Gender medicine: what is hydrocele

By Cristiano Antonino On May 24, 2023

Hydrocele is a condition that leads to the abnormal accumulation of cytrinous fluid (transparent yellow colour) between the parietal and visceral leaflets of the tunica vaginalis, the serosa that surrounds the testicles

Commonly known as a ‘swollen testicle’, this condition can occur at birth (1 to 10 out of 100 newborns are affected) and in men over the age of 40.

Hydrocele manifests as a swelling of the scrotum that in newborns

Generally, it disappears without the need for any treatment while in adults it may be the result of trauma or inflammation of the scrotum or, more rarely, a tumour or inguinal hernia.

This pathology arises due to an imbalance between the fluid that pours into this space and that which is reabsorbed.

Hydrocele can be annoying but is usually not painful and occurs bilaterally in only 7-10% of cases (source: Prevention, diagnosis and treatment of andrological disorders from paediatric age to young adulthood).

In fact, it appears to be more common in the right hemiscrotum, due to organogenesis issues.

If it persists in adults, hydrocele requires surgery, which involves a small incision at the level of the scrotum or lower abdomen to remove the excess fluid.

It is therefore very important to prevent future complications by seeing your doctor for a full test to investigate the cause and identify the correct treatment.

Symptoms

The main symptom of hydrocele is the perception of a different consistency of the scrotal sac, which may appear softer or very tight, a condition that can vary throughout the day. Many subjects complain of discomfort especially in the evening hours.

In fact, during the night, lying down can promote the outflow of the fluid contained in the hydrocele into the abdomen.

The extent of the swelling varies from patient to patient and depends, above all, on the underlying causes.

In some patients, pain in one or both testicles, redness at the level of the scrotum and a sense of pressure at the base of the penis may also appear in addition.

The patient complaining of these symptoms may be unable to move.

In some cases the skin covering the penis is affected by the process, giving a feeling of a false micropenis in a flaccid state.

The only way to notice the symptoms early on remains self-examination.

Hydrocele may be

primary: when it is not caused by other pathologies,
secondary: when it occurs concurrently with or after other pathologies such as inguinal hernia, infections, testicular neoplasia.

It can occur in new-born babies, due to the failure to reabsorb the fluid in the sacs that form during testicular development.

Usually at birth these sacs are completely closed and, if fluid remains inside them, it is called a ‘non-communicating hydrocele’.

In the case of a communicating hydrocele, the sacs remain open.

Finally, there is also the form of ductus deferens hydrocele, a non-communicating hydrocele localised in the high scrotal site and often confused with an inguinal hernia.

It usually disappears in children without surgery: 80% of congenital hydrocele cases resolve spontaneously within the first 2 years of life.

In the child’s early years, fever and infections can cause fluid to accumulate in the abdominal cavity, which can pass into the scrotum if a sac has not closed properly.

In older children and adolescents, hydrocele is more often acquired and occurs as a result of inflammatory processes, testicular torsion, testicular infarction, radiotherapy, trauma and tumours.

In adults, on the other hand, a hydrocele may be the consequence of inflammation of the epididymis or testis caused by trauma or infection (e.g. tuberculosis, syphilis or epididymitis).

In this case we speak of a ‘reactive’ or ‘secondary’ hydrocele.

Otherwise, it may be caused by water retention in the lower limbs or, more rarely, be a consequence of a testicular tumour.

In elderly subjects, on the other hand, the hydrocele may be due to an accumulation of fluid around the testicle area due to an alteration in its drainage mechanisms.

Diagnosis

At the first suspicious symptoms of a hydrocele, a visit to the doctor (urology specialist) should be arranged for an objective test.

The doctor assesses whether the scrotum is swollen and painless to the touch, applying pressure to the scrotum and abdomen to check for a possible inguinal hernia.

He may then prescribe a blood and urine test (to rule out infection) and a scrotal ultrasound (to rule out concomitant pathologies).

The latter test, in particular, allows a more reliable assessment: it is a completely harmless diagnostic imaging test for which an ultrasound probe is used that, placed on the patient’s scrotum, transfers an image of the internal organs and tissues onto a monitor.

The scrotal ultrasound allows the exact size and, above all, the nature of the bulge to be detected.

If a hydrocele is found, the scrotal bulge will be caused by fluid.

If there are other types of changes, findings attributable to solid masses, such as testicular neoplasms, may emerge.

As with all pathologies, resolution of the problem, especially if caused by other serious pathologies, depends on early diagnosis: cases detected early have a higher probability of cure than those diagnosed in more advanced stages.

Risks and complications

Any male individual who notices a swollen testicle (or a parent who notices a swollen testicle in their child) should contact their doctor.

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Early diagnosis is very important: if the swelling is related to a serious condition, a late diagnosis could lead to very serious consequences such as impaired sexual function and/or reduced sperm production.

A strained hydrocele (containing a lot of fluid) may be prone to skin fissures (especially in defected, diabetic and immunocompromised patients), which may complicate the condition or make healing difficult.

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Hydrocele is associated with an increased risk of infertility as it appears to interfere with sperm production

The hydrostatic pressure of the liquid collection may exceed that of the scrotal blood vessels and may therefore be the cause of reduced blood supply resulting in reduced testicular volume to the point of atrophy.

It must be said that this condition, in most cases, if diagnosed and treated early, is not particularly dangerous and does not interfere with either sexual function or fertility.

Interventions and treatment

If the hydrocele causes symptoms such as pain or difficulty walking (this mostly occurs in adults), surgery is performed, which involves removing the vaginal tunic through a small incision in the scrotal skin.

This operation can be performed under local anaesthesia and the patient is discharged within the same day.

After this procedure, the patient must dress the wound and take antibiotics to avoid infection.

After about 10 days, a check of the stitches (which are often resorbable and therefore remove themselves) is performed, and a second visit after about a month with a scrotal ultrasound check.

Afterwards, a spermiogram should be performed to assess the number and vitality of the spermatozoa, as the hydrocele may recur after surgery.

In young children, the hydrocele tends to disappear spontaneously, but if it does not, the doctor (a specialist in paediatric surgery) may deem it necessary to resort to surgery, i.e. an operation to drain the fluid present.

There are two types of surgery possible:

Needle aspiration of the fluid: carried out when the hydrocele is of medium size and responsible for annoying symptoms (the main advantage is the reduced invasiveness but the risk of recurrence is greater).
Hydrocelectomy: an operation performed in the presence of large and very painful hydrocele under general or local anaesthesia, involving an incision at the scrotal level or on the lower abdomen and drainage of the fluid present in the scrotum (effective, but even this operation does not rule out the possibility of the hydrocele recurring in the future).

Prevention

While there is no way to prevent congenital hydrocele, the only way to prevent secondary hydrocele is to protect the scrotum from trauma or injury from activities that cause pressure, such as horse riding.

In older children and adolescents, hydrocele may occur in those who have had orchitis, testicular torsion or trauma, radiotherapy, infarction, or testicular tumours, so it is advisable to check these subjects more frequently.

All male subjects, from adolescence to middle age, should perform a self-examination regularly, preferably after a hot shower or bath, which facilitate the manoeuvre as it causes the scrotum to relax.

Self-palpation allows one to perceive the shape and consistency of one’s genitals in order to detect any suspicious changes.

Alterations in the shape, position and volume of the testicles can be a sign of such disorders.

In case of abnormalities, the subject should undergo a urological examination and a scrotal ultrasound.

In the case of childhood hydrocele, being a congenital condition, there is no specific form of prevention.

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