Treatment of Congenital Hydrocele

What is a Congenital Hydrocele?

• (a) Vaginal (communicating/congenital) hydrocele - open processus throughout
• (b) Infantile hydrocele - proximal processus patent, distal closed
• (c) Hydrocele of the cord - only mid-portion patent
• (d) Closed non-communicating (vaginal) hydrocele

Figure 86.8 from Bailey & Love's Surgery 28e - Types of hydrocele (red circles indicate the site of the patent processus)

Key Points Before Treatment

• More than 80% of newborn boys have a patent processus vaginalis, but most close spontaneously within 18 months of age.
• A communicating hydrocele can be identified clinically by a history of enlargement with activity or in the evening, and reduction when supine (fluid drains back into the peritoneal cavity when lying down).
• The hydrocele may be intermittent; bilateral swellings in a child should prompt exclusion of ascites.
• Ultrasound is valuable in all cases to assess the testis and epididymis, particularly when they are impalpable within the hydrocele, and to exclude a secondary cause such as testicular tumour.
• If a tumour is suspected, the hydrocele must not be aspirated (risk of malignant needle-track implantation).

Treatment Principles

1. Conservative Management (Watchful Waiting)

"In the majority of infants, there is no indication for surgery within the first 24 months of age because they resolve spontaneously." - Campbell-Walsh-Wein Urology

• The hydrocele persists beyond 18-24 months of age
• It is associated with a symptomatic inguinal hernia (warrants earlier repair)
• There is rapid enlargement or concern for an underlying pathology

2. Surgical Treatment - Herniotomy (High Ligation of the Patent Processus Vaginalis)

"Congenital hydroceles are treated by ligation of the patent processus vaginalis (herniotomy) if they do not resolve spontaneously." - Bailey & Love's Surgery 28e

"The operation performed is high ligation of the patent processus vaginalis, the same procedure as that performed for inguinal hernia repair." - Campbell-Walsh-Wein Urology

• An inguinal (groin) incision is used to access and divide/ligate the processus at the internal ring - the "high" ligation.
• The distal sac (around the testis) is left open and widely divided rather than excised, to avoid creating a closed space in which fluid could reaccumulate.
• The operation is performed under general anaesthesia as a day-case procedure.
• If a scrotal hernia coexists with hydrocele, it is best to remove the hernia sac in its entirety whenever possible; if complete removal is not possible, the distal sac is opened widely and never tied off (tying off the distal sac creates a closed space and a new hydrocele).

3. Special Considerations by Age Group

4. Surgical Techniques for Acquired/Non-communicating Hydroceles (Relevant for Older Children and Adults)

1. Plication (Lord's operation) - best when the sac wall is thin. Multiple interrupted absorbable sutures gather and bunch the redundant tunica vaginalis at the testis margin. Minimal dissection; reduced risk of haematoma.
2. Eversion (Jaboulay's procedure) - the sac is opened and everted behind the testis, which is then placed in a fascial pouch. Risk of haematoma from cut edges is higher; overrunning sutures at the cut edge reduce this.
3. Excision - the sac wall is excised entirely; used when walls are thick (as in established acquired hydroceles). Highest risk of haematoma.

5. Aspiration and Sclerotherapy (Not for Children)

• Aspiration is simple but the fluid almost always reaccumulates within a week. It is only suitable for men unfit for surgery.
• Sclerotherapy (injection of agents such as tetracycline) can be effective but is painful and is not used in the paediatric setting.

Summary of Management Algorithm

Congenital hydrocele diagnosed in infant
          ↓
     Age < 18-24 months?
    /                  \
  Yes                   No (or associated hernia)
   ↓                          ↓
Watchful waiting       High ligation of patent
                       processus vaginalis
                       (inguinal herniotomy)
          ↓
  Persists beyond 24 months?
          ↓
  Surgical repair indicated

• Bailey & Love's Short Practice of Surgery, 28th Ed., pp. 1586-1587 (Hydrocele: Treatment)
• Campbell-Walsh-Wein Urology, 12th Ed., Chapter on Scrotal Mass (Hernia and Hydrocele in Children)
• 2025 systematic review on global prevalence: Salari et al., BMC Pediatrics 2025 (PMID 39987032) - found resolution rates support conservative management in infants

Types of Hydrocele

Structural / Anatomical Classification

Figure 86.8 from Bailey & Love's Surgery 28e - Types of hydrocele (red circles mark the site of the patent processus vaginalis)

Type 1 - Vaginal (Non-communicating) Hydrocele

• The processus vaginalis is fully closed; there is no communication with the peritoneal cavity.
• Fluid accumulates within the tunica vaginalis due to excessive production or defective absorption by the tunica, usually from disruption to lymphatic drainage.
• If idiopathic, it is called a primary hydrocele - this is the most common type globally, typically seen in middle-aged and older men.
• Secondary non-communicating hydroceles are caused by local injury, infection, torsion, neoplasm, or radiotherapy.

Type 2 - Communicating (Congenital) Hydrocele

• The processus vaginalis remains fully patent from the peritoneal cavity down to the tunica vaginalis.
• Peritoneal fluid flows freely into the scrotum; the hydrocele is intermittent - enlarges when upright/active, reduces when supine.
• Associated with indirect inguinal hernias (same anatomical defect, just larger opening).
• Seen predominantly in infants and young children.
• The opening is usually too small to allow herniation of abdominal contents.

Type 3 - Infantile Hydrocele

• The distal end of the processus vaginalis closes correctly, but the mid-portion and proximal end remain patent and communicate with the tunica vaginalis.
• Fluid fills the whole cord from the internal ring down to and including the tunica vaginalis around the testis.
• The processus is closed above the internal ring (does not communicate with the peritoneal cavity).

Type 4 - Hydrocele of the Cord (Encysted Hydrocele of the Cord)

• The mid-portion only of the processus vaginalis remains patent; both ends are closed (the proximal peritoneal end and the distal tunica vaginalis end are obliterated).
• Results in an isolated cystic swelling along the spermatic cord, separate from the testis.
• Clinically: a smooth, oval swelling above the testis that moves downward and becomes less mobile when the testis is pulled gently downward.
• Can be mistaken for an inguinal hernia.
• The equivalent in females is the hydrocele of the canal of Nuck (related to the round ligament, partially within the inguinal canal).

Aetiological Classification

Secondary Hydrocele - Common Causes

• Infection: Epididymo-orchitis, filariasis (Wuchereria bancrofti - accounts for up to 80% of hydroceles in tropical countries, and can produce chylocele if a lymphatic varix ruptures into the sac)
• Trauma/Torsion: Acute presentation
• Neoplasm: Testicular tumour - must be excluded in any young man with an acute hydrocele; do NOT aspirate if malignancy suspected
• Iatrogenic: Post-varicocelectomy (from lymphatic obstruction); post-inguinal hernia repair

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