Hydroceles are acquired or congenital serous fluid collection between the layers of the tunica vaginalis surrounding a testis or spermatic cord. They are the most common form of testicular enlargement, and present with painless enlargement of the scrotum. On all modalities, hydrocoeles appear as simple fluid, unless complicated by infection or haemorrhage.
Hydrocele can be diagnosed at any age, with congenital hydrocele being more common in children.
Most hydrocele are acquired and present with progressing painless scrotal mass. During physical examination, hydrocele characteristically transilluminates when evaluted with light source. However, hydroceles can be secondarily infected (see pyocele).
There are two main subtypes of congenital hydrocele:
- a communicating hydrocele
- a spermatic cord hydrocele 1-2.
In the communicating type fluid collects around a patent processus vaginalis, it having failure to successfully obliterate.
The spermatic cord hydrocele is further subdivided into:
- encysted type with no communication with the peritoneum or tunica vaginalis, also called spermatic cord cyst
- funicular type which communicates with the peritoneum at the internal ring and doesn't surround the testis
- this type is also called funiculocele
- they are more frequently encoutered in children and premature infant 2
Ultrasound is the first modality usually used to evaluate hydroceles. It presents as a simple fluid collection surrounding the testis. It is avascular on Doppler evaluation. It may contain septations, calcifications or cholesterol 2.
A funiculocele is a subtype of spermatic cord hydrocele, however, it doesn't surround the testis. They can also appear larger with straining (Valsalva Manouerve) 2. It may contain fibrous adhesions, giving a beaded appearance to the spermatic cord (pachyvaginalitis) 3.
The encysted subtype of spermatic cord hydrocele shows no communication with the peritoneum and it usually only involves the spermatic cord.
On MRI, signal characteristics of the hydroceles are
- T1: low signal
- T2: high signal
This represents the simple serous fluid component of the hydrocele.
Treatment and prognosis
In infants, most hydroceles (around 90%) resolve spontaneously and their are thought to result in incomplete obliteration of the processus vaginalis 4. It is important to assess for any associated herniations in these patients.
Imaging differential considerations include
Ultrasound - testicular and scrotal
- ultrasound (introduction)
testicular and scrotal ultrasound
unilateral testicular lesion
- testicular torsion
- testicular rupture
- germ cell tumours of the testis
- sex cord / stromal tumours of the testis
- bilateral testicular lesion
- paratesticular lesions
- tubular ectasia of the rete testis
- cystadenoma of the rete testis
- testicular sarcoidosis
- testicular tuberculosis
- spermatic cord
- fibrous pseudotumour of the scrotum
- scrotal leiomyosarcoma
- testicular adrenal rest tumours (TARTs)
- tunica vaginalis testis mesothelioma
- splenogonadal fusion
- unilateral testicular lesion
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- 2. Garriga V, Serrano A, Marin A et-al. US of the tunica vaginalis testis: anatomic relationships and pathologic conditions. Radiographics. 2009;29 (7): 2017-32. doi:10.1148/rg.297095040 - Pubmed citation
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- 4. Naji H, Ingolfsson I, Isacson D et-al. Decision making in the management of hydroceles in infants and children. Eur. J. Pediatr. 2012;171 (5): 807-10. doi:10.1007/s00431-011-1628-x - Pubmed citation
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