My Clinical Approach
A hydrocele is one of the most common causes of scrotal swelling I see in the clinic — and, at the same time, one of the most underestimated conditions. Many patients live with the weight and discomfort for years before seeking assessment.
The first step is never the decision to operate — it is confirming the diagnosis. Before discussing treatment, I want to be certain the swelling really is a hydrocele, and that the testicle itself has been adequately assessed.
Hydrocele ≠ automatic surgical indication. The decision is individualised based on symptoms, size, progression, and impact on daily life.
What Is a Hydrocele
A hydrocele is a collection of clear fluid between the two layers of the tunica vaginalis — the thin membrane surrounding the testicle. The result is a usually painless or mildly uncomfortable swelling of the scrotum, which can vary considerably in size.
A classic clinical sign is transillumination — light from a torch passes through the hydrocele fluid. However, this does not replace ultrasound when the diagnosis is not entirely clear or when the testicle cannot be adequately palpated.
“Is It Really a Hydrocele?”
Scrotal swelling does not always mean a hydrocele. Before any treatment decision, other possible causes must be ruled out:
Inguinal / inguinoscrotal hernia
Bowel or omentum protruding through the inguinal canal.
Spermatocele / epididymal cyst
A cystic lesion arising from the epididymis.
Varicocele
Dilation of the spermatic cord veins.
Hematocele
A collection of blood around the testicle.
Pyocele
A collection of purulent fluid — an infectious cause.
Epididymo-orchitis
Inflammation of the epididymis/testicle.
Testicular tumour
Must always be ruled out in unclear findings.
Scrotal swelling of other cause
E.g. systemic oedema, local skin inflammation.
Hydrocele and Testicular Tumours
A hydrocele is generally a benign condition. The issue is that the fluid around the testicle can make clinical palpation of the testicle itself more difficult — potentially delaying detection of an underlying lesion.
Important clarification:
A hydrocele is not testicular cancer. However, a hydrocele must never be allowed to mask an intratesticular lesion. This is why, for any new or clinically unclear hydrocele in an adult, appropriate testicular examination and ultrasound are performed as indicated.
Primary vs. Secondary Hydrocele
Primary / Idiopathic (adults)
No clear underlying cause is identified. This is the most common form in adults.
Secondary
Related to inflammation (epididymo-orchitis), trauma, prior surgery (e.g. after varicocelectomy), tumour, or other scrotal pathology — the underlying cause should be addressed when present.
Adult vs. Paediatric Hydrocele
Adult hydrocele is managed according to the principles of scrotal/urological surgery described on this page, depending on the cause.
A paediatric/communicating hydrocele often follows a different diagnostic and surgical approach, related to a patent processus vaginalis. The adult hydrocelectomy approach does not automatically apply to children — paediatric hydroceles are assessed and managed separately by an appropriately specialised physician.
The Role of Ultrasound
Scrotal ultrasound (± Doppler) can:
- Confirm the presence of fluid around the testicle.
- Assess the testicular parenchyma for intratesticular lesions.
- Evaluate the epididymis.
- Detect other scrotal pathology (varicocele, spermatocele, hernia).
- Assess blood flow when inflammation or torsion is suspected.
Transillumination is a useful clinical sign, but it is not sufficient on its own when the diagnosis is unclear or the testicle cannot be adequately assessed clinically.
Hydrocele vs. Varicocele
Hydrocele
A collection of fluid around the testicle, between the layers of the tunica vaginalis.
Varicocele
Dilation of the pampiniform plexus veins, due to reflux of venous blood flow.
They differ in anatomy, symptoms, effect on fertility, and treatment. For varicocele and its microsurgical repair, see our dedicated page on Microsurgical Varicocelectomy.
Hydrocele vs. Spermatocele / Inguinal Hernia
Spermatocele / epididymal cyst
A cystic lesion arising from the epididymis, usually palpable separately from the testicle. Not used interchangeably with the term hydrocele.
Inguinal / inguinoscrotal hernia
Contains a portion of bowel or omentum protruding through the inguinal canal — can resemble or coexist with a hydrocele. Clinical examination and imaging help distinguish before any surgery.
Hydrocele After Varicocelectomy
Hydrocele is a recognised possible complication after varicocele surgery, partly related to disruption of lymphatic drainage around the testicle. The microsurgical, lymphatic-sparing technique is designed specifically to reduce this risk.
Developing a hydrocele after varicocele surgery does not automatically mean the surgery failed or was negligently performed — it is a recognised possible risk of any varicocelectomy technique.
Does Every Hydrocele Need Surgery?
No. Observation can be an appropriate option for selected small, stable, asymptomatic, and clearly benign adult hydroceles.
There is no single hydrocele size that means every patient must undergo surgery. Treatment is individualised.
Reasons that may prompt a discussion about surgery include:
Significant scrotal swelling
A noticeable size increase that bothers the patient.
Heaviness / discomfort
Impact on daily activity.
Difficulty examining the testicle
The fluid prevents adequate clinical examination.
Progressive enlargement
Steadily growing over time.
Impact on quality of life
Cosmetic, functional, or psychological burden.
Patient preference
After full discussion of the alternatives.
Pain and Hydrocele
A hydrocele typically causes a sensation of heaviness, pressure, or dragging, rather than severe pain.
Sudden, severe scrotal pain is not typical of a simple hydrocele and requires immediate evaluation for other conditions, including testicular torsion, regardless of a known history of hydrocele.
Hydrocele and Fertility
A typical, uncomplicated hydrocele is not equivalent to a varicocele and should not automatically be regarded as a cause of male infertility. A very large or tense hydrocele, or a coexisting underlying testicular condition, may have different implications that are assessed separately.
Hydrocelectomy is not performed as a fertility-enhancing procedure. If male infertility is present, it is investigated separately — it is not automatically attributed to the hydrocele.
What Is Surgical Repair (Hydrocelectomy)
Hydrocelectomy is the surgical treatment of a hydrocele, in which the fluid is drained and the hydrocele sac is managed — by eversion/reconstruction, plication, or partial excision, depending on the anatomy and the chosen technique — aiming to reduce the risk of fluid re-accumulation. There is no single technique suitable for every case.
Surgical Techniques
Eversion/reconstruction technique (Jaboulay / Winkelmann)
The hydrocele sac is opened and managed by eversion or reconstruction behind or around the testicle. Often useful for larger or thicker hydroceles.
Plication technique (Lord)
The tunica vaginalis is plicated (folded) around the testicle instead of being extensively excised or everted. May require less dissection in selected, usually smaller, hydroceles.
No single technique is universally superior. The choice depends on the size of the hydrocele, the thickness of the sac, the anatomy, any prior surgery, and the surgeon’s experience.
Aspiration & Sclerotherapy
Aspiration (needle drainage of the fluid) may have a role in selected patients — for example, those unfit for surgery, or for temporary symptomatic relief. Because the hydrocele sac remains untouched, fluid recurrence after simple aspiration is common — it is not a definitive solution.
Sclerotherapy after aspiration may reduce the likelihood of recurrence compared with aspiration alone, in selected patients. However, compared with surgical repair, it can be associated with pain/inflammation and the need for repeat treatment.
| Surgical Repair | Aspiration ± Sclerotherapy | |
|---|---|---|
| Nature | Definitive surgical treatment | Non-surgical, needle-based |
| Anaesthesia | Required | Usually local / none |
| Recurrence | Generally lower | Generally higher — the sac remains |
| Recovery | Surgical recovery | Shorter initial recovery |
| Suitability | Not for everyone | Not for everyone |
| Role | Standard definitive option in suitable patients | Selected cases |
How the Procedure Is Performed
The testicle is not removed in a routine hydrocelectomy — the goal is to manage the sac while preserving the testicle. Orchiectomy is not part of a standard hydrocele operation. If an unexpected testicular finding is discovered intraoperatively, a different clinical pathway is followed.
Drain & Urinary Catheter
Is a drain required?
Not necessarily. Used selectively based on hydrocele size, extent of dissection, and any bleeding tendency — not routine.
Is a urinary catheter required?
In a straightforward, isolated hydrocelectomy, usually not. Depends on the type of anaesthesia, risk of urinary retention, or a concurrent procedure.
Is Scrotal Swelling Normal After Surgery?
Yes, some degree of swelling, bruising, and localised tissue firmness is expected after surgery.
The scrotum does not necessarily return to its final size immediately — resolution of the swelling is gradual and the timeframe varies from patient to patient.
Prompt evaluation is needed if the swelling increases rapidly, is accompanied by severe pain, or coincides with fever or significant bleeding.
Possible Complications
Scrotal swelling / bruising
Expected, transient reaction to surgery.
Hematoma
Minor bruising is expected; a large or expanding hematoma needs reassessment.
Wound infection
Redness, pus, or fever require evaluation — routine prolonged antibiotics are not needed.
Hydrocele recurrence
Possible after any technique — see the recurrence section below.
Injury to the epididymis / vas deferens
A recognised but uncommon surgical risk.
Compromise of testicular blood supply
A rare, recognised complication.
Persistent chronic pain
Rarely, pain can persist after healing.
Wound healing problems
Delayed healing, wound breakdown, or local numbness.
Can the Hydrocele Come Back?
Yes. Recurrence is possible after any treatment — surgical, aspiration, or sclerotherapy. The risk depends on the technique, the anatomy, any underlying cause, and the healing course.
Surgical repair is generally associated with a lower recurrence risk than simple aspiration, but no technique offers a “permanent” or 0% guarantee against recurrence.
Recovery
Hospital stay
A straightforward hydrocelectomy can often be done as a day-case procedure — the exact duration depends on anaesthesia, coexisting conditions, size/bilateral hydrocele, and the post-operative course.
Scrotal support
May be recommended during recovery to reduce dragging and discomfort.
Return to work
Depends on the type of work, pain, swelling, and the healing course — not a fixed number of days for everyone.
Exercise / heavy lifting
Gradual resumption according to the surgeon’s guidance.
Sexual activity
Resumes once the wound has healed and discomfort allows, following the surgeon’s guidance.
When to Contact Us Urgently
Contact us immediately if you notice:
- Sudden, severe scrotal or testicular pain
- Rapidly enlarging swelling
- A firm, tense hematoma
- Fever or chills
- Purulent discharge from the incision
- Persistent significant bleeding
- Dark or ischaemic-looking skin changes
- Vomiting or general deterioration
Sudden, severe scrotal pain should always be urgently evaluated to rule out testicular torsion, regardless of any known history of hydrocele.
The Patient Journey
Scrotal swelling
Starting point: clinical examination.
Is it really a hydrocele?
Ruling out varicocele, hernia, spermatocele, hematocele/pyocele, inflammation, testicular pathology.
Ultrasound ± Doppler when indicated
Confirming the diagnosis and assessing the testicle itself.
Confirmed simple, benign hydrocele
Distinguishing primary/secondary cause.
Is it causing significant clinical problems?
No → monitoring. Yes → treatment discussion.
Surgical repair or aspiration ± sclerotherapy
Choice individualised to the case.
Monitoring swelling/hematoma/infection/recurrence
Recovery and follow-up.
Frequently Asked Questions (FAQ)
What is a hydrocele?
A hydrocele is a collection of clear fluid between the layers of the tunica vaginalis, the membrane surrounding the testicle. It causes a usually painless or mildly uncomfortable swelling of the scrotum.
Why does a hydrocele develop?
It can be primary/idiopathic, with no clear identifiable cause, or secondary to inflammation (epididymitis/orchitis), trauma, prior surgery (for example after varicocelectomy), or, less commonly, a testicular tumour.
Is a hydrocele dangerous?
A simple, primary adult hydrocele is not dangerous by itself. However, it can make the testicle itself harder to examine — which is why a new or unclear hydrocele should be assessed with ultrasound.
Can a hydrocele be cancer?
A hydrocele itself is not cancer. But the fluid around the testicle can hide an underlying mass that would otherwise be palpable — which is why evaluating the testicle itself with ultrasound is necessary in any new or unclear case, not because a hydrocele “causes” cancer.
Is ultrasound always necessary?
For a new, sudden, or clinically unclear hydrocele in an adult, yes — to confirm the diagnosis, assess the testicle itself, and rule out other scrotal conditions.
Does every hydrocele need surgery?
No. Small, stable, asymptomatic, and clearly benign hydroceles can simply be monitored. There is no single size that automatically mandates surgery for every patient.
When is surgery recommended?
When the hydrocele causes significant swelling, heaviness or discomfort, interferes with daily activities, prevents adequate examination of the testicle, keeps enlarging progressively, or meaningfully affects quality of life — always after an informed discussion with the patient.
Does size alone determine the decision?
Size is one factor, not the sole criterion. Management is individualised based on symptoms, progression, and impact on daily life, not on a single numeric measurement.
Is a hydrocele painful?
It typically causes a sensation of heaviness, pressure, or dragging rather than severe pain. Sudden, severe scrotal pain is not typical of a simple hydrocele and needs urgent evaluation for other conditions, including testicular torsion.
What is the difference between a hydrocele and a varicocele?
A hydrocele is a fluid collection around the testicle. A varicocele is dilation of the veins of the pampiniform plexus. They differ in anatomy, symptoms, effect on fertility, and treatment — they are not the same condition.
What is the difference between a hydrocele and an inguinal hernia?
An inguinal (or inguinoscrotal) hernia contains a portion of bowel or omentum protruding through the inguinal canal, while a hydrocele contains only fluid. Clinical examination, transillumination, and imaging help distinguish between them — they can also coexist.
What is the difference between a hydrocele and a spermatocele?
A hydrocele surrounds the testicle. A spermatocele is a cystic lesion arising from the epididymis, usually palpable separately from the testicle. The terms are not interchangeable.
What is hydrocelectomy?
It is the surgical procedure in which the fluid is drained and the hydrocele sac is appropriately managed (by eversion, plication, or partial excision, depending on the anatomy), to reduce the risk of fluid re-accumulation.
How is the procedure performed?
Through a small incision in the scrotum (or, less commonly, the groin), the fluid is drained, the testicle is examined as indicated, the sac is managed according to the chosen technique, haemostasis is secured, and the incision is closed.
What is the Lord technique?
It is a plication (folding/pleating) technique of the tunica vaginalis around the testicle, without extensive excision or eversion of the sac. It may require less dissection in selected, usually smaller, hydroceles.
What is the Jaboulay/Winkelmann technique?
The hydrocele sac is opened and managed by eversion/reconstruction behind or around the testicle. It is often useful for larger or thicker hydroceles.
Which technique is better?
No single technique is ideal for every patient. The choice depends on the size of the hydrocele, the thickness of the sac, the anatomy, any prior surgery, and the surgeon’s experience.
Is a drain required after surgery?
Not necessarily. Drain use is decided selectively based on the size of the hydrocele, the extent of dissection, and any bleeding tendency — it is not routine for every patient.
Is a urinary catheter required?
In a straightforward, isolated hydrocelectomy, a permanent urinary catheter is not usually required. The need depends on the type of anaesthesia, the risk of urinary retention, or any concurrent procedure.
Is scrotal swelling normal after surgery?
Yes, some degree of swelling, bruising, and localised firmness is expected. The scrotum does not necessarily return to its final size immediately.
How long does the swelling last?
It varies from patient to patient. There is no fixed timeline that applies to everyone — resolution is gradual. Rapidly worsening swelling, severe pain, or fever require prompt reassessment.
Can a hematoma develop?
Yes, this is a recognised possible complication. Minor bruising is expected; a large or expanding hematoma needs reassessment by the surgeon.
Can the hydrocele come back after surgery?
Yes, recurrence is possible after any treatment, surgical or otherwise. The risk depends on the technique, the anatomy, any underlying cause, and the healing course — no technique carries a zero risk of recurrence.
Can aspiration be done instead of surgery?
Aspiration (needle drainage of the fluid) may have a role for selected patients — for example, those unfit for surgery, or for temporary symptom relief. Because the hydrocele sac remains untouched, fluid recurrence after simple aspiration is common — it is not a definitive solution the way surgical repair is.
What is sclerotherapy?
After aspiration, a sclerosing agent may be instilled into the sac in selected patients, aiming to reduce the likelihood of recurrence compared with simple aspiration. It does not replace surgical repair and can be associated with pain/inflammation and the need for repeat treatment.
Does a hydrocele affect fertility?
A typical, uncomplicated hydrocele is not equivalent to a varicocele and should not automatically be regarded as a cause of male infertility. Hydrocelectomy is not performed as a fertility-enhancing procedure.
When should I contact the doctor urgently?
In case of sudden severe scrotal pain, rapidly enlarging swelling, a firm/tense hematoma, fever, purulent discharge from the incision, persistent significant bleeding, or general deterioration.
Related Topics
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The correct management of a hydrocele begins with confirming that the swelling is truly due to fluid around the testicle and not another scrotal condition. When a hydrocele causes significant symptoms or progressive enlargement, surgical repair offers a more definitive treatment than simple aspiration, with the appropriate technique chosen according to anatomy and sac size.
References
- Campbell-Walsh-Wein Urology, chapter on scrotal conditions and hydrocele — surgical principles and techniques (Jaboulay/Winkelmann, Lord).
- EAU Guidelines on Paediatric Urology — communicating hydrocele / patent processus vaginalis (paediatric reference).
- EAU Guidelines on Testicular Cancer — assessment of intratesticular lesions, role of ultrasound.
- Evidence note: formal guideline-level documentation specific to adult hydrocele is more limited than for oncological or stone-related conditions; much of clinical practice is based on surgical consensus and observational data rather than strong randomised trials.
Medical Review
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas provides individualised assessment and surgical treatment of hydrocele, with emphasis on accurate differential diagnosis before any treatment decision.
View Full ProfileThis article is for informational purposes only and does not replace medical advice, diagnosis, or treatment. Not every hydrocele requires surgery; adult hydrocele differs from paediatric hydrocele; a hydrocele must never prevent adequate assessment of the testicle; sudden severe scrotal pain requires urgent evaluation; surgery does not guarantee zero recurrence; post-operative swelling may temporarily persist; and it does not promise improved fertility. Always consult your urologist for individualised management of your case.
