A tension hydrocele is a rare form of hydrocele that may result in impeded arterial inflow and venous outflow to and from the testis 1; testicular ischemia may result, leading to necrosis of the testicular parenchyma 2.
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Diagnosis
Tension hydrocele can be diagnosed through a combination of clinical and radiological findings. The first may help in recognizing the hydrocele, Doppler ultrasonography can confirm the tensional aspect of it.
Reversibility of the hemodynamic disturbance after the evacuation of the collection and the absence of torsion are suggestive 10.
Clinical presentation
Patients present with sharp, intense, and continuous pain that mimics testicular torsion 3. They may mention aching orchialgia that deteriorates progressively, felt to the inguinal ligament, tightness especially in the inguinal canal, and/or positional pain accompanied by nausea and discomfort, that may hinder sleep 1.
On physical examination, the affected hemiscrotum is extremely tender to palpation, and the cremasteric reflex may be absent on this side 4. Hydroceles characteristically transilluminate when evaluated by a light source 5.
Aside from intratesticular flow alterations, the degree of pain is also dependent on the duration of the hydrocele and how rapidly its volume has increased 3.
Pathology
A hydrocele is defined as a pathological fluid collection between the two laminae of the tunica vaginalis. Due to the increase in hydrocele volume, intratesticular pressure also increases, and when it becomes greater than the perfusion pressures of the vasculature of the testis, arterial and venous flows are both impaired. The pathogenic mechanism is similar to that of compartment syndrome or tension pneumothorax; vessels are compressed when the pressure arises in a confined compartment 1. In ischemic testes, reactive hyperemia may be observed as ischemic factors like nitric oxide and lactate are accumulated, leading to vasodilation 9.
Pain may be caused due to spermatic cord orchialgia 6. In the literature, a postoperative etiology has been mentioned, concerning a compressive hematocele following Lichtenstein hernioplasty, that eventually led to testicular ischemia 7.
Tension hydrocele may lead to testicular compartment syndrome, which accounts for a rare cause of acute scrotum in pediatric patients 4.
Radiographic features
Ultrasound
Ultrasound is the modality of choice for the evaluation of tension hydrocele, which presents as a collection of anechoic or echolucent fluid 11. In the majority of cases, Doppler US will reveal a decreased flow to the testis 1.
However, there is evidence that there are at least four distinct variations of flow patterns 3.
- no flow visible
- reversed diastolic flow
- absent diastolic flow; lack of diastolic flow has been reported even in an asymptomatic case 8
- increased RI
Treatment and prognosis
Surgery is considered the gold standard treatment of tension hydrocele, a.k.a. hydrocelectomy 11,12. Under anesthesia, the scrotum and dartos muscle are incised; the tunica vaginalis is found firm, under extreme pressure due to the hydrocele’s tension, and serous fluid will spurt vigorously following incision 1. However, hydrocelectomy may be accompanied by a number of complications, including 11:
- reactionary hemorrhage
- pyocele
- infection
- sinus formation
- recurrent hydrocele
Aspiration may be performed, either before surgery to relieve symptoms or as a monotherapy in patients unable to tolerate surgery 11. When this technique follows sclerosant injection, like tetracycline or doxycycline, chances of success rise despite the pain 13. The pain is decreased when fluid is aspirated from the hydrocele, which will eventually become mildly smaller with a flow amelioration in both arteries and veins 2,3. In this case, complications can also occur, like reaccumulation of fluid, hematocele, and infection 11.
A few months after any therapeutic intervention, Doppler ultrasonography of the testis is advised to ensure perfusion is normal and to exclude testicular atrophy 3. In the majority of cases, the preoperative high-resistance flow to the testis is substituted for low-resistance flow that resettles postoperatively 8.
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