Hydrocele is a condition in which fluid fills the scrotum, causing it to swell. It usually is not painful or harmful, but it can be bothering.
It can affect males at any age, from newborns to older men, or rarely females. However, it is more common in newborns and children younger than 1 year old. It affects 6% of newborn males across the world.
Within this article, you will find answers to some of the most common questions surrounding this condition. For example, how does it form, what kind of fluid it has on the inside, among other important questions, would be answered.
By reading this article, you will obtain critical insights about Hydrocele, its causes, symptoms, and diagnosis. Therefore, please continue reading to get pearls on this specific topic at the hands of a Doctor.
How does a hydrocele form?
It will depend as there are different types. There are four different types of mechanisms by which hydrocele can develop, which are the following:
- Connection with the abdomen by a defect during fetal development.
- Excessive production of fluid
- Defective absorption of fluid
- Interruption of the lymphatic drainage of the scrotum
The most common type of hydrocele occurs in newborns and children younger than 1-year-old. Hydroceles begin to develop during fetal development in these cases. More specifically, during the seventh month, the testicles begin to move from the abdomen to the scrotum. While the testicles begin to descend, the testicle brings part of the abdominal cavity forming a little sac. This happens in every child during their fetal development as it is an integral part of it.
The new sac that surrounds the testes receives the name of processus vaginalis. It allows that the fluid present in the abdomen surrounds the testes. Normally this sac gets obliterated (disappears) within the first weeks after birth, forming the tunica vaginalis.
The tunica vaginalis is an important layer within the scrotal sac as it directly covers the testes. In this type of hydrocele, the principal problem is the patent processus vaginalis that allows the connection between the abdominal cavity and the testes. It remains open until the child has between 1 to 2 years old. It is the typical case of the child with variation in testicle size throughout the day as it worsens when children make pressure with the abdomen.
By the time of birth, around 80% to 90% of children have a patent processus vaginalis. However, these numbers reduce significantly to 25-40% at two years old. Although it is relatively common, only 6% of the cases become clinically apparent after the newborn period.
What are the types of a hydrocele?
There are different classifications for hydroceles, and it will depend on the mechanism that causes them. The first classification divides the hydrocele into two different types, which are the following:
The primary hydrocele has a direct link to the congenital defect of the obliteration of the processus vaginalis. Although it is a type of hydrocele that most of the time resolves on its own, it happens to children younger than 2 years old. The primary hydrocele has 4 different subtypes depending on the site of obliteration of the processus vaginalis.
- Congenital Hydrocele: On this type, the processus vaginalis is patent and allows communication with the peritoneal cavity. Although it allows the free movement of the peritoneal fluid, the gap is too small to allow the abdominal content to come through.
- Infantile Hydrocele: The processus vaginalis closes up in the inguinal canal, but the rest of it remains patent, allowing fluid collection.
- Encysted Hydrocele of the Cord: In this type, the processus vaginalis closes itself in two portions, creating a balloon accumulating fluid.
- Vaginal Hydrocele: The processus vaginalis remains patent around the testicles allowing the scrotal swelling and hydrocele formation.
It is usually known as adult hydrocele as well. It usually occurs as a result of several processes. Among the processes are the following:
- Infection: Among the infectious causes is syphilis, tuberculosis of the epididymis, and filariasis, which causes filarial hydrocele.
- Injury: The causes which can cause hydrocele are trauma or complications after hydrocele repair surgery.
- Malignancy or testicular cancer.
The previous types classify the hydrocele depending on the cause that allows its development. The other type of classification focuses on the movement of the fluids.
This type of hydrocele happens when the canal does not close, allowing communication with the abdominal cavity, which results in a fluid-filled sac. This type of hydrocele may look smaller in the morning and more prominent throughout the day. It is known as a baby’s hydrocele or pediatric hydrocele.
With the non-communicating hydrocele, the case is different from the communicating hydrocele. It is a common type in newborns, but it is more common in adults receiving the name of adult hydrocele. In this type, there is no communication between the abdominal cavity and the hydrocele sac. In newborns, the hydrocele often resolves on its own and goes away with time. There are other causes like testicular torsion, infectious diseases, or testicular tumors in older children and adults.
How common is it?
Around 80% to 90% of male newborns have a patent processus vaginalis that will close on its own in the next few weeks after birth. By the time these infants grow up and reach two years old, these numbers decrease. At two years of age, around 25% to 40% of the male infants have a patent process vaginalis. For adults, the numbers also decrease to 20%.
Keep in mind that a patent processus vaginalis means being at risk of developing the disease. Still, only 6% of the patients with a patent processus vaginalis will develop symptoms and become clinically evident after the newborn period.
What are the symptoms?
The presentation of hydrocele is straightforward and has a cardinal symptom which is a swollen scrotum. It is usually not painful, but it can be very concerning for the patient if it is a large hydrocele. Normally, the child’s scrotum will be filled on one side, rarely on both testes.
Nonetheless, there are cases in which this disease can be painful, but this is more likely to be a symptom of another disease. For example: If the sac remains open for a long period, part of the intestines can go through the gap, causing a hernia. There are other cases in which the testicles become twisted, causing testicular torsion. In these cases, the blood flow is blocked, causing an accumulation of fluid around the testes.
Adult men can feel a sensation of heaviness in the scrotum due to the fluid collection within it. Depending on the cause, the swelling of the scrotum may vary differently between morning and evening. This can happen either in children or adults and will change because of gravity and the patient’s position if he is walking or lying down.
How is it diagnosed?
The first step in the diagnosis of hydrocele is the physical examination. The doctor will ask if there is any pain or history of trauma previous to the condition. The doctor will also ask the patient or its family the history behind it. During the physical examination, the doctor will touch the scrotum to check if it is swollen and painful.
The doctor may also perform a simple test that receives the name of transillumination. With this test, the doctor will put a light on the scrotum, helping him determine if there is a presence of fluid. Suppose there is the presence of hydrocele fluid. In that case, the scrotum will allow light transmission through it, meaning that it is a simple hydrocele. However, if the cause is a solid mass, the light will not go through the scrotum. Doctors will also rule out other conditions and may ask for other tests like the following:
- Laboratory tests: Among the laboratory tests, the doctor will ask for blood tests and urine tests to rule out infectious causes like epididymitis.
- Imaging tests: The doctor may also ask for an ultrasound to help them rule out another condition like hernias, testicular tumors, or other swelling causes.
What is the treatment for it?
This will depend on the type of hydrocele and its cause. The treatment of choice for this disease is surgery if it does not resolve spontaneously. It is also the choice for patients with pain and complications that may affect their testes.
The procedure to remove a hydrocele receives the name of hydrocelectomy. It is a procedure that can be done under general or regional anesthesia. In hydrocelectomy, the surgeon will perform a small incision in the scrotum or the lower abdomen to remove the hydrocele. Depending on the incision location, the patient may require a drainage tube for a few days. The doctor may also recommend a follow-up examination as hydrocele can recur.
There are two different types of approaches for hydrocelectomy:
- Plication: It is a technique most commonly used in hydroceles with a thin wall. The surgeon will make a minimal incision which will help to prevent further infections. The doctor will suture the sac with itself to hold together the walls and form fibrous tissue.
- Excision and Eversion: It is a technique proper for hydrocele with a thick and large wall. This procedure removes the tunica vaginalis and everting the sac behind the testicle. Later the testicle is placed in a new pocket using the tissue within the scrotum.
Another method to treat this disease aside from surgery is an aspiration. This is an option for patients who cannot tolerate surgery. However, this method does not attack the primary cause but instead the symptom. With this method, patients can suffer from liquid reaccumulation after a week or so. Also, the risk of injury and infection after this procedure is high.
Among the common complications of the surgery, the patients can suffer from infections, sinus formation, recurrent hydrocele, pyocele and reactionary hemorrhage.
Who is at risk of it?
First of all, it is important to emphasize that this condition can affect either males or females. However, hydrocele in females is not so common. The most common group that develops hydrocele is newborn males and children younger than 2 years old. At least 5% of newborn males have hydrocele. Newborns who are born prematurely and low birth weight have a higher risk of developing hydrocele.
Male adults are also at risk of developing hydrocele but for other causes rather than congenital disease. Among the causes that may represent a risk for developing hydrocele are the following:
- Injury or direct trauma to the scrotum
- Infectious diseases alongside sexually transmitted infections (STI)
What kind of fluid is in a hydrocele?
Hydrocele fluid comes directly in most cases from the peritoneum if it is a communicating hydrocele. It will depend, but normally hydrocele accumulates serous fluid in the tunica vaginalis forming a sac around the testicle.
This serous fluid can be transparent or slightly yellowish. However, there are cases in which there is a deficiency in the elimination of liquids. Among the possibilities also exists the pyocele; this results from an infectious disease causing the tunica vaginalis to be filled with pus.
Also, the possibility of developing hematocele, the content of this type is blood, and it occurs after a trauma or direct injury to the sac. The hematocele and pyocele are common complications of surgical procedures; nonetheless, the risk of this happening is low. When the doctor tries to aspirate the content of the hydrocele, the risk of developing hematocele and pyocele becomes higher. The coloration of the hematocele can be reddish, sometimes a little bit darker, and the pyocele is yellow or green.
What do hydroceles look and feel like?
This will usually depend on the size of the hydrocele as they can vary in size, but they usually look all the same. It looks like a swollen scrotum on one or both sides, although both sides are not the common thing to happen.
The scrotum will become bigger, and it may feel heavier due to the liquid collection. It usually feels like a soft balloon, and the patient may feel tenderness if someone touches it.
There are cases in which the hydrocele can occur secondary to a primary condition like testicular torsion or testicular tumor. If this is the case, it can be a little hard when touching it, and sometimes it can be painful as well. The size may vary, but with testicular torsion and tumor, the size is not common to be very large.
Is it a hydrocele or a hernia?
This will depend on the symptoms that the patient develops. Usually, the first and main symptom is scrotum swelling; however, the symptoms will differ for hydrocele and hernias.
Depending on the type, the hydrocele will not reduce its size if someone applies pressure to it. On the other side, hernias can reduce their size and re-introduce the intrabdominal content back into the abdomen.
There are cases in which the hernia cannot go inside the abdominal cavity. If this happens, it can be troublesome and require immediate attention.
The simple hydrocele will not be painful, but it can be uncomfortable due to the scrotum swelling. On the other side, hernias can be painful by itself and even more painful if it does not go back into the abdomen.
To determine if it is a hydrocele or a hernia, the doctor will perform a physical examination to achieve a clinical diagnosis. The doctor can also use imaging tests to confirm if it is a hernia or hematocele if there are doubts about it.
Will a hydrocele affect fertility?
Hydrocele is usually a condition that by itself will not cause harm to the testes. In most cases, hydrocele will not affect fertility and will not be a dangerous condition. However, there are cases in which patients may have infertility caused by a non-treated hydrocele. This will cause underdevelopment of spermatozoids leading to infertility. But to be very clear, this is not very likely to happen, but there is a slight possibility that it does. Doctors recommend that if there is no clear cause for infertility, the doctor who manages the case should think about hydrocele.
Do you have symptoms that are similar to the ones presented here?
This tool is a Hydrocele Symptoms Checker. It gathers the most important signs, symptoms, and risk factors for the disease. Therefore, the tool will tell anybody who uses it the likelihood of their symptoms because of hydrocele. Using the tool is free and would only take a few minutes.