A hydrocele is an abnormal accumulation of serous fluid within the tunica vaginalis the thin double-layered sac that surrounds and encloses the testicle. It is the most common cause of painless scrotal swelling and is broadly classified into two types: primary (idiopathic) hydrocele, which has no identifiable underlying cause and is most prevalent in infants and young boys due to a failure of the processus vaginalis to close completely after testicular descent and secondary hydrocele, which arises in adults as a response to an underlying pathology such as infection, trauma, epididymo-orchitis or rarely, a testicular tumour.
Symptoms
The condition typically presents as a smooth, soft, non-tender swelling of the scrotum that may involve one or both sides. Patients usually report a feeling of heaviness or dragging discomfort in the scrotum, particularly when the hydrocele becomes large. The swelling characteristically transilluminates meaning a beam of light passes through the fluid-filled sac and lights it up which is a key clinical finding that distinguishes it from a solid testicular mass. Large hydroceles may cause significant discomfort during walking, physical activity or sexual intercourse and rarely a secondary hydrocele may be accompanied by pain if the underlying cause is inflammatory in origin.
Diagnosis
Clinical examination and transillumination test are usually sufficient to raise a strong suspicion. Scrotal ultrasound is the gold standard confirmatory investigation, clearly demonstrating anechoic (echo-free) fluid surrounding the testicle while also allowing thorough assessment of the underlying testis to exclude any coexisting tumour, epididymo-orchitis or torsion. In cases of secondary hydrocele, relevant blood tests including tumour markers (AFP, β-hCG, LDH) may be requested if a testicular neoplasm is suspected.
Treatment
In neonates and infants, primary hydrocele is managed conservatively as the vast majority resolve spontaneously by the age of 12–24 months when the processus vaginalis closes naturally. In adults, small and asymptomatic hydroceles require no treatment beyond periodic observation. For large, symptomatic or persistent hydroceles, surgical repair is the definitive treatment of choice. Jaboulay's procedure (eversion of the tunica vaginalis) or Lord's procedure (plication of the sac) are the most commonly performed operations both performed under general or spinal anaesthesia through a small scrotal or inguinal incision and carry an excellent success rate with minimal recurrence. Aspiration with or without sclerotherapy offers a non-surgical alternative for patients unfit for surgery, though recurrence rates are significantly higher compared to operative repair. Secondary hydroceles are managed by treating the underlying cause in addition to surgical drainage if required.