A hydrocele represents a collection of fluid between the serosal and peritoneal layers of the tunica vaginalis and can be distinguished as either communicating or noncommunicating. A communicating hydrocele arises from a patency of the processus vaginalis that has failed to close following testicular descent. This represents a spectrum of disease that includes an indirect inguinal hernia. Communicating hydroceles occurring within the first years of life seldom require operation because they will often disappear without treatment. If a communicating hydrocele persists beyond 2 years of age or is symptomatic at any time, surgery is recommended, and typically these are addressed via an inguinal incision in a method similar to repair of an indirect inguinal hernia.
A noncommunicating hydrocele arises from abnormal tunica vaginalis lining that can no longer resorb excess fluid. Noncommunicating hydroceles show little tendency toward spontaneous regression and should be removed if symptomatic. Most hydroceles are painless, and symptoms arise only from the inconvenience caused by their size or weight. The long-continued presence of a hydrocele infrequently causes atrophy of the testicle. Open operation is the method of choice for removing the hydrocele because the pathology arises from the abnormal tunica vaginalis, which must be partially excised or otherwise addressed. Aspiration of the hydrocele contents and injection with sclerosing agents are generally regarded as unsatisfactory treatment because of the high incidence of recurrences. Occasionally, severe infection can be introduced by aspiration. Simple aspiration, however, often may be used as a temporary measure in patients in whom surgery is contraindicated or must be postponed.
The accuracy of the diagnosis determines surgical management. Hydrocele must be differentiated from scrotal hernia, tumor of the testicle, and varicocele. Often physical examination is sufficient to determine the diagnosis. However, if the diagnosis is uncertain, or if the hydrocele is so large as to obscure the physical examination of the testicle, an ultrasound of the scrotum can be useful. A hernia usually can be reduced, transmits a cough impulse, and is not translucent. A hydrocele cannot be reduced into the inguinal canal and gives no impulse on coughing unless a hernia is also present. Additionally, a hydrocele typically transilluminates with application of a penlight, helping to distinguish from a solid mass or hernia.
Either spinal or general anesthesia is satisfactory in adults. General anesthesia is commonly chosen in children, although spinal anesthesia in an experienced setting may be performed. Local infiltration anesthesia is generally unsatisfactory because it fails to abolish abdominal pain produced by traction on the spermatic cord. Uncomplicated hydroceles may be excised as an ambulatory surgical procedure.
Patients are placed on their back on a level table with the legs slightly separated. The surgeon stands on the side of the patient ipsilateral to the site of pathology.