Levels of evidence (1a-4) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Diagnosis
The classic description of a communicating hydrocele is that of a hydrocele that vacillates in size, usually related to activity. It may be diagnosed by history; physical investigation and transillumination of the scrotum make the diagnosis in the majority of cases. If the diagnosis is that of a hydrocele, there will be no history of reducibility and no associated symptoms; the swelling is translucent, smooth and usually non-tender. If there are any doubts about the character of an intrascrotal mass, scrotal ultrasound should be performed and has nearly 100% sensitivity in detecting intrascrotal lesions. Doppler ultrasound studies help to distinguish hydroceles from varicocele and testicular torsion, although these conditions may also be accompanied by a hydrocele.
Treatment
In the majority of infants, the surgical treatment of hydrocele is not indicated within the first 12-24 months because of the tendency for spontaneous resolution (level of evidence: 4, grade C recommendation). Early surgery is indicated if there is suspicion of a concomitant inguinal hernia or underlying testicular pathology. The question of contralateral disease should be addressed by both history and examination at the time of initial consultation. Persistence of a simple scrotal hydrocele beyond 24 months of age may be an indication for surgical correction. However, there is no evidence that this type of hydrocele risks testicular damage. In the paediatric age group, the operation consists of ligation of patent processus vaginalis via inguinal incision and the distal stump is left open, whereas in hydrocele of the cord the cystic mass is excised or unroofed (level of evidence: 4, grade C recommendation). In expert hands, the incidence of testicular damage during hydrocele or inguinal hernia repair is very low (0.3%) (level of evidence: 3, grade B recommendation). Sclerosing agents should not be used because of the risk of chemical peritonitis in communicating processus vaginalis peritonei (level of evidence: 4, grade C recommendation). The scrotal approach (Lord or Jaboulay technique) is used in the treatment of a secondary non-communicating hydrocele.
Definitions:
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from at least one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
