Hydrocele - Standard Treatment Guidelines

Hydrocele is collection of fluid between two layers of tunica vaginalis of testis. It can be congenital or acquired which is further of two types i.e. primary or secondary.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Hydrocele. Following are the major recommendations :

Incidence

Hydrocele is quite a common condition with little high incidence in zones or areas affected by filariasis. Those present since birth are called congenital hydrocele where the processus vaginalis is essentially patent. Secondary hydrocele is most commonly due to tuberculosis, malignancy or chronic infection.

Differential Diagnosis

Primary hydrocele in adults has to be differentiated from

1. Inguinal Hernia- One can not get above swelling and trans illumination is absent (except congenital hernia ).


2. Epididymal cyst – The testis is palpable separately.


3. Spermatocele – The testis is palpable separately.


4. Testicular tumor - The consistency is firm to hard, Testicular sensation and fluctuations are absent and transillumination can not be elicited.

Prevention and Counseling

There are no specific preventive measures for both congenital and adult hydrocele except that wherever filariasis is endemic or prevalent, anti filarial prophylaxis may be taken or whenever the person suffers from it, prompt and proper treatment should be taken.

Optimal diagnostic criteria, Investigations, Treatment and referral criteria ( Situation 1 )

Clinical Diagnosis

For primary hydrocele in adults, 3 classical signs i.e. can get above the swelling, presence of fluctuations and transillumination are diagnostic of hydrocele. Secondary hydrocele is generally very small and soft and signs of primary pathology may be present. In congenital variety, classical history of no scrotal swelling in morning and full blown swelling in the evening coupled with above signs is diagnostic.

Investigations

In most of the cases practically no investigations are required to confirm the diagnosis of primary hydrocele and congenital hydrocele. At the most, ultrasound may be done to find out testicular morphology . For secondary hydrocele , complete battery of investigation consisting of ultrasound, FNAC, CT scan and investigations for tuberculosis and tumor markers etc will be required depending upon the possible primary pathology.

This battery is unlikely to be available in situation 1; hence referral to higher centre would be advisable.

Treatment

In Patient

Congenital hydrocele is treated surgically by herniotomy through inguinal approach. Adult hydrocele (primary) is treated by eversion or excision or plication depending upon size of hydrocele and thickness of the sac. Since hematoma is a very common complication , hence perfect hemostasis must be achieved in this surgery.

Out-patient – None.

Day-care

For congenital hydrocele , overnight stay is routine. For adult hydrocele , in appropriate setting , the operative procedure can be considered on day care basis if surgery has been done under local anesthesia.

Referral Criteria

Referral may be considered in secondary hydrocele if the primary cause turns out to be testicular malignancy.

Optimal diagnostic criteria, Investigations, Treatment and referral criteria (Situation 2)

Clinical Diagnosis

For primary hydrocele in adults, 3 classical signs i.e. can get above the swelling, presence of fluctuations and transillumination are diagnostic of hydrocele. Secondary hydrocele is generally very small and soft and signs of primary pathology may be present. In congenital variety, classical history of no scrotal swelling in morning and full blown swelling in the evening coupled with above signs is diagnostic.

Investigations

In most of the cases practically no investigations are required to confirm the diagnosis of primary hydrocele and congenital hydrocele. At the most, ultrasound may be done to find out testicular morphology. For secondary hydrocele, complete battery of investigation consisting of ultrasound, FNAC, CT scan and investigations for tuberculosis and tumor markers etc will be required depending upon the possible primary pathology.

This battery is unlikely to be available in situation 1; hence referral to higher centre would be advisable.

Treatment

In-Patient

Congenital hydrocele is treated surgically by herniotomy through inguinal approach. Adult hydrocele (primary) is treated by eversion or excision or plication depending upon size of hydrocele and thickness of the sac. Since hematoma is a very common complication , hence perfect hemostasis must be achieved in this surgery.

Out-patient – None.

Day care

All the surgical options mentioned for congenital and primary variety of adult hydrocele can be considered on day care basis in situation 2 .

Referral Criteria

None

Who Does What? and Timelines

Doctor

The job of diagnosis, treatment including surgery, post-operative care and follow up.

Nurse

Pre-operative care, operative assistance, post-operative care, administration of treatment instructed by the doctor and monitoring as instructed.

Technician

Keeps all machines and equipments in order and assist the anesthetist during operation.

Further reading

• Bailey & Love’s Short Practice of Surgery


• Schwartz’s Textbook of Surgery

Resources required for one patient/procedure

Guidelines by The Ministry of Health and Family Welfare :

Dr Ajit Sinha Department of Surgery Safdarjung Hospital New Delhi