Hydrocele: Symptoms, Types, Causes and Treatment

Hydrocele is a relatively common medical condition, especially in males, where a collection of fluid accumulates in the scrotum, causing swelling and discomfort. Although often painless, hydroceles can be distressing and may signal underlying health issues. Understanding the symptoms, types, causes, and available treatments is essential for both patients and healthcare providers. In this article, we provide a comprehensive overview based on the latest research.

Symptoms of Hydrocele

Hydroceles typically present with noticeable but often benign symptoms. Recognizing these early signs can help prevent complications and guide appropriate medical evaluation and treatment.

Symptom	Description	Typical Population	Source(s)
Swelling	Painless scrotal enlargement	Adults, Children	4 6 8 9
Discomfort	Heaviness or mild pain	Mostly adults	3 6 8
Fluctuation	Size may change with posture	Infants, congenital	5 6 8
Complications	Infection, hemorrhage, torsion	Complex or untreated	2 3

Table 1: Key Symptoms

Overview of Hydrocele Symptoms

Hydroceles most commonly present as a painless enlargement of the scrotum. This swelling is usually soft and smooth, and the overlying skin appears normal. Many patients, especially adults, may notice a sense of heaviness or mild discomfort, particularly when the hydrocele becomes large. In infants and young boys, parents may observe a change in scrotal size, which sometimes fluctuates during the day or with changes in posture, especially in communicating hydroceles that connect with the abdominal cavity 4 5 6 8.

Symptom Progression and Complications

While hydroceles are usually benign, complications can occur if they are left untreated or if they are associated with underlying conditions. These may include infection (leading to redness and pain), hemorrhage into the sac, torsion of the hydrocele or testicle, and, rarely, pressure effects on surrounding structures 2 3. Large hydroceles can also cause embarrassment, psychosocial distress, and interfere with daily activities.

Types of Hydrocele

The classification of hydrocele is essential for determining management strategies and understanding the underlying cause. Several types exist, each with distinct characteristics.

Type	Key Features	Common Age Group	Source(s)
Congenital	Communicates with abdominal cavity	Infants, children	4 5 6 8
Non-communicating	No abdominal communication	Adults, older boys	3 4 5 6
Secondary	Linked to disease, trauma, or surgery	All ages	3 6 7 8 9
Abdominoscrotal	Scrotal + abdominal extension	Pediatrics, rare	1 2

Table 2: Hydrocele Types

Major Classifications

Congenital Hydrocele

Congenital hydroceles are present at birth or develop soon after. These typically communicate with the peritoneal (abdominal) cavity through a patent processus vaginalis, allowing fluid to flow freely. The swelling may fluctuate in size, often increasing during the day or with standing 4 5 8. This type is most common in infants and young children.

Non-communicating (Vaginal) Hydrocele

Non-communicating hydroceles occur when the connection to the abdominal cavity is closed. Fluid accumulates within the tunica vaginalis without exchange with the peritoneum. This is the typical adult form and usually presents as a persistent, non-fluctuating swelling 3 4 6.

Secondary Hydrocele

Secondary hydroceles develop as a result of underlying conditions such as infections, trauma, tumors, surgery (especially varicocelectomy), or other diseases. They can occur at any age and often require investigation to identify and treat the root cause 3 6 7 8 9.

Abdominoscrotal Hydrocele

This rare variant features a hydrocele that extends from the scrotum into the abdomen, forming a dumbbell-shaped mass. It is more frequently seen in pediatric populations. Abdominoscrotal hydroceles may be associated with other congenital anomalies and have unique management challenges 1 2.

Other Notable Types

• Hydrocele of the Cord: Fluid collection along the spermatic cord, distinct from the tunica vaginalis 5.
• Giant Hydrocele: Exceptionally large hydroceles, often in adults, with significant impact on quality of life 3.
• Hydrocele of the Canal of Nuck: A rare form seen in females, along the round ligament 3.

Causes of Hydrocele

Understanding why hydroceles form is crucial for proper management and prevention of recurrence. Causes can be primary (idiopathic) or secondary to other factors.

Cause	Mechanism/Trigger	Age Group	Source(s)
Idiopathic	Imbalance in fluid production/absorption	Mostly adults	6 8 9
Congenital	Patent processus vaginalis	Infants/children	4 5 6 8
Infection	Inflammation, filariasis, TB	All ages	8 9 10
Trauma/Surgery	Postoperative, injury	Adults/adolescents	6 8 9
Tumor	Testicular or paratesticular mass	Adults, elderly	3 8 9
Radiotherapy	Lymphatic obstruction, fibrosis	Cancer patients	7

Table 3: Common Causes

Idiopathic and Primary Causes

The most frequent cause of hydrocele in adults is idiopathic, meaning no clear underlying reason is identified. It is believed to result from an imbalance between the secretion and absorption of serous fluid by the tunica vaginalis. This may be due to increased production, decreased lymphatic drainage, or both 6 8 9.

Congenital Factors

In newborns and children, hydroceles often arise from a patent processus vaginalis, a channel that usually closes before birth. If it remains open, fluid can flow from the abdomen into the scrotum. This mechanism is also responsible for many pediatric inguinal hernias 4 5 6 8.

Secondary Causes

Hydrocele may also develop secondary to:

• Infection: Inflammation from bacterial or parasitic infections, such as filariasis or tuberculosis, may increase fluid production or block drainage 8 9 10. In regions where filariasis is endemic, it is a leading cause of hydrocele in adults.
• Trauma or Surgery: Injury or surgical procedures (notably varicocelectomy or inguinal surgeries) can disrupt lymphatic drainage or cause inflammation, leading to hydrocele formation 6 8 9.
• Tumors: Testicular or paratesticular tumors can cause secondary hydrocele by obstructing lymphatic flow or directly irritating the tunica vaginalis 3 8 9.
• Radiotherapy: Particularly in cancer patients, radiotherapy can induce fibrosis and lymphatic blockage, resulting in hydrocele. This is observed in patients treated for Hodgkin's disease 7.

Rare and Complex Causes

• Abdominoscrotal Hydrocele: The exact etiology is debated, with several hypotheses including abnormal fluid dynamics, congenital anomalies, and progressive extension due to pressure 1 2.
• Congenital Anomalies: Some hydroceles are associated with undescended testicles (cryptorchidism) or other developmental abnormalities 1 2.

Treatment of Hydrocele

Treatment depends on the type, cause, patient's age, and the presence of symptoms or complications. While many hydroceles resolve spontaneously, persistent or symptomatic cases often require intervention.

Treatment	Method	Success/Complications	Source(s)
Observation	Watchful waiting	Often resolves in children	4 5 6 8
Aspiration	Needle drainage of fluid	Quick relief, recurrence	11 12 13
Sclerotherapy	Injection of sclerosing agent	High recurrence, less invasive	11 13 14
Surgery	Hydrocelectomy (inguinal/scrotal)	Gold standard, some risks	1 6 8 9 11 12
Medical Therapy	Anti-filarial (e.g., doxycycline)	Effective in filarial cases	10

Table 4: Treatment Approaches

Observation and Conservative Management

In infants and young children, many hydroceles—especially congenital, communicating types—resolve on their own within the first year of life. Thus, observation is often recommended unless the hydrocele is very large, persists beyond 12-18 months, or causes complications 4 5 6 8.

Aspiration and Sclerotherapy

For adults or those unfit for surgery, aspiration (draining the fluid with a needle) provides temporary relief. However, recurrence rates are high unless combined with sclerotherapy, where a sclerosing agent (such as doxycycline or tetracycline) is injected to obliterate the space and prevent fluid reaccumulation 11 12 13 14.

• Pros: Minimally invasive, quick recovery, suitable for patients not eligible for surgery.
• Cons: Higher risk of recurrence (up to 35%), lower long-term satisfaction compared to surgery, potential for pain and local reactions 11 13 14.
• Notes: Recent studies with doxycycline report an 84% success rate in simple hydroceles after a single treatment 13.

Surgery: Hydrocelectomy

Hydrocelectomy—surgical removal or correction of the hydrocele sac—is the definitive treatment and considered the gold standard, particularly for persistent, large, or complicated hydroceles 1 6 8 9 11 12. Surgical approaches include:

• Inguinal Approach: Preferred for hydroceles with associated hernia or in children.

• Scrotal Approach: Common in adults; simpler, with fewer complications for idiopathic cases 1 6 9.

• Combined/Laparoscopic: Reserved for complex cases like abdominoscrotal hydrocele or when coexisting pathology is present 1.

• Complications: Infection, hematoma, injury to surrounding structures, and recurrence (low with proper technique).

Medical Therapy

For hydroceles related to filarial infection, anti-filarial medications like doxycycline, ivermectin, and albendazole have been shown to reduce hydrocele size and improve symptoms, sometimes obviating the need for surgery 10.

Special Considerations

• Abdominoscrotal Hydrocele: Almost always requires surgical intervention, often using a combined approach to address associated anomalies and minimize morbidity 1 2.
• Post-Surgical Hydroceles: Observation may suffice initially, but persistent cases after operations like varicocelectomy may need surgical correction 6.

Conclusion

Hydroceles are a common cause of scrotal swelling in males of all ages, with a range of types, causes, and treatments. Most are benign and easily managed, but proper diagnosis and tailored therapy are essential to rule out underlying disease and ensure optimal outcomes.

Key Points:

• Symptoms: Most commonly present as painless scrotal swelling, with discomfort and fluctuating size in some cases.
• Types: Include congenital, non-communicating, secondary, and rare forms like abdominoscrotal hydrocele.
• Causes: Range from idiopathic (most adult cases) to congenital anomalies, infections (e.g., filariasis), trauma, surgery, tumors, and radiotherapy.
• Treatment: Options include observation (especially in children), aspiration with/without sclerotherapy, surgery (hydrocelectomy), and medical therapy for filarial hydroceles. Surgery remains the gold standard for most adults and complicated cases.

Early recognition, appropriate classification, and individualized management are key to successful hydrocele care. If you experience scrotal swelling, seek medical evaluation to ensure a proper diagnosis and peace of mind.