Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Management of hydrocele in adolescent patients

Nature Reviews Urology volume 7, pages 379–385 (2010)Cite this article

Subjects

Abstract

Hydrocele is defined as an abnormal collection of serous fluid in the potential space between the parietal and visceral layers of the tunica vaginalis. In the majority of affected adolescents, hydrocele is acquired and is idiopathic in origin. The pathogenesis of idiopathic hydrocele is thought to be an imbalance in the normal process of fluid production and reabsorption. The diagnosis is usually clinical. Taking a thorough history is essential to rule out any fluctuation in size, which is an indication of a patent processus vaginalis. Scrotal ultrasonography is mandatory in nonpalpable testicles to rule out a subtending testicular solid mass requiring inguinal exploration. Otherwise, open hydrocelectomy via a scrotal incision is the standard treatment of idiopathic hydroceles. The second most common cause of hydrocele in adolescents is varicocelectomy. The risk of hydrocele formation is higher with non-artery-sparing procedures or those performed without microsurgical aid, and in surgery requiring cord dissection. If hydrocele occurs after varicocelectomy, initial management should include observation with or without hydrocele aspiration. Large persistent hydroceles are best served by open hydrocelectomy.

Key Points

  • Hydrocele in adolescents is most often idiopathic and seldom owing to a persistently patent processus vaginalis

  • Varicocelectomy is the second most common cause of hydrocele in adolescents in developed countries; prevalence varies according to surgical technique

  • The diagnosis of hydrocele is generally clinical, but idiopathic cases with a nonpalpable testicle should undergo scrotal ultrasonography to rule out a subtending solid testicular mass

  • Open hydrocelectomy via scrotal incision is the standard approach for idiopathic hydrocele in adolescents

  • Observation should be the initial approach in postvaricocelectomy hydrocele, unless the hydrocele is very large and tense

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Excision hydrocelectomy: delivery of the vaginal sac.
Figure 2: Excision hydrocelectomy: fluid removal.
Figure 3: Excision hydrocelectomy: tunica vaginalis resection.
Figure 4: Excision hydrocelectomy: closing up.

Similar content being viewed by others

References

  1. Wallace, A. F. Aetiology of the idiopathic hydrocele. Br. J. Urol. 32, 79–96 (1969).

    Article  Google Scholar 

  2. Rubenstein, R. A., Dogra, V. S., Seftel, A. D. & Resnick, M. I. Benign intrascrotal lesions. J. Urol. 171, 1765–1772 (2004).

    Article  PubMed  Google Scholar 

  3. Oyen, R. H. Scrotal ultrasound. Eur. Radiol. 12, 19–34 (2002).

    Article  PubMed  Google Scholar 

  4. Leung, M. L., Gooding, G. A. & Williams, R. D. High-resolution sonography of scrotal contents in asymptomatic subjects. AJR Am. J. Roentgenol. 143, 161–164 (1984).

    Article  CAS  PubMed  Google Scholar 

  5. Turgut, A. T. et al. A novel parameter by EFOV US for the quantification and the distinction of physiological amount of scrotal fluid and hydrocele: ratio of testis volume/scrotum volume. Eur. J. Radiol. 63, 414–419 (2007).

    Article  PubMed  Google Scholar 

  6. Christensen, T., Cartwright, P. C., Devries, C. & Snow, B. W. New onset of hydroceles in boys over 1 year of age. Int. J. Urol. 13, 1425–1427 (2006).

    Article  PubMed  Google Scholar 

  7. Wilson, J. M., Aaronson, D. S., Schrader, R. & Baskin, L. S. Hydrocele in the pediatric patient: inguinal or scrotal approach? J. Urol. 180, 1724–1727 (2008).

    Article  PubMed  Google Scholar 

  8. Ozdilek, S. The pathogenesis of idiopathic hydrocele and a simple operative technique. J. Urol. 77, 282–284 (1957).

    Article  CAS  PubMed  Google Scholar 

  9. Rinker, J. R. & Allen, L. A lymphatic defect in hydrocele. Am. Surg. 17, 681–686 (1951).

    CAS  PubMed  Google Scholar 

  10. Pierik, F. H., Dohle, G. R., van Muiswinkel, J. M., Vreeburg, J. T. & Weber, R. F. Is routine scrotal ultrasound advantageous in infertile men? J. Urol. 162, 1618–1620 (1999).

    Article  CAS  PubMed  Google Scholar 

  11. Misseri, R., Gershbein, A. B., Horowitz, M. & Glassberg, K. I. The adolescent varicocele. II: the incidence of hydrocele and delayed recurrent varicocele after varicocelectomy in a long-term follow-up. BJU Int. 87, 494–498 (2001).

    Article  CAS  PubMed  Google Scholar 

  12. Esposito, C. et al. Incidence and management of hydrocele following varicocele surgery in children. J. Urol. 171, 1271–1273 (2004).

    Article  PubMed  Google Scholar 

  13. Hassan, J. M., Adams, M. C., Pope, J. C. 4th, Demarco, R. T. & Brock, J. W. 3rd. Hydrocele formation following laparoscopic varicocelectomy. J. Urol. 175, 1076–1079 (2006).

    Article  PubMed  Google Scholar 

  14. Ein, S. H., Nasr, A., Wales, P. & Gerstle, T. The very large recurrent postoperative scrotal hydrocele after pediatric inguinal hernia repair: a rare problem. Pediatr. Surg. Int. 25, 239–241 (2009).

    Article  PubMed  Google Scholar 

  15. Lemack, G. E., Uzzo, R. G., Schlegel, P. N. & Goldstein, M. Microsurgical repair of the adolescent varicocele. J. Urol. 160, 179–181 (1998).

    Article  CAS  PubMed  Google Scholar 

  16. Minevich, E., Wacksman, J., Lewis, A. G. & Sheldon, C. A. Inguinal microsurgical varicocelectomy in the adolescent: technique and preliminary results. J. Urol. 159, 1022–1024 (1998).

    Article  CAS  PubMed  Google Scholar 

  17. Cayan, S., Acar, D., Ulger, S. & Akbay, E. Adolescent varicocele repair: long-term results and comparison of surgical techniques according to optical magnification use in 100 cases at a single university hospital. J. Urol. 174, 2003–2006 (2005).

    Article  PubMed  Google Scholar 

  18. Yaman, O., Soygur, T., Zumrutbas, A. E. & Resorlu, B. Results of microsurgical subinguinal varicocelectomy in children and adolescents. Urology 68, 410–412 (2006).

    Article  PubMed  Google Scholar 

  19. Zaupa, P., Mayr, J. & Höllwarth, M. E. Antegrade scrotal sclerotherapy for treating primary varicocele in children. BJU Int. 97, 809–812 (2006).

    Article  PubMed  Google Scholar 

  20. Beutner, S. et al. Treatment of varicocele with reference to age: a retrospective comparison of three minimally invasive procedures. Surg. Endosc. 21, 61–65 (2007).

    Article  CAS  PubMed  Google Scholar 

  21. Diamond, D. A. et al. Varicocele surgery: a decade's experience at a children's hospital. BJU Int. 104, 246–249 (2009).

    Article  PubMed  Google Scholar 

  22. DeVries, C. R. The role of the urologist in the treatment and elimination of lymphatic filariasis worldwide. BJU Int. 89 (Suppl. 1), 37–43 (2002).

    Article  PubMed  Google Scholar 

  23. Noroes, J. et al. Pathogenesis of filarial hydrocele: risk associated with intrascrotal nodules caused by death of adult Wuchereria bancrofti. Trans. R. Soc. Trop. Med. Hyg. 97, 561–566 (2003).

    Article  PubMed  Google Scholar 

  24. Taskinen, S., Fagerholm, R., Aronniemi, J., Rintala, R. & Taskinen, M. Testicular tumors in children and adolescents. J. Pediatr. Urol. 4, 134–137 (2008).

    Article  PubMed  Google Scholar 

  25. Wolanske, K. & Nino-Murcia, M. Malignant mesothelioma of the tunica vaginalis testis: atypical sonographic appearance. J. Ultrasound Med. 20, 69–72 (2001).

    Article  CAS  PubMed  Google Scholar 

  26. de Lima, G. R. et al. A rare case of malignant hydrocele in a young patient. J. Pediatr. Urol. 5, 243–245 (2009).

    Article  PubMed  Google Scholar 

  27. Zaslau, S., Perlmutter, A. E., Farivar-Mohseni, H., Chang, W. W. & Kandzari, S. J. Rhabdomyosarcoma of tunica vaginalis masquerading as hydrocele. Urology 65, 1001 (2005).

    Article  PubMed  Google Scholar 

  28. Tarantino, L., Giorgio, A., de Stefano, G. & Farella, N. Echo color Doppler findings in postpubertal mumps epididymo-orchitis. J. Ultrasound Med. 20, 1189–1195 (2001).

    Article  CAS  PubMed  Google Scholar 

  29. Cozzi, D. A. et al. Infantile abdominoscrotal hydrocele: a not so benign condition. J. Urol. 180, 2611–2615 (2008).

    Article  PubMed  Google Scholar 

  30. Turgut, A. T. et al. Unilateral idiopathic hydrocele has a substantial effect on the ipsilateral testicular geometry and resistivity indices. J. Ultrasound Med. 25, 837–843 (2006).

    Article  PubMed  Google Scholar 

  31. Nye, P. J. & Prati, R. C. Jr. Idiopathic hydrocele and absent testicular diastolic flow. J. Clin. Ultrasound 25, 43–46 (1997).

    Article  CAS  PubMed  Google Scholar 

  32. Ahorlu, C. K., Dunyo, S. K., Asamoah, G. & Simonsen, P. E. Consequences of hydrocele and the benefits of hydrocelectomy: a qualitative study in lymphatic filariasis endemic communities on the coast of Ghana. Acta Trop. 80, 215–221 (2001).

    Article  CAS  PubMed  Google Scholar 

  33. Ku, J. H., Kim, M. E., Lee, N. K. & Park, Y. H. The excisional, plication and internal drainage techniques: a comparison of the results for idiopathic hydrocele. BJU Int. 87, 82–84 (2001).

    Article  CAS  PubMed  Google Scholar 

  34. Ali, M. Z. Fournier's gangrene—a rare complication of hydrocele aspiration. J. Coll. Physicians Surg. Pak. 14, 304–305 (2004).

    PubMed  Google Scholar 

  35. Horstman, W. G. Scrotal imaging. Urol. Clin. North Am. 24, 653–671 (1997).

    Article  CAS  PubMed  Google Scholar 

  36. Norões, J. et al. Ultrasonographic evidence of abnormal lymphatic vessels in young men with adult Wuchereria bancrofti infection in the scrotal area. J. Urol. 156, 409–412 (1996).

    Article  PubMed  Google Scholar 

  37. Bassel, Y. S., Scherz, H. C. & Kirsch, A. J. Scrotal incision for undescended testes with or without a patent processus vaginalis. J. Urol. 177, 1516–1518 (2007).

    Article  PubMed  Google Scholar 

  38. Onol, S. Y. et al. A novel pull-through technique for the surgical management of idiopathic hydrocele. J. Urol. 181, 1201–1205 (2009).

    Article  PubMed  Google Scholar 

  39. Lord, P. H. A bloodless operation for the radical cure of idiopathic hydrocele. Br. J. Surg. 51, 914–916 (1964).

    Article  CAS  PubMed  Google Scholar 

  40. Singh, D. R., Gupta, S. K. & Gupta, S. Lord's procedure: a curative outpatient operation for primary hydrocele. J. Indian Med. Assoc. 94, 141–142 (1996).

    CAS  PubMed  Google Scholar 

  41. Shah, P. A., Dewoolkar, V. V. & Changlani, T. T. Ambulatory hydrocele surgery: a review of 50 cases. J. R. Coll. Surg. Edinb. 37, 385–386 (1992).

    CAS  PubMed  Google Scholar 

  42. Nigam, V. K. Window operation: new technique for hydrocele. Urology 24, 481–482 (1984).

    Article  CAS  PubMed  Google Scholar 

  43. Arslan, M., Kilinç, M., Yilmaz, K. & Oztürk, A. A new approach in the management of the hydrocele with a silicone catheter. Urology 63, 170–173 (2004).

    Article  PubMed  Google Scholar 

  44. Rodriguez, W. C., Rodriguez, D. D. & Fortuno, R. F. The operative treatment of hydrocele: a comparison of 4 basic techniques. J. Urol. 125, 804–805 (1981).

    Article  CAS  PubMed  Google Scholar 

  45. Albrecht, W., Höltl, W. & Aharinejad, S. Lord's procedure—the best operation for hydrocele? Br. J. Urol. 68, 187–189 (1991).

    Article  CAS  PubMed  Google Scholar 

  46. Kiddoo, D. A., Wollin, T. A. & Mador, D. R. A population based assessment of complications following outpatient hydrocelectomy and spermatocelectomy. J. Urol. 171, 746–748 (2004).

    Article  PubMed  Google Scholar 

  47. Hopps, C. V. & Goldstein, M. Microsurgical reconstruction of iatrogenic injuries to the epididymis from hydrocelectomy. J. Urol. 176, 2077–2079 (2006).

    Article  PubMed  Google Scholar 

  48. Beiko, D. T., Kim, D. & Morales, A. Aspiration and sclerotherapy versus hydrocelectomy for treatment of hydroceles. Urology 61, 708–712 (2003).

    Article  PubMed  Google Scholar 

  49. Shan, C. J., Lucon, A. M. & Arap, S. Comparative study of sclerotherapy with phenol and surgical treatment for hydrocele. J. Urol. 169, 1056–1059 (2003).

    Article  PubMed  Google Scholar 

  50. Fracchia, J. A., Armenakas, N. A. & Kohan, A. D. Cost-effective hydrocele ablation. J. Urol. 159, 864–867 (1998).

    Article  CAS  PubMed  Google Scholar 

  51. Musa, M. T., Fahal, A. H. & el Arabi, Y. E. Aspiration sclerotherapy for hydroceles in the tropics. Br. J. Urol. 76, 488–490 (1995).

    Article  CAS  PubMed  Google Scholar 

  52. Bullock, N. & Thurston, A. V. Tetracycline sclerotherapy for hydroceles and epididymal cysts. Br. J. Urol. 59, 340–342 (1987).

    Article  CAS  PubMed  Google Scholar 

  53. Stattin, P., Karlberg, L. & Damber, J. E. Long-term outcome of patients treated for hydrocele with the sclerosant agent sodium tetradecyl sulphate. Scand. J. Urol. Nephrol. 30, 109–113 (1996).

    Article  CAS  PubMed  Google Scholar 

  54. Badenoch, D. F., Fowler, C. G., Jenkins, B. J., Roberts, J. V. & Tiptaft, R. C. Aspiration and instillation of tetracyline in the treatment of testicular hydrocele. Br. J. Urol. 59, 172–173 (1987).

    Article  CAS  PubMed  Google Scholar 

  55. Khaniya, S., Agrawal, C. S., Koirala, R., Regmi, R. & Adhikary, S. Comparison of aspiration-sclerotherapy with hydrocelectomy in the management of hydrocele: a prospective randomized study. Int. J. Surg. 7, 392–395 (2009).

    Article  PubMed  Google Scholar 

  56. Van der Brink, B. A., Palmer, L. S., Gitlin, J., Levitt, S. B. & Franco, I. Lymphatic-sparing laparoscopic varicocelectomy versus microscopic varicocelectomy: is there a difference? Urology 70, 1207–1210 (2007).

    Article  Google Scholar 

  57. Glassberg, K. I., Poon, S. A., Gjertson, C. K., DeCastro, G. J. & Misseri, R. Laparoscopic lymphatic sparing varicocelectomy in adolescents. J. Urol. 180, 326–330 (2008).

    Article  PubMed  Google Scholar 

  58. Oswald, J., Körner, I. & Riccabona, M. The use of isosulphan blue to identify lymphatic vessels in high retroperitoneal ligation of adolescent varicocele—avoiding postoperative hydrocele. BJU Int. 87, 502–504 (2001).

    Article  CAS  PubMed  Google Scholar 

  59. Schwentner, C. et al. Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial. BJU Int. 98, 861–865 (2006).

    Article  PubMed  Google Scholar 

  60. Makari, J. H. et al. Safety and efficacy of intratesticular injection of vital dyes for lymphatic preservation during varicocelectomy. J. Urol. 178, 1026–1030 (2007).

    Article  PubMed  Google Scholar 

  61. Barroso, U. Jr, Andrade, D. M., Novaes, H., Netto, J. M. & Andrade, J. Surgical treatment of varicocele in children with open and laparoscopic Palomo technique: a systematic review of the literature. J. Urol. 181, 2724–2728 (2009).

    Article  PubMed  Google Scholar 

  62. Castagnetti, M., Cimador, M., DiPace, M. R., Catalano, P. & De Grazia, E. 'Preemptive hydrocelectomy' in subinguinal varicocelectomy. Urol. Int. 81, 14–16 (2008).

    Article  PubMed  Google Scholar 

  63. Tsikopoulos, G. K., Roussis, X. S., Georgakis, J., Papouis, G. & Tryfonas, G. J. Does incision of the tunica vaginalis during the Palomo procedure prevent post-operative hydrocele? Br. J. Urol. 81, 612–613 (1998).

    Article  CAS  PubMed  Google Scholar 

  64. Castagnetti, M. et al. Evolving management of adolescent varicocele. J. Pediatr. Urol. 4, 107–112 (2008).

    Article  PubMed  Google Scholar 

  65. Zampieri, N., El-Dalati, G., Ottolenghi, A. & Camoglio, F. S. Percutaneous aspiration for hydroceles after varicocelectomy. Urology 74, 1122–1124 (2009).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department for Mother & Child Care, Pediatric Surgical Unit, University of Palermo, Via Alfonso Giordano 3, 90100 Palermo, Italy,

    Marcello Cimador & Enrico De Grazia

  2. Department of Oncological and Surgical Sciences, Section of Pediatric Urology, Urology Unit, University Hospital of Padua, Monoblocco Ospedaliero, Via Giustiniani 2, 35128, Padua, Italy

    Marco Castagnetti

Authors
  1. Marcello Cimador
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marco Castagnetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Enrico De Grazia
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marcello Cimador.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Cimador, M., Castagnetti, M. & De Grazia, E. Management of hydrocele in adolescent patients. Nat Rev Urol 7, 379–385 (2010). https://doi.org/10.1038/nrurol.2010.80

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrurol.2010.80

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing