Hydrocele: formation, diagnosis and treatment

• Hydrocele is the accumulation of serous fluid inside the testicle in men, increasing its size.
• There are 3 types of hydrocele, depending on whether they are congenital, acquired or idiopathic in origin.
• The only definitive way to treat hydrocele is surgical intervention.

Hydrocele is the accumulation of fluid inside the testicle in men between two of the layers of tissue that form it, so that the affected reproductive organ is enlarged, causing pain and mechanical complications.

Hydrocele is a medical problem whose definitive solution involves surgery to solve the problem.

The testicles are the male reproductive organs. There are two of them and they are housed inside a bag of connective tissue called the scrotum, which keeps them away from the human body at a temperature between one and two degrees below body temperature. 

The testicles, as male reproductive organs, are involved in the production of sperm fluid and in the maturation of spermatozoa, forming the semen that is finished thanks to the fluid that is subsequently produced by the seminal vesicle just next to the prostate gland.

However, they also play an important role in the human hormonal system by manufacturing and elaborating sex hormones with great systemic involvement, such as testosterone, a hormone involved in the formation and development of a large part of the functions of the male body.

Broadly speaking, we can say that the testicles, which are the organs in which the hydroceles are formed, are almond-shaped, approximately 4-8 cm long and 2-4 cm wide, and are made up of lobules, which are small groups of sperm ducts where the sperm gonocytes mature and are transformed by the maturation process into spermatozoa.

These lobules, formed by the ducts mentioned above, all communicate with each other to form the testicular network, join with the epididymis (a narrow, elongated tube at the back of the testicle) and together they end in a duct that runs from the scrotum towards the back of the prostate to the seminal vesicles.

If we were to view the testicles from a lateral view, we could clearly distinguish each of the layers that form it and visualise more accurately the layers involved in the formation of the hydrocele. 

The layers that form the hydrocele from the outside in are: the scrotum, the dartos muscle, a thin serous layer, the cremaster muscle, another thin serous layer and the main player in the formation of the hydrocele, the tunica vaginalis of the testicle.

The tunica vaginalis of the testicle is the last layer surrounding the testicle and is made up of two distinct parts, the parietal part and the visceral part. The visceral part is so called because it is the part closest to the viscera, in this case the testicle. The parietal part is the part that is closest to the "wall", i.e. furthest away from the testicle.

This part is important in the formation of hydrocele because this pathology is generated by the accumulation of fluid from the peritoneum or from the formation of the testicle itself between these two layers. 

The visceral part of the tunica vaginalis of the testicle does not completely surround the male reproductive organ but leaves the upper and lower parts uncovered, which is one of the causes of hydrocele formation.

In general terms, there are several ways of classifying the different types of hydrocele. If we talk from a point of view of its origin we can find hydrocele of congenital origin, hydrocele of acquired origin and hydrocele of idiopathic origin. 

If it is a congenital hydrocele we are talking about a hydrocele that is generated as an accumulation of peritoneal fluid at birth due to an alteration of the layer that we have previously called the tunica vaginalis or a persistence of a duct that should disappear at birth and which communicates the inside of the abdomen with the testicle.

An acquired hydrocele is an accumulation of peritoneal fluid that is caused by an alteration between the inflow and outflow of the fluid between the two parts of the tunica vaginalis.

A hydrocele of idiopathic origin is the accumulation of fluid in the tunica vaginalis without a clear origin of the alteration that has produced this pathology, there are numerous entities that can cause this type of hydrocele in a secondary way, such as traumatic or infectious causes, testicular torsion or as a consequence of tumour formation.

The suspicion of a hydrocele is very clear, a growth in the size of one of the testicles with respect to the other is usually observed. 

In early stages this growth may not be very noticeable to the naked eye, in these cases there is usually no pain or any other alteration unless it is a hydrocele secondary to any of the causes that we have discussed above, being the signs or symptoms of the disease compatible with those of the underlying disease that causes them, if it is an infection we will have pain and stinging when urinating, if it is a trauma we will have a blow that triggers it and possibly a hematoma surrounding the perineal area, if it is a testicular torsion the most characteristic symptom is a strong pain that increases with movement and palpation.

If, on the other hand, what we have is a hydrocele in more advanced stages, we will find one testicle much larger than the other. In these cases, there may be pain on mobilisation and evident signs of discomfort on the part of the patient due to the large size that can be reached.

Hydrocele or accumulation of fluid in the tunica vaginalis, which is one of the layers that make up the testis, is unlikely to be associated with the appearance or finding of a testicular tumour; however, in up to 10% of cases where a testicular tumour is found affecting the male sex organs it is possible that it will initially manifest with a mild hydrocele. This relationship must therefore be taken into account in any differential diagnosis by a health professional.

Hydroceles, being an accumulation of fluid in the testicles that enlarges the size of one of them, are quickly suspected, therefore, a simple inspection and palpation can confirm an initial diagnosis. If during the physical examination there are doubts about the differential diagnosis with a varicocele, it is possible to bring a light closer and see if it passes through the accumulation of fluid or not. This diagnostic technique, known as translucency, differentiates varicocele from hydrocele with high sensitivity.

If a thorough physical examination still leaves any doubt as to the origin of the lesion, it is possible and definitive that a testicular Doppler ultrasound can be used to define the lesion categorically.

The definitive treatment for hydrocele is surgical intervention. Surgical intervention for hydrocele lasts no more than 30-60 minutes and allows the patient to be discharged 24 hours after the operation. 

The usual schematic steps are as follows:

1. Application at home of a cream with a mixture of local anaesthetics in which a well-known substance called Lidocaine predominates. This cream is known as EMLA and should be applied 24 hours before the operation.
2. Go to the hospital where the operation is to be performed on the same day as the hydrocele operation. Once in the operating theatre and after shaving the pubic hair necessary to prevent or reduce the risk of infection of the surgical wound, a shock dose of an antibiotic is administered as infectious prophylaxis. Cefuroxime 750 mg is generally used, although there are a wide variety of antibiotics that can be used for prevention or infectious prophylaxis.
3. The anaesthetist will apply the appropriate spinal anaesthesia for this type of operation, although on some rare occasions it can be performed under local anaesthesia.
4. Once the anaesthetic has worn off, the urological surgeon proceeds to dissect, i.e. separate each of the layers that make up the testicle, as mentioned in previous sections, starting with the scrotum and ending with the tunica vaginalis of the testicle with the hydrocele.
5. The liquid content of the hydrocele is then drained until almost all of it has been absorbed. If the layers that form the tunica vaginalis of the testicle are normal in appearance, a series of absorbable stitches are simply placed along the skin layer (so that they do not need to be removed again). If one of the layers is enlarged or hypertrophic, it is preferable to resect or remove part of it, as stitches in this inflamed area may not seal it effectively enough and the hydrocele may reproduce.
6. If a series of stitches have simply been given, all that is needed is to close all parts of the testicle layer by layer until the scrotum is reached and close it with stitches. If we have had to remove part of the tunica vaginalis, a drain will be placed so that if there is a small amount of bleeding, it can drain out through the drain.
7. Finally, a sterile dressing is applied to the outer scar site and the patient is fitted with a jockstrap. The patient will be taken to the recovery room where he/she will remain for 2 to 4 hours for observation.
8. If everything has gone normally, the patient will be discharged home for recovery. This operation is usually followed up 15 to 30 days after the operation.

The patient can go home 24 hours after the operation to repair a hydrocele. Painkillers must be taken for the first few hours as it is possible that after the anaesthesia wears off the patient may suffer some slight discomfort. 

The use of a jockstrap is compulsory to hold the testicles in place and prevent them from moving to prevent the inner and outer stitches that have been made from coming loose.

Normal life can be resumed in 4-5 days. The external stitches are usually removed progressively and intermittently after about 10 days.