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A hydrocele is a collection of watery fluid around the testicle. This is a common problem in newborn

males and usually goes away within the first year of life. When the testicle drops into the scrotum (about

the eighth month of pregnancy), a sac (the processus vaginalis) from the abdominal cavity travels along

with the testicle. Fluid can then flow to the scrotum to surround the testicle. This sac usually closes and

the fluid is absorbed. When the sac closes and the fluid remains, this is called a noncommunicating

hydrocele. This means that the scrotal sac can be compressed and the fluid will not flow back into the

abdomen. This type of hydrocele is often found in newborns and the fluid will usually be absorbed withtime. If the scrotal sac is compressed and the fluid slowly goes back up into the abdomen or if the

hydrocele changes size, this is called a communicating hydrocele. This type of hydrocele usually appears

smaller in the morning when the child wakes up and larger in the evening after activity. A communicating

hydrocele shows that the sac or processus vaginalis is still open.

 Alternatively, hydroceles can be divided into those that represent a persistent communication with theabdominal cavity and those that do not. Fluid excesses are from exogenous sources (the abdomen) incommunicating hydroceles, whereas noncommunicating hydroceles develop increased scrotal fluid fromabnormal intrinsic scrotal fluid shifts.

Communicating hydrocelesWith communicating hydroceles, simple Valsalva probably accounts for the classic variation in size duringday-sleep cycles. Nonetheless, with the incidence of patent processus so great, why children withclinically apparent hydroceles are relatively few remains somewhat inexplicable. Chronically increasedintra-abdominal pressure (eg, as in chronic lung disease) or increased abdominal fluid production (eg,children with ventriculoperitoneal shunts) probably warrants early surgical intervention.

Noncommunicating hydroceles

In noncommunicating hydroceles, the pathophysiology may occur as a result of increased fluid productionor as a consequence of impaired absorption. A sudden onset of scrotal hydrocele in older children hasbeen noted after viral illnesses. In such cases, viral-mediated serositis may account for the net increasedfluid production. Posttraumatic hydroceles likely occur secondary to increased serosal fluid productiondue to underlying inflammation. Although rare in the United States, filarial infestations are a classic causeof the decreased lymphatic fluid absorption resulting in hydroceles.

During fetal development, an extension of the peritoneum migratesdistally through the inguinal canal with the gubernaculum in the firsttrimester. Normally, this thin membrane that extends through the inguinalcanal and descends into the scrotum (processus vaginalis) is obliteratedproximally at the internal inguinal ring, and the distal portion forms thetunica vaginalis. [3] [6]

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Normal

anatomyCreated by the BMJ GroupIn the majority of cases, the processusvaginalis closes within the first year of life. [5] [6] [7] [8]If it is notobliterated at the internal ring, it is referred to as a patent processusvaginalis, and the tunica vaginalis communicates with the peritoneum, sothat peritoneal fluid flows freely between both structures and acommunicating hydrocele forms.

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Communicating

hydroceleCreated by the BMJ GroupIf the communication is large enough,intra-abdominal structures, such as intestine, omentum, bladder, orgenital contents, may be found in the inguinal canal, and this

complication is known as an indirect inguinal hernia. [2] [3] While the processus vaginalis forms in both sexes in the first trimester, itdoes not enlarge in females. Hydrocele of the canal of Nuck is rare andresults from the failure of the processus vaginalis to close, which causesfluid to accumulate within the inguinal canal.

 A non-communicating or simple hydrocele occurs in cases where theprocessus vaginalis is obliterated and secretion exceeds absorption offluid from the tunica vaginalis.

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Non-

communicating hydroceleCreated by the BMJ Group An abdominoscrotalhydrocele is a simple hydrocele that enlarges through the inguinal canalresulting in an abdominal component. A hydrocele of the spermatic cord

is the result of segmental closure of the processus vaginalis. It isloculated and usually does not communicate with the peritonealcavity. [2] 

Common causes:

  In infants, usually due to the following:o  Incomplete closure of the processus vaginalis from the peritoneum

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o  Residual peritoneal fluid that has yet to be reabsorbed after processus closure (a patent processusvaginalis accompanies the testis during normal descent and normally fuses spontaneously after the testisreaches the scrotum; incomplete obliteration of the patent processus vaginalis can result in simplehydrocele, hydrocele of the cord, communicating hydrocele through a narrow patent processus vaginalis,or a widely patent processus with complete inguinal hernia)

  In older boys and men may be idiopathic but usually due to abnormal absorption or secretion secondaryto another pathologic process such as:o  Traumao  Ischemiao  Infection (sexually transmitted or other)o  Testicular tumor  o  Increased intra-abdominal pressure

Rare causes:

  Infants may sometimes present with hydrocele secondary to intrascrotal or intra-abdominal pathology

  Infant girls may have a hydrocele of the canal of Nuck or meconium hydrocele of the labia

  Filariasis may produce hydrocele in infected boys and men

  Hydrocele may be seen following ipsilateral renal transplantation

Serious causes:

  Hydrocele may be secondary to testicular torsion or incarcerated/strangulated hernia

  Hydrocele may be secondary to testicular cancerRisk factors 

  Premature and low-birth-weight infants

  Indirect inguinal hernia

  Primary testicular/intrascrotal pathology

  Trauma

  Surgery

  Increased intra-abdominal pressure

  Lymphatic obstruction

  Ventriculoperitoneal shunt

  Peritoneal dialysis

  Ehlers-Danlos syndrome

  Bladder exstrophy

Screening 

Summary approach

  Screening for hydrocele in the general population is not indicated, as early detection will not significantlychange outcome or management in the majority of cases

  Infants with congenital communicating hydrocele (ie, with associated indirect inguinal hernia) may benefitfrom exploration of the contralateral side to assess need for bilateral hernia sac ligation, but this is

controversial and usually reserved for infants at high risk such as premature infants and those withincreased abdominal pressure

Screening modalities

Surgical explorat ion

  If contralateral patent processus vaginalis is found, can electively repair at the same time

  Controversial, as it exposes patient to longer surgical time and increases risks of surgical complications

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Predisposing factors-modifiable

Scrotal Injury

Infection (STI)

Precipitating-non-modifiable

AGE

GENDER

Abnormal absorption or secretion of residual peritoneal fluid

Retention of fluid inside the scrotum

Scrotal swelling

Reduced blood flow in the testes