List of Abbreviations
US – ultrasound examination
CBC – complete blood count
UA – urinalysis
PCR – polymerase chain reaction
UGT – urogenital tract
ESR – erythrocyte sedimentation rate
MRI – magnetic resonance imaging
ATC – Anatomical Therapeutic Chemical Classification System
LCE – level of confidence of evidence
LoR – level of conviction of recommendation
РКИ – randomized controlled trial
Terms and Definitions
Hydrocele is a painless swelling of the scrotum due to the accumulation of serous fluid between the proper tunics of the testis, causing it to increase in size.
Hematocele – accumulation of blood in the intermembranous space
Pyocele (infected hydrocele) is a condition developing secondary to inflammation of the testis or epididymis.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
N43.0, N43.1 – Hydrocele testis – painless swelling of the scrotum due to the accumulation of serous fluid between the proper tunics of the testis, causing it to increase in size. A common finding in newborns, also occurring in 1% of adult men.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Acquired hydrocele occurs in acute or chronic orchitis, testicular trauma, cardiovascular failure, or neoplasms of the scrotal organs. Genital surgeries can also lead to hydrocele. This is the so-called reactive "symptomatic" hydrocele, which resolves as the underlying disease is treated. It should be noted that the inner surface of the tunic is lined with mesothelium (simple squamous epithelium). Due to trauma, local inflammatory processes, metabolic-degenerative disorders, and other causes, fluid secretion by the mesothelium begins to predominate over reabsorption. This is precisely what leads to the accumulation of transudate between the layers of the tunica propria of the testis.
Hydrocele of the tunica vaginalis develops painlessly and without any functional disorders. Fluid accumulation proceeds slowly and imperceptibly, sometimes intermittently. The enlargement of the scrotum may be slight, but sometimes it reaches the size of a goose egg and, in rare cases, an infant's head.
Very large hydrocele of the testis causes difficulties with urination and sexual intercourse. Diaphanoscopy reveals translucency of the entire formation. The translucency sign is negative only when the tunica vaginalis is markedly thickened, there is hematocele or pyocele (blood or pus in the tunica vaginalis), or in case of a testicular tumor. Hematocele is hemorrhage into the cavity of the hydrocele, which can result from trauma, hemorrhagic diatheses, or an unsuccessful hydrocele puncture. "Purulent" or infected hydrocele most frequently occurs in infectious orchitis and epididymitis and/or with an abscess of the testis or epididymis.
Congenital form. Normally, the testicular primordium forms in the retroperitoneal region, after which the formed testis migrates into the scrotum under the influence of male hormones, guided by the gubernaculum testis and surrounded by the processus vaginalis peritonei. The lumen of this process should completely close by the time of birth. When obliteration (closure) processes are disrupted, a communicating hydrocele or inguinal hernia develops, depending on the diameter of the process.
In this case, fluid from the abdominal cavity freely enters the tunica vaginalis via the tract. Sometimes only partial closure of the processus vaginalis occurs. In this case, the processus vaginalis peritonei obliterates at various levels of the inguinal canal and testis. This leads to such conditions as isolated hydrocele (testicular cyst), isolated hydrocele of the spermatic cord (spermatocele/cyst of the spermatic cord), and combined isolated hydrocele of the spermatic cord and testis (cyst of the spermatic cord and testis).
The tunica vaginalis of the testis produces fluid that serves as a lubricant for the testis and facilitates its free movement within the scrotum. Normally, a balance is maintained between the production of this fluid and its reabsorption.
The so-called physiological hydrocele is associated with a dysfunction of this mechanism. It occurs in approximately 10% of newborns and disappears spontaneously in more than half of the cases by the end of the child's first year of life. The cause of its development lies in the immaturity of the lymphatic apparatus of the inguinal region in newborns and infants, which leads to delayed reabsorption (absorption) of the serous fluid accumulating between the tunica vaginalis layers. As the child grows, completion of processus vaginalis obliteration and an increase in the absorption properties of its membranes are possible, which leads to spontaneous resolution of the hydrocele in a significant number of children.
1.3 Epidemiology of the Disease or Condition
Hydrocele is observed in some mammals, including humans. Most often it is a unilateral process, but it can also be bilateral in 7–10% of cases. Hydrocele is recorded both in young men of reproductive age (from 1.5 to 3.9%) and in elderly and senile men. In the latter case, the most likely cause of hydrocele is cardiac decompensation, which increases fluid exudation and significantly decreases its absorption due to blood stasis in the microvasculature of the tunica vaginalis, causing fluid accumulation between the layers of the tunica vaginalis.
1.4 Features of Coding the Disease or Condition
N43.0 Hydrocele
Incl.: hydrocele of spermatic cord, testis or tunica vaginalis
Excl.: congenital hydrocele (P83.5)
N43.0 Encrypted hydrocele
N43.1 Infected hydrocele
Use additional code (B95-B98), if desired, to identify infectious agent.
N43.2 Other hydrocele
N43.3 Hydrocele, unspecified
1.5 Classification of the disease or condition
In adults, the disease is more commonly acquired.
Hydrocele should be classified by etiology or by the acuity of the disease.
By etiology: congenital and acquired.
Congenital form can be communicating or non-communicating.
Acquired form: primary (idiopathic) or secondary (symptomatic).
By the nature of the disease:
- acute or chronic form.
1.6 Clinical presentation of the disease or condition
Usually, clinical manifestations are typical. There is an enlargement of one half of the scrotum (on the affected side). A hydrocele has a smooth surface and a firm-elastic consistency, is painless upon palpation, and fluctuation is determined. The skin of the scrotum is easily pinched into a fold. The testis is usually not palpable, and only in a small/non-tense hydrocele can it be palpated at the lower edge of the enlarged part of the scrotum. In infected hydrocele, erythema and edema of the scrotum, as well as pain syndrome, are noted.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for diagnosis.
The diagnosis is established based on:
1) history data (trauma, inflammatory diseases of the scrotal organs, surgical interventions for varicocele)
2) physical examination (inspection, palpation)
3) laboratory tests (complete blood count, urinalysis, microscopic examination of urethral discharge and prostatic fluid, microscopic examination of urethral discharge, detection of DNA of sexually transmitted pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma genitalium) in urethral discharge by PCR)
4) instrumental examination (ultrasound of the scrotum, diaphanoscopy, MRI of the scrotum).
2.1 Complaints and Anamnesis
It is recommended to take the patient's complaints and medical history to determine the examination strategy:
- duration of symptom onset;
- changes in the volume of the formation during the day;
- presence of pain syndrome in the scrotum and inguinal region;
- past diseases and surgical interventions on the scrotal organs and inguinal canal [26].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.2 Physical Examination
It is recommended to perform an inspection and palpation of the male genitalia (Palpation in pathology of the male genitalia) with an assessment of their symmetry and the presence of fluid between the layers of the tunica vaginalis in order to determine the examination strategy when hydrocele is suspected [26].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.3 Laboratory Diagnostics
Laboratory diagnostic methods lack specific specificity and are general in nature. As a rule, no changes are registered in the complete blood count and urinalysis. Characteristic changes are possible when the hydrocele is of an infectious nature (leukocytosis, elevated ESR, left shift of the leukogram, and leukocyturia is often registered).
It is recommended to perform expanded laboratory tests in the presence of signs of an infectious process: complete blood count, urinalysis, microscopic examination of urethral discharge for the differential diagnosis with infectious diseases of the scrotal organs and to determine the treatment strategy [8, 9, 10].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: If changes in the complete blood count and urinalysis are detected, additional diagnostics are required in the form of: 1) Microscopic examination of urethral discharge and prostatic fluid, microscopic examination of urethral discharge to verify the possible bacterial landscape of the urogenital tract.
In case of clinical or anamnestic signs of coagulopathy, a coagulogram (screening test of the hemostatic system) must be performed before invasive interventions.
2.4 Instrumental Diagnostics
It is recommended to perform an ultrasound examination of the scrotum in all patients with suspected hydrocele (with dopplerography if possible) to establish the diagnosis and exclude concomitant pathology (tumor, varicocele, orchiepididymitis) [7, 27].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: High-resolution scrotal ultrasound is the main instrumental diagnostic method. This technique allows for high-precision detection of fluid accumulation between the testicular tunics and an unchanged testis, as well as assessment of fluid volume and its structure.
Another diagnostic method that has long been used in urological/surgical practice and has high validity is diaphanoscopy, a method based on transillumination of the contents of the enlarged half of the scrotum. In hydrocele, the fluid contents transilluminate evenly. After past inflammation of the testicular tunics or in the presence of a hematocele, transillumination may be uneven. Diaphanoscopy also allows for differential diagnosis with hernias (intestines, omental fat) when light transmission through the enlarged half of the scrotum is impaired.
It is recommended to perform magnetic resonance imaging of the scrotum (with contrast enhancement if necessary) in case of diagnostic difficulties, significant hydrocele volumes, or spread of the hydrocele into the retroperitoneal space (abdominoscrotal hydrocele) to clarify the diagnosis [17, 18, 28, 29, 31].
GCR CLoE 5 Grade of Recommendation C (Level of Evidence – 5)
Comments: In cases where scrotal ultrasound does not help to establish a diagnosis with sufficient reliability, it makes sense to perform a contrast-enhanced MRI of the scrotum. The MRI technique allows for a highly accurate diagnosis.
2.5 Other Procedures
It is recommended to perform ultrasonic dopplerography of the spermatic cord vessels in cases of tense hydrocele and pain syndrome to exclude testicular ischemia [32, 33, 34].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 «Conservative treatment»
It is recommended to perform antibacterial therapy for infected hydrocele, taking into account the probable pathogen spectrum and the results of laboratory tests [10, 35].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: Conservative treatment of hydrocele is used only in cases of an infected hydrocele. In such cases, antibacterial therapy is administered, selected according to the identified pathogen and its susceptibility (fluoroquinolones, cephalosporins (ATX – J01DE 4th-generation cephalosporins) [35].
3.2 Surgical treatment:
Surgical treatment of hydrocele is recommended in the case of:
✓ increase in hydrocele volume during the observation period;
✓ concomitant inguinal/inguinoscrotal hernia or other non-acute testicular pathology on the affected side;
✓ visible scrotal asymmetry;
✓ abdominoscrotal hydrocele form;
✓ complicated hydrocele form (tense, infected) [4, 5, 16, 19, 30].
GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)
Comments: In adults, the main treatment method for a clinically significant hydrocele is surgical correction (Winkelmann/Bergmann/Lord/Ross procedures) with an individualized choice of technique based on examination findings (fluid volume, membrane thickness, duration of the condition).
Winkelmann procedure. During this surgical intervention, one of the layers of the tunica vaginalis testis is incised along the anterior surface, everted, and sutured behind the testis. As a result, fluid accumulation no longer occurs.
Bergmann procedure. A part of the inner layer of the tunica vaginalis testis is excised, and the remaining part is sutured. In the postoperative period, systemic antibacterial drugs are prescribed, along with the wearing of a scrotal support (suspensory) for a certain period.
Lord procedure. This surgery involves incising the testicular tunics, releasing the hydrocele fluid, and so-called plication (reefing) of the tunica vaginalis around the testis. The testis itself is not freed from surrounding tissues and is not luxated into the wound. This helps reduce trauma to the adjacent tissues and the testicular nourishing vessels.
It is recommended to perform ultrasound-guided puncture/aspiration with sclerotherapy in patients with high anesthetic risk or those who refuse surgery, with notification of the higher risk of recurrence [15, 16, 31].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Puncture and aspiration of the intermembrane fluid are performed under ultrasound guidance and local anesthesia.
Nevertheless, there is no fundamental difference between the proposed operations (Winkelmann, Bergmann, or Lord). Thus, in most cases, the surgeon/urologist determines the type of testicular tunic plasty during the surgery itself. For example, it is irrational to perform the Winkelmann or Lord procedure for large-scale hydroceles with an excess of membranes. The Lord procedure is also unsuitable for longstanding hydroceles when the membranes become rigid, and their plication will lead to poor aesthetic results.
Diet therapy: Not applied.
Pain management: Carried out as part of the relevant surgical procedures.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
As a rule, rehabilitation measures consist of postoperative wound healing and patient observation at the inpatient stage for the duration of the hospital stay. The outpatient stage does not require specific rehabilitation methods other than a sparing regimen for 10 days after hospital discharge. Spa treatment (sanatorium-resort treatment) is not indicated in this case!
5. Prevention and Dispensary Observation
Specific prophylaxis and dispensary follow-up have not been developed
6. Organization of Medical Care
Indications for planned hospitalization: surgical intervention to eliminate the hydrocele.
Indications for emergency hospitalization: development of complications, pain syndrome.
Indications for patient discharge from the hospital: completion of the surgical intervention.
7. Additional Information
No additional information available.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1. | Anamnesis was collected in patients with suspected hydrocele | Yes/No |
2. | Examination and palpation of male genitalia (palpation in male genital pathology) were performed in patients with suspected hydrocele | Yes/No |
3. | Ultrasonography of the scrotum was performed in patients with suspected hydrocele | Yes/No |
4. | Treatment with antibacterial drugs taking into account the probable pathogen spectrum was performed for infected hydrocele | Yes/No |
5. | Surgical treatment of hydrocele was performed in the presence of indications (hydrocele with: ✓ increase in hydrocele volume during the observation period; ✓ concomitant inguinal/inguinoscrotal hernia or other non-acute testicular pathology on the affected side; ✓ visible scrotal asymmetry; ✓ abdominoscrotal hydrocele form; complicated hydrocele form (tense, infected) and absence of contraindications | Yes/No |
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Appendix A1. Working Group Composition
Alexander I. Neymark, MD, PhD, Professor, Head of the Department of Urology and Andrology with DPO Course, Altai State Medical University of the Russian Ministry of Health; Chief freelance urologist of Altai Krai and the Siberian Federal District; Chairman of the regional branch of the Russian Society of Urology (RSU)
Andrey V. Yakovlev, PhD, Assistant Professor at the Department of Urology and Andrology with DPO Course, Altai State Medical University of the Russian Ministry of Health; member of the RSU.
Revaz R. Kharchilava, PhD, Director of the Praxi Medica Training Center for Medical Practice, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow.
Conflict of interest: the authors declare no conflict of interest
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines:
Urologist
Surgeon
Medical students, residents, postgraduate students
In these clinical guidelines, all data are ranked by level of reliability (evidence) depending on the quantity and quality of studies on the issue.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for grading levels of recommendation certainty (LRC) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
No reference materials available
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
What is a hydrocele? It is an accumulation of serous fluid in the tunica vaginalis of the testis between the two layers of the tunica propria, caused by dysfunction of the tunica propria epithelium. The accumulation of serous fluid occurs between the layers of the tunica vaginalis, which forms from the peritoneum during testicular descent. It should be noted that the inner surface of the membrane is lined with mesothelium (simple squamous epithelium). Due to trauma, local inflammatory processes, metabolic and degenerative disorders, and other causes, fluid secretion by the mesothelium begins to outweigh reabsorption. This leads to the accumulation of transudate between the layers of the tunica propria of the testis, and the removal of the dysfunctional epithelium is a pathogenetically substantiated method of treating this pathology. Indications for surgery include the mere presence of a hydrocele due to its negative impact on blood circulation, testicular metabolism, and spermatogenesis. As it enlarges, the hydrocele "sac" causes pain and discomfort during walking, creates difficulties with urination, hinders sexual intercourse, chafes against clothing, and causes physical and psycho-emotional discomfort. Hydrocele remains one of the most common andrological conditions, and its management is highly relevant in the modern world due to its high prevalence and the lack of a consensus regarding the choice of treatment method.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Rating scales and other questionnaires are not used.