Testicular hydrocele

• Testicular hydrocele occurs in approximately 10% of Spanish men and its definitive treatment is surgery.
• There are three types of hydrocele depending on the reason for its appearance, congenital testicular hydrocele, acquired testicular hydrocele and idiopathic testicular hydrocele.
• There are several types of treatment to solve a testicular hydrocele, with surgery being the most commonly used.

A testicular hydrocele is an accumulation of serous fluid, originating from the proprio testicle or peritoneum, between two of the many layers of tissue that envelop the testis. Testicular hydrocele is one of the most prevalent benign pathologies from a human urological point of view and its definitive treatment is necessarily surgical.

Anatomically, the testicle is surrounded by a number of different layers that envelop and protect it. One of the most important layers is the tunica vaginalis. 

This layer is the last tissue that surrounds the testicle as such and is made up of two distinct structures: the parietal layer and the vaginal layer. It is between these two substructures that the accumulation of serous fluid occurs, which will later form the hydrocele.

Testicular hydrocele occurs in about 10% of the Spanish male population and is the main surgical intervention of major outpatient surgery from the urological point of view.

There are many ways to classify testicular hydrocele within the many subtypes it presents. One of the most enlightening is the classification according to its origin. In order to better understand this type of categorisation, it is first necessary to explain a number of concepts. 

The peritoneovaginal duct is a communication between the tunica vaginalis and its vaginal layer and the peritoneum (layer of serous tissue that covers the abdominal cavity above the abdominal viscera), at the moment of birth this duct remains open and communicating an intra-abdominal part of the body with another extra-abdominal part, this communication must be closed in a habitual way before the first year of life.

If the communication closest to the abdominal wall remains open, hernias may form at that point (hernia is defined as the outflow of intra-abdominal material either fatty or intestinal through the open duct) and if both orifices close at the same time, the formation of a chordal cyst is possible (a benign entity although much less prevalent than testicular hydrocele).

Taking this premise into account, testicular hydrocele can be referred to in 3 different ways: congenital testicular hydrocele (when there is no obliteration of the peritoneovaginal duct, it is a congenital communicating hydrocele), acquired testicular hydrocele (in this case of testicular hydrocele, the peritoneovaginal duct is correctly obliterated, in this type of hydrocele the alteration is caused by a dysfunction in the secretion and reabsorption of serous fluid generated by the testicle in a natural way for the correct functioning of the tunica vaginalis) and idiopathic testicular hydrocele (testicular hydrocele in which the origin of the hydrocele is unknown).

In any case, in testicular hydrocele it is often extremely difficult to find the absolute origin of the hydrocele, in any case, it is very important to rule out a secondary cause as a trigger for the hydrocele. 

The processes that usually cause testicular hydrocele may be testicular cancer (it is estimated that around 10% of testicular cancers may debut as hydrocele), testicular torsion, epididymitis, infectious and inflammatory processes, etc.

Testicular hydrocele is usually a benign entity that does not usually cause many symptoms, apart from discomfort due to the increase in the size of the testicle in the most severe cases (they are usually bothersome beyond a volume of 300 ml and can be serious if they are larger than 500 ml). 

On very rare occasions it can be painful, especially if the size of the testicle reaches significant proportions. It is usually a soft mass that can sometimes be lobulated, translucent to a beam of light and not painful on palpation.

Hydroceles are usually diagnosed in the urology specialist's office or in the primary care clinic when the patient comes because he/she has noticed an enlargement of one testicle in relation to the contralateral one. The diagnosis of a testicular hydrocele is usually based on a correct anamnesis and a proper physical examination.

A testicular hydrocele is diagnosed by a thorough physical examination. The way to recognise a testicular hydrocele is usually easy and quick for those who are trained to do so. A hydrocele is usually a collection of fluid that can vary in size and enlarges the size of the affected testicle relative to the opposite testicle. It is not painful on palpation and usually allows light to pass through it. Occasionally, especially if the hydrocele is chronic or if we suspect it may be infected, the translucency of the testicular hydrocele may not be as clear as usual.

The diagnosis of hydrocele is therefore usually clear. However, finding out the origin of the hydrocele is usually not so simple. Sometimes, the specialist will have to request or carry out a testicular ultrasound scan.

In this testicular ultrasound we can clearly differentiate a varicocele from a hydrocele, a testicular cancer from a hydrocele and even a scrotal hernia from a hydrocele (usually during the usual physical examination the specialist has already ruled out the presence of a scrotal hernia by asking the patient to perform Valsalva manoeuvres with which the scrotal hernia is mobilised, differentiating it from a testicular hydrocele).

Modern urology offers three general therapeutic options for the treatment of testicular hydrocele. A testicular hydrocele can be partially solved by means of an aspiration puncture, by sclerosis of the layers of the tunica vaginalis and by surgical intervention.

Aspiration of testicular hydrocele fluid by means of an aspiration puncture is an extremely simple and inexpensive technique. It is generally reserved for those types of patients whose morbidity and mortality are not candidates for any type of surgical intervention, however innocuous and simple it may be. 

This type of option does not resolve the pathology of testicular hydrocele, and recurrence of testicular hydrocele is the usual trend associated with this type of therapeutic weapon. 

However, despite its simplicity, it is not free of complications such as testicular infections and the formation of scrotal haematomas.

Sclerotherapy, which is nothing more than the infiltration of substances that scleroses or deforms the layers of the tunica vaginalis, is an alternative that for many years has been considered inferior to surgical intervention but which has recently been growing in popularity and effectiveness with the new substances that are used. 

This type of intervention simply involves injecting substances such as polidocanol or ethanolamine between the parietal and vaginal layers of the tunica vaginalis to deform and enlarge these layers in order to prevent the accumulation of fluid between them.

The main problem with this technique is that a single instillation of these sclerosing agents is usually not enough to be effective, and there is a proportional relationship between the size of the testicular hydrocele and the number of injections needed to be truly effective.

Surgical intervention continues to be the technique of choice due to its effectiveness and lower complication rate for the resolution of testicular hydrocele. This type of technique is included in the Major Outpatient Surgery plan of the list of surgical interventions of any Urology programme.

This concept encompasses a series of pathologies that can be performed on an outpatient basis thanks to the development of more effective anaesthetic techniques that are shorter and less invasive. In this way it is possible that with only a stay of 4-5 hours in a recovery or resuscitation room after the operation, the patient can be discharged and continue with the postoperative period at home.

Immediate recovery from testicular hydrocele surgery takes only a few hours. If the entire operation has gone well, the patient may be able to leave the hospital or clinic after 4 to 5 hours in a recovery or resuscitation room.

Care of the incision is kept to a minimum, with the wound being kept dry and treated daily with disinfectant solutions. The use of a jockstrap during the first few days makes the stitches heal more quickly and correctly.

Stitch removal can vary between 10 and 15 days. Returning to normal lifestyle habits, avoiding sudden exercise, is possible in 4-5 days.