When should I consider referring a patient with a hydrocele for surgical intervention?

Consider referring a patient with a hydrocele for surgical intervention in the following situations:

• If an infant has a congenital hydrocele that is not decreasing in size or still present after 12 months of age.
• If there is a concomitant inguinal hernia or suspected underlying testicular pathology.
• If the hydrocele is localized to the spermatic cord or there is a palpable abdominal mass suggesting an abdomino-scrotal hydrocele.
• For adolescents or adults, if the hydrocele is large and symptomatic, referral to a urologist or paediatric surgeon should be arranged.
• If an underlying cause such as testicular torsion, cancer, epididymo-orchitis, trauma, or previous varicocele surgery is suspected, urgent referral or hospital admission is warranted.
• In adults aged 18–40 years or if the testis cannot be palpated, arrange an urgent scrotal ultrasound to exclude malignancy before referral.

For idiopathic hydroceles without underlying cause and minimal symptoms, reassurance and advice on scrotal support may be appropriate without immediate referral.

Alternative treatments like aspiration and sclerotherapy may be considered for patients unfit for or unwilling to undergo surgery, but these have lower success rates.

These recommendations are based on UK clinical guidelines and expert consensus from the British Association of Paediatric Surgeons, the European Association of Urology, the Royal College of Surgeons, and NICE.

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