Get That Hydrocele Treated—Even If That Means Wait and See

When men come to urologist Michael Eisenberg, M.D., with a hydrocele, he gives a quick anatomy lesson.

"Just like around our brain, there is fluid around the testicle to protect it," Eisenberg, the director of male reproductive medicine and surgery at Stanford University, tells his patients. "There's a layer around that testicle that secretes fluid and absorbs fluid to keep everything lubricated and allow the testicle to move around within the scrotum."

A hydrocele is a disturbance to this steady state, leading to more secretion, less absorption and, therefore, an accumulation of fluid. A sac filled with fluid forms in the scrotum, which can cause swelling and make one of the testicles look bigger than the other.

Most men seek treatment for a hydrocele when it reaches a bothersome size, according to Martin Kathrins, M.D., assistant professor of surgery at Harvard Medical School and a urologist at Brigham and Women's Hospital in Boston.

"It can be uncomfortable in certain positions," Kathrins said. "It's not like acute pain. It's sort of in the way and bothersome, and it's got to be large enough. I probably tell more men that they don't need intervention than they do."

'For reasonably sized hydroceles, if it bothers them, I think it's reasonable to intervene and do something about it.'

An ultrasound may indicate a man has a hydrocele, but if it's not significantly impacting his life, Kathrins will likely tell him to do nothing, treatment-wise.

Usually, a hydrocele is something that's developed over years, Eisenberg said, and there may or may not be a clear etiology, or cause.

"Sometimes, prior surgical treatments can disturb fluid reabsorption pathways," he said. "Sometimes, there can be a history of an infection in the area that led to inflammatory fluid accumulation which never resolved. A lot of times, I think these just occur without any clear etiology."

Hydroceles are not a serious or dangerous condition.

"When there's a lot more mass down there, they may have to be more cognizant when they're putting on clothes, sitting down, lying in bed, riding a bike—it just gets in the way more than it used to. That's the most common complaint that I hear," Eisenberg said.

Treatment options

While there are no oral medications for a hydrocele, minimally invasive approaches and surgical interventions are available.

Kathrins said he increasingly offers minimally invasive approaches, such as needle aspiration, which involves draining the fluid. The patient comes to the clinic and receives numbing medication, such as lidocaine. Kathrins uses a cleaning solution, such as Betadine, a hypodermic needle and an angiocatheter.

"I don't need ultrasound," he said. "We just puncture it right into the hydrocele sac and we aspirate the fluid, which is usually clear."

Aspirations have a fairly high recurrence rate, though, according to Kathrins. He applies medication that will sclerose the hydrocele sac, a process known as sclerotherapy.

"I use an antibiotic called doxycycline and I instill that into the scrotum after the aspiration at the same time," he said. "It causes some inflammation, so men can have pain for usually one to two days. But that's fairly effective. Greater than 50 percent of men will see a durable response."

What is hydrocelectomy?

The open-surgery procedure to remove the hydrocele is called hydrocelectomy and is typically performed with the patient under anesthesia. The surgeon makes a small incision in the scrotum and drains the fluid in the hydrocele using suction.

The patient has considerable swelling for a number of weeks, Kathrins said.

"I tell most men they're going to come back and see me two weeks later and it's going to look the same," he said. "Over the course of a few months, the body reabsorbs some of the swelling from the surgery, and the majority of men have resolution."

There is a risk of a bleeding complication and men are usually sore for a few weeks. For this reason, Kathrins usually offers the minimally invasive approach first, because even after the open surgery, about 20 percent of men can have a recurrence.

"It's just because the scrotum is such a distensible area, it's unfortunately really good at accumulating things," he said. "There's not a lot of tension in that area."

Determining the right approach

While hydroceles are typically not a serious health issue, you should let your primary care provider know if you experience any pain or swelling in the scrotum. They may refer you to a urologist who specializes in treating hydroceles and other testicular conditions. A urologist can help develop the best treatment plan for your unique situation.

When choosing the approach for the hydrocele, Eisenberg said it's ultimately up to the individual.

"If it's very, very small, I'll try to counsel them about what's normal and whether [treatment is] worth it," Eisenberg said. "For reasonably sized hydroceles, if it bothers them, I think it's reasonable to intervene and do something about it. The man can decide. If it's not worth the surgery to fix, then it might not be worth doing anything."