Did you know that hydroceles are one of the most common causes of painless scrotal swelling, affecting men at any age? A hydrocele is a fluid-filled sac surrounding the testicle that causes swelling in the scrotum. This condition occurs when clear fluid accumulates between the layers of tissue that envelop the testicle. The result is a smooth, typically painless enlargement.
The scrotum contains two layers of tissue called the tunica vaginalis (a protective membrane that surrounds each testicle). These layers normally produce a small amount of fluid to lubricate the testicles. When the balance between fluid production and absorption is disrupted, excess fluid collects and forms a hydrocele. This swelling can range from barely noticeable to the size of a grapefruit. It may affect one or both testicles.
Types of Hydrocele
Communicating Hydrocele
A communicating hydrocele maintains an open connection between the scrotum and the abdominal cavity through a patent processus vaginalis, which is a small passage that usually closes before or shortly after birth. This opening allows fluid to flow between these two spaces. The hydrocele size fluctuates throughout the day. The swelling typically increases when standing or during physical activity. It decreases when lying down. Communicating hydroceles occur in infants and young children, though cases sometimes persist into adulthood.
The processus vaginalis closes typically before birth or within the first year of life. When it remains open, peritoneal fluid (the fluid that surrounds organs in the abdomen) can travel into the scrotum. This same pathway can allow abdominal contents to enter, potentially leading to an inguinal hernia (a condition in which tissue pushes through a weak spot in the abdominal muscles). Parents often notice their child’s scrotum changing in size. It appears larger in the evening and smaller in the morning.
Non-Communicating Hydrocele
Non-communicating hydroceles develop when fluid accumulates within a closed tunica vaginalis (the sac surrounding the testicle) with no connection to the abdominal cavity. The fluid becomes trapped around the testicle. This creates a consistent swelling that doesn’t change with position or activity. This type is common in adult hydroceles and can result from inflammation, injury, infection, or tumour.
Adult-onset non-communicating hydroceles often develop gradually without an identifiable cause. The tunica vaginalis produces more fluid than it absorbs, leading to progressive accumulation. Some men notice the swelling after minor trauma to the scrotum. However, the injury may draw attention to an existing hydrocele rather than causing it. Inflammatory conditions like epididymitis (inflammation of the coiled tube at the back of the testicle) or orchitis (inflammation of the testicle itself) can trigger excess fluid production. This creates a reactive hydrocele that may resolve once the underlying inflammation subsides.
Causes and Risk Factors
Hydroceles in newborns result from incomplete closure of the processus vaginalis (a membrane-like passage that connects the abdomen to the scrotum) during development before birth. The testicles form in the abdomen. They descend through the inguinal canal (a passage in the groin) into the scrotum before birth, accompanied by an extension of the peritoneum (the lining of the abdominal cavity). This extension should seal off, separating the scrotum from the abdominal cavity. When closure fails, fluid can accumulate around the testicle.
Adult hydroceles develop through different mechanisms. Trauma to the scrotum, even minor injuries, can disrupt the normal fluid balance within the tunica vaginalis (the membrane surrounding the testicle). Infections of the testicle (orchitis) or epididymis (epididymitis or inflammation of the coiled tube at the back of the testicle) trigger inflammatory responses that increase fluid production. Sexually transmitted infections, such as gonorrhoea and chlamydia, can cause epididymitis leading to reactive hydroceles.
Testicular tumours occasionally present with hydrocele formation. This makes ultrasound evaluation useful for adult-onset cases. Radiation therapy to the pelvic region can disrupt the lymphatic drainage of the scrotum (the system that removes excess fluid), leading to fluid accumulation. Surgical procedures in the groin or scrotal area, including hernia repairs and varicocelectomies (procedures to remove enlarged veins in the scrotum), may disrupt normal anatomy and lead to hydrocele formation.
Filariasis, a mosquito-transmitted parasitic infection, causes hydroceles in tropical regions where the disease is endemic. The parasitic worms block lymphatic vessels. This prevents proper drainage of fluids from the scrotum. Men who have undergone kidney transplantation may experience hydrocele development, possibly related to immunosuppressive medications (drugs that reduce immune system activity) or altered fluid dynamics.
Recognising the Symptoms
The primary sign of a hydrocele is gradual scrotal swelling over weeks to months. The enlarged scrotum feels smooth and tense, similar to a water balloon. It does not have the irregular texture associated with other scrotal masses. Most men experience no pain, though large hydroceles can cause discomfort from the swelling’s weight and bulk.
The affected side of the scrotum appears larger and may hang lower than the unaffected side. The skin overlying the hydrocele remains normal in colour and temperature. This distinguishes it from inflammatory conditions (such as infections or injuries) that cause redness and warmth. Some men report a sensation of heaviness or dragging in the groin, particularly after prolonged standing or physical activity.
💡 Did You Know?
Transillumination testing involves shining a light through the scrotum in a dark room. Hydroceles allow light to pass through the clear fluid, creating a reddish glow, while solid masses like tumours block the light transmission.
Large hydroceles can interfere with daily activities and clothing fit. Sexual intercourse may become uncomfortable or embarrassing due to scrotal enlargement. Walking or sitting for extended periods can cause aching sensations. The testicle on the affected side is usually not felt separately from the hydrocele fluid. This doesn’t necessarily indicate any damage to the testicle itself.
Diagnosis and Evaluation
Physical examination provides the initial assessment for suspected hydrocele (fluid accumulation around the testicle). The urologist evaluates the scrotum’s size, consistency, and tenderness while the patient is standing and lying down. Communicating hydroceles typically reduce in size when the patient is supine, whereas non-communicating types remain unchanged. The examiner checks for inguinal hernias (groin bulges) that can coexist with hydroceles.
Scrotal ultrasound is a diagnostic tool that shows fluid around the testicle. Ultrasound distinguishes hydroceles from other scrotal masses, evaluates the testicle’s appearance, and measures blood flow to rule out testicular torsion (a condition where the testicle twists, cutting off its blood supply). The imaging can identify underlying causes such as tumours, inflammation, or trauma-related changes. Doppler ultrasound helps differentiate acute from chronic scrotal conditions.
Your provider may order blood tests when infection is suspected, including:
- Complete blood count (which measures different components of your blood to detect infection or inflammation)
- Inflammatory markers (proteins that indicate inflammation in the body)
Urinalysis can detect urinary tract infections that might spread to the epididymis (the tube at the back of the testicle that stores and carries sperm). Tumour markers like alpha-fetoprotein, beta-human chorionic gonadotropin, and lactate dehydrogenase (proteins measured in blood that can be elevated in certain cancers) may help rule out testicular cancer in appropriate clinical contexts.
Treatment Options
Conservative Management
Small, asymptomatic hydroceles often require no treatment beyond periodic monitoring. Many infant hydroceles resolve spontaneously by age two as the processus vaginalis closes naturally. Adults with minimal symptoms may choose to be observed. Follow-up examinations every six to twelve months monitor size changes and rule out underlying conditions.
Scrotal support with well-fitting underwear or athletic supporters can help alleviate discomfort from larger hydroceles. Ice application for several minutes, multiple times daily, may temporarily reduce swelling, though it doesn’t address the underlying fluid accumulation. Modifying activities to avoid heavy lifting or strenuous exercise can help prevent symptom exacerbation.
Aspiration and Sclerotherapy
Needle aspiration removes hydrocele fluid through the scrotal skin under local anaesthesia. This office procedure provides immediate relief but has a high recurrence rate. Fluid typically reaccumulates within weeks to months. Repeated aspirations increase infection risk and can cause scrotal haematomas.
Sclerotherapy involves injecting a sclerosing agent after fluid aspiration. This promotes adhesion between the layers of the tunica vaginalis, helping prevent fluid reaccumulation. Common sclerosing agents include:
- Tetracycline
- Polidocanol
- Ethanol
This technique can be effective but may require multiple sessions. Complications include pain, infection, and chemical inflammation that can affect fertility if the agent contacts the testicle.
Surgical Repair (Hydrocelectomy)
Surgery can address symptomatic hydroceles. Healthcare providers perform the procedure under general or regional anaesthesia. The surgeon makes an incision in the scrotum or lower abdomen to access the hydrocele sac. The surgeon drains the fluid and either removes excess tunica vaginalis tissue or reverses it to help prevent fluid reaccumulation.
The scrotal approach allows the surgeon to see the hydrocele and testicle directly. After opening the tunica vaginalis and draining the fluid, the surgeon employs various techniques to help prevent recurrence. The Jaboulay procedure involves turning the sac inside out behind the testicle. The Lord procedure creates multiple stitches to collapse the sac without extensive cutting.
Healthcare providers may use the inguinal approach for:
- Communicating hydroceles
- Large hydroceles extending into the inguinal canal
- Cases when hernia repair is needed simultaneously
This approach provides access to the processus vaginalis for complete closure and allows exploration of the inguinal canal.
Recovery and Post-Operative Care
Post-surgical recovery typically involves rest with a gradual return to normal activities over several weeks. Patients wear scrotal support continuously for the first week to minimise swelling and provide comfort. Ice packs applied periodically during the first couple of days can help reduce post-operative swelling.
Pain management usually requires only over-the-counter pain relievers like paracetamol or ibuprofen. The surgical site should remain dry initially. After this period, gentle washing with soap and water is permitted. Antibiotic ointment may be applied to the incision as directed. Dissolvable sutures eliminate the need for removal. Follow-up appointments monitor healing progress.
⚠️ Important Note
Contact your urologist immediately if you experience fever, excessive bleeding, increasing pain, or signs of infection such as redness, warmth, or pus draining from the surgical site.
Men typically return to desk work within a few days. Heavy lifting and strenuous exercise should be avoided for several weeks as advised by your healthcare professional. Sexual activity can typically resume after a few weeks, once comfort allows. Scrotal swelling and bruising are commonly seen and may persist for several weeks before complete resolution. The scrotum may temporarily appear larger than before surgery due to post-operative swelling.
Potential Complications
Untreated large hydroceles can lead to complications beyond cosmetic concerns. Chronic pressure on the testicle may compromise blood flow. This can potentially affect hormone production and fertility. The weight of large hydroceles can stretch scrotal skin, causing permanent enlargement even after treatment. Sudden pain in a hydrocele may indicate infection, bleeding into the sac, or testicular torsion (a condition where the testicle twists, cutting off its blood supply). This requires urgent evaluation.
Surgical complications, though uncommon, include:
- Haematoma formation (a collection of blood under the skin)
- Wound infection
- Injury to scrotal structures
Haematomas typically resolve spontaneously but may require drainage if large or painful. Infection rates remain low with proper surgical technique and post-operative care. Damage to the vas deferens (the tube that carries sperm from the testicle) or testicular blood vessels is rare but can affect fertility.
Recurrence after hydrocelectomy (surgical removal of the hydrocele) occurs in some cases. Reactive hydroceles may develop after surgery due to inflammation, but usually resolve within several months. Some patients experience chronic pain and may require additional treatment, including nerve blocks (injections that temporarily interrupt pain signals) or a pain management consultation.
Practical Management Strategies
Daily Comfort Measures
Wear supportive underwear that lifts the scrotum without excessive compression. Boxer briefs or athletic supporters work well for managing hydrocele-related discomfort. Choose clothing with adequate room in the crotch area to avoid pressure on the enlarged scrotum.
Position adjustments throughout the day can help minimise symptoms. When sitting for extended periods, use a small cushion or a rolled towel to slightly elevate the scrotum. Sleep on your back or on your side, with a pillow between your knees to reduce pressure on the affected area.
Activity Modifications
Adjust exercise routines to low-impact activities, such as swimming or stationary cycling, to avoid aggravating scrotal swelling. Avoid activities involving jumping, running, or direct trauma risk to the groin area. Weight training can continue with modifications, focusing on seated or lying exercises that don’t increase intra-abdominal pressure (the pressure inside your abdomen).
Plan regular breaks during prolonged standing or walking to elevate the scrotum and reduce dependent swelling (fluid collecting in the lowest part of the scrotum). When travelling long distances, schedule stops to walk and adjust position. Consider scheduling physically demanding activities for the morning, when swelling may be less pronounced.
Monitoring Guidelines
Perform monthly self-examinations to monitor hydrocele size and detect any changes in testicular texture. Note any new symptoms, including pain, rapid size changes, or skin changes over the hydrocele. Document observations to share with your healthcare professional during follow-up appointments.
✅ Quick Tip
Take periodic photographs of the scrotum from consistent angles to objectively track size changes over time, providing useful information for your healthcare professional to assess progression or improvement.
When to Seek Professional Help
- Rapid increase in scrotal size over days to weeks
- New onset of pain or tenderness in the scrotum
- Fever accompanying scrotal swelling
- Inability to feel the testicle separate from the swelling
- Skin changes, including redness, warmth, or breakdown
- Difficulty with urination or bowel movements
- Nausea or vomiting with scrotal pain
- Hydrocele (fluid-filled swelling around the testicle) interfering with daily activities or quality of life
- Any scrotal swelling in adult men not previously evaluated
Commonly Asked Questions
Can hydroceles affect fertility?
Small hydroceles typically don’t impact fertility. Significant, longstanding hydroceles may increase scrotal temperature or compress the testicle. This can affect sperm production (the process by which the testicles produce sperm). Surgical repair can usually restore normal anatomy without permanent effects on fertility. Complications like vas deferens injury (damage to the tube that carries sperm from the testicle) are possible but rare.
Is a hydrocele cancer?
Hydroceles are benign fluid collections and not cancerous. However, testicular tumours occasionally present with reactive hydroceles (fluid build-up in response to another condition). This underscores the importance of ultrasound evaluation in adult-onset cases. Ultrasound clearly distinguishes between simple fluid accumulation and solid testicular masses that require further investigation.
Can hydroceles come back after surgery?
Recurrence after hydrocelectomy (surgical removal of the hydrocele sac) is uncommon. Risk factors for recurrence include incomplete sac excision (when the surgeon doesn’t remove all of the fluid-filled sac), postoperative haematoma (blood collection after surgery), and underlying conditions that continue to produce fluid. Revision surgery can treat most recurrent hydroceles.
How long do hydroceles last without treatment?
Infant hydroceles often resolve by age two without intervention. Adult hydroceles rarely resolve spontaneously and may enlarge progressively over months to years. Some reactive hydroceles, caused by infection or inflammation (swelling in response to injury or illness), resolve once the underlying condition is treated. This process may take several months.
Can exercise cause or worsen hydroceles?
Exercise doesn’t cause hydroceles but may temporarily worsen symptoms in existing cases. Increased intra-abdominal pressure (pressure inside the abdomen) during heavy lifting or straining can enlarge communicating hydroceles (hydroceles connected to the abdominal cavity through a small opening). High-impact activities may cause discomfort from the weight of larger hydroceles bouncing against the thigh.
Conclusion
Treatment options for hydroceles depend on the size and symptoms present. Small hydroceles may require only monitoring, whereas larger or symptomatic cases benefit from surgical intervention. Hydrocelectomy provides definitive treatment with low complication rates and excellent outcomes for most patients.
If you’re experiencing scrotal swelling, discomfort during activities, or concerns about hydrocele symptoms, consult a urologist for proper evaluation and treatment recommendations.
