Diseases

The diagnosis of a hydrocele is generally made clinically. An apt description of a hydrocele surrounding a palpable (something that can be felt) testis would be that of a small water balloon containing a peanut. The differences between communicating and non-communicating hydroceles described above help to support the suspected diagnosis.A bedside test, transillumination, provides confirmation of the condition. Transillumination involves placing a small light source (commonly an otoscope - the medical device used to examine the ear) against the swollen scrotum. The fluid filled nature of the hydrocele side is distinctly different from the non-involved side of the scrotum. In some cases, a scrotal ultrasound may be indicated. In unusual cases where a hydrocele may be a secondary phenomenon to pathologic cause (caused by disease), surgical exploration may be necessary to establish the diagnosis.

The differential diagnosis (list of possibilities) of chronic non tender scrotal swellings (besides hydroceles) includes:Hernia: A hernia involves the introduction of a segment of the small intestine into the inguinal canal. A sign of a hernia in the small intestinal region is swelling in the groin alone, or may also include the scrotum on the same side. Many complain of an "ache" or "sense of fullness" during this time. If the small intestine spontaneously slides back into the abdominal cavity or if a physician reduces it, the patient is generally referred to a surgeon for closure of the inguinal canal as a preventative move to preclude a repeat experience.If the small intestine is trapped and cannot be reduced, this is a surgical emergency. The patient will need urgent surgery in order to avoid intestinal swelling which may result in decreased blood flow to the intestine, and consequent death of the trapped bowel tissue.Varicocele: A varicocele represents engorgement of the testicular veins and clinically has been likened to a "bag of worms". While it is a relatively rare finding in the preadolescent, approximately 20% of late teens and adult men have been found to have a varicocele. More common on the left side of the scrotum, the varicocele characteristically "deflates" when the male reclines, and becomes engorged due to gravity when standing.In the older teen and adult, varicoceles generally require no specific management other than observation. In a younger male, if the varicocele becomes painful, or there is an associated size decrease in the same sided testicle, evaluation with a doctor specializing in urology conditions (urologist) should be sought. The sudden onset of a varicocele, especially if it occurs on the right side, may indicate the presence of kidney cancer and should always be evaluated by a physician.Tumor: childhood tumors of the structures contained within the scrotum are more often benign when compared to those of teens and adults. The most common tumor in this latter age range is testicular cancer. As a response to the notoriety of Lance Armstrong's battle with testicular cancer, the recommendation for monthly self-testicular exams (especially for teens and young adults who have a predisposition for this cancer) has found a more receptive audience than in the past.

A hydrocele is characterized as a non-painful, soft swelling of the scrotum (one or both sides). The overlying skin is not tender or inflamed. There are two types of hydroceles:

1. communicating, and
2. non-communicating.

Embryology Between the 28th and 36th week of gestation, the testes, associated blood vessels and nerves migrate from the upper posterior abdominal wall adjacent to the kidneys to the lower abdominal cavity and through a tunnel (inguinal canal) into the scrotum. As each gonad exits the pelvic region through the inguinal canal into the scrotum, it is preceded by a thinly lined "sack" called the process vaginalis. Once the testes and associated structures have entered the scrotum, the trailing end of the process vaginalis generally closes off, completely isolating the contents of the abdominal cavity and obstructing their passage into the inguinal canal or scrotum. Should this closure be incomplete and the communication narrow, free fluid in the abdominal cavity (peritoneal fluid) may seep into and through the process vaginalis and collect in the scrotum forming a hydrocele. If the connection is larger and a portion of the small intestine migrates out of the abdominal cavity into the inguinal canal and/or scrotum, a hernia has developed.

A hydrocele is a scrotal collection of clear fluid ("hydro" = water) in a thin walled sack ("cele" = swelling) that also contains the testicle. Less frequently, due to the common embryological background of male and female gonadal structures, female children or women may also experience a hydrocele. In this case, the sack and connection exist in the labia majora (the outermost and larger of the two labial structures). Because of less potential concern for complications in females with hydroceles, this article will focus predominantly on the male gender. A hydrocele may involve either one side (unilateral) or both sides (bilateral) of the scrotum.

In 95% of congenital (present at birth) hydroceles, the natural history is one of gradual and complete resolution by one year of age. For those lasting longer than one year or for those non-communicating hydroceles that manifest after the first year, surgical repair is indicated since these rarely resolve spontaneously.