with Indirect inguinal hernias In a noncommunicating hydrocele, a patent processus vaginalis is present, but no communication with the peritoneal cavity (

Adult hydroceles are usually late-onset (secondary). Late-onset hydroceles may present acutely from local injury, infections, and radiotherapy; they may present chronically from gradual fluid accumulation. Hydrocele can adversely affect fertility Infant hydroceles are ussually caused by a patent processus vaginalis

More than 80% of newborn boys have a patent processus vaginalis, but most close spontaneously within 18 months of age. The incidence of hydrocele is rising with the increasing survival rate of premature infants, VP shunts, and dialysis Hydrocele is a disease observed only in males Most hydroceles are congenital at aged 1-2 years. Chronic or secondary hydroceles usually occur in men older than 40 years.

Most hydroceles are asymptomatic or subclinical The usual presentation is a painless enlarged scrotum, pain may be an indication of an accompanying acute epididymal infection. The patient may report a sensation of heaviness, fullness Patients occasionally report mild discomfort radiating along the inguinal area to the mid portion of the back The size may decrease with recumbency or increase in the upright position

Hydroceles are located superior and anterior to the testis, in contrast to spermatoceles, which lie superior and posterior to the testis. Hydrocele is bilateral in 7-10% of cases. Hydrocele often is associated with hernia, especially on the right side of the body. Transillumination is common, but it is not diagnostic for hydrocele. Transillumination may be observed with other etiologies of scrotal swelling (eg, hernia). Aspiration --- not recommended

Communicating hydrocele is caused by failed closure of the processus vaginalis at the internal ring. Noncommunicating hydrocele results from pathologic closure of the processus vaginalis and trapping of peritoneal fluid Adult-onset hydrocele may be secondary to orchitis or epididimitis. Hydrocele also can be caused by tuberculosis

Testicular torsion may cause a reactive hydrocele in 20% of cases. The clinician may be misled by focusing on the hydrocele, which delays the diagnosis of torsion. Tumor, especially germ cell tumors or tumors of the testicular adnexa may cause hydrocele Traumatic (ie, hemorrhagic) hydroceles Associated with vp shunt, dialysis, renal transplant, radiation

Hernia inguinalis Testiscular torsion Orchitis

A CBC with differential may indicate the existence of an inflammatory process. Urinalysis may detect proteinuria or pyuria

Inguinal-scrotal imaging ultrasound

May be useful to identify abnormalities in the

testis, complex cystic masses, tumors, appendages, spermatocele, or associated hernia

Doppler ultrasound flow study

This must be performed emergently if there is

suspicion of testicular torsion or of traumatic hemorrhage into a hydrocele or testes

Observe infants with hydrocele for 1-2 years or until definite communication is demonstrated. Spontaneous closure is unlikely in children older than 1 year. In children, hydrocele is treated through inguinal incisions with high ligation of the patent processus vaginalis and excision of the distal sac

Men diagnosed with hydroceles, where there is suspicion for concomitant malignancy, should undergo high-resolution scrotal ultrasound. If malignancy is suspected, an inguinal approach should be used to allow control of the spermatic cord in preparation for radical orchiectomy. If this approach is taken and no malignancy is encountered, the testis can be spared and the hydrocele can be repaired by one of the techniques described below.

When there is no evidence of malignancy on physical examination and high-resolution ultrasound, hydroceles may be approached scrotally through a median raphe or a transverse unilateral incision. In all techniques, the hydrocele is dissected and delivered intact to allow the easiest dissection.

The hydrocele is opened with a small skin incision without further preparation. The hydrocele sac is reduced (plicated) by suture, suitable for medium-sized and thin-walled hydroceles. The advantage of the plication technique is the minimized dissection with a reduced complication rate esp hematome.

Incision of the hydrocele sac after complete mobilization of the hydrocele. Partial resection of the hydrocele sac, leaving a margin of 12 cm Care is taken not to injure testicular vessels, epididymis or ductus deferens the edges are sewn together behind the spermatic cord Hydrocele surgery with excision of the hydrocele sas is useful for large or thick-walled hydroceles and multilocular hydroceles.

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