Hydrocele vs. Varicocele: Types of Scrotal Swelling

Hydrocele and varicocele are two conditions affecting the external male genitalia. Hydrocele is the swelling of the scrotum caused by the accumulation of fluid around one or both testicles, while varicocele is the swelling of a group of veins servicing the testicles.

Hydrocele and varicocele differ not only by their causes and symptoms but also by the age groups they affect. Depending on the severity or persistence of symptoms, the conditions may or may not require treatment. Surgery may be recommended if there is pain or signs of infertility or other complications such as low testosterone or a groin hernia.

Location

One of the primary differences between hydrocele and varicocele is their location in the reproductive tract of a person with testicles, as follows:

• Hydroceles form when abdominal fluids seep through an opening called the processus vaginalis and accumulate in the sac surrounding the testicle called the tunica vaginalis. This causes swelling of the scrotum, usually on one side (unilateral) but sometimes on both (bilateral).
• Varicoceles form when blood accumulates in the collection of veins that service a testicle, the pampiniform venous plexus (PVP). This causes the enlargement of blood vessels similar to varicose veins, typically in the left scrotum. The condition is most often unilateral.

Causes

Hydrocele and varicocele differ in the structures they affect and in the causes of the abnormal fluid buildup, as follows:

• Hydroceles usually occur during fetal development when the testicles descend through a passage called the inguinal canal into the scrotum. Rather than creating a seal between the scrotum and abdomen as it is supposed to, a gap remains that allows fluid to seep in.
• Varicoceles are thought to be caused by faulty valves in the PVP, which cause blood to pool rather than return to the heart as it is supposed to. The left PVP is mainly affected because it bends at a 45-degree angle to connect the main renal vein, unlike the right PVP, which remains straight.

Who Is Affected?

Hydrocele and varicocele can affect anyone with testicles but are more common in certain age groups, such as:

• Hydroceles are mainly congenital, meaning something that you are born with. While infants and babies are most commonly affected, adolescents and adults can also develop a hydrocele if an infection or injury causes leakage through the processus vaginalis.
• Varicoceles can occur at any age, although many cases are congenital, only causing symptoms during the onset of puberty or no symptoms at all. Most varicoceles are diagnosed between the ages of 15 and 25. Cases in older adults are often due to blockage of the renal vein by a tumor.

How Common Are They?

Hydroceles and varicoceles are common urological conditions that are generally not serious. The frequency of these conditions varies by age group, such as:

• Hydroceles affect one out of 10 baby boys at birth and often clears without treatment within a year. Around 1% of adult males are also affected, secondary to conditions like severe epididymitis, testicular trauma, or testicular cancer. Only around 7% to 10% of cases are bilateral.
• Varicoceles affect roughly 15% of healthy males and up to 35% of those with primary infertility. Only around 1% of cases are bilateral, while less than 0.5% of cases are right-sided.

Appearance and Size

Hydrocele and varicocele have distinctive features but can sometimes be mistaken for other conditions. These two conditions can also occur alongside each other:

• Hydroceles cause generalized swelling of the scrotum, which can increase or decrease during the day. The size of a hydrocele can vary greatly, with the swelling being overt in some people and subtle in others. Hydrocele can cause one side of the scrotum and one testicle to hang lower.
• Varicoceles are more often felt than seen, although severe cases can cause scrotal swelling or a visible bulge near the top of the scrotum. The enlarged veins are often described as feeling like a twisted “bag of worms.”

Pain and Other Symptoms

Other than the swelling, hydrocele and varicocele can often be asymptomatic (without symptoms). Scrotal pain is generally a sign that the condition needs treatment.

• Hydrocele is typically painless but can sometimes cause a feeling of heaviness and discomfort. Symptoms are experienced more in the morning than evening as lying for prolonged periods can cause pooling. In severe cases, the intestine can bulge into the inguinal canal, causing an inguinal hernia.
• Varicocele is also usually painless but can sometimes cause a dull ache or pain. The intensity tends to increase during the day or when engaging in strenuous activities that overheat the testicles. In severe cases, varicoceles can lead to hypogonadism (low testosterone) due to testicular shrinkage (atrophy).

Risk of Infertility

With hydrocele and varicocele, the risk of infertility differs significantly, as follows:

• Hydroceles are not associated with an increased risk of infertility, particularly when first occurring in infants and babies. While the same is generally true for when they develop adulthood, the underlying cause of the swelling (such as a severe case of syphilis) can lead to infertility if both testicles are affected.
• Varicoceles do not cause infertility but are closely linked to it. While varicoceles affect 15% of males overall, roughly 1 in 3 males with infertility has varicoceles. It is thought that excess heat caused by blood pooling damages sperm and lowers sperm counts.

When to Treat Symptoms

Treatment is not always needed for hydrocele or varicocele but may be recommended in specific situations. While neither condition is inherently serious, complications can sometimes occur. The appropriate treatment dispensed at the appropriate time can help avoid these, such as:

• Hydroceles are usually left untreated in babies and allowed to resolve on their own. If the swelling persists for more than a year or an inguinal hernia develops, surgery may be needed. In adults, treatment may be pursued if the swelling is large and disruptive or persists after the underlying cause is treated.
• Varicoceles are usually not treated unless there is cause for concern, such as chronic pain, clinical hypogonadism, or a low sperm count (oligospermia). Treatment may also be pursued based on the varicocele’s grade, ranging from grade 0 for no symptoms to grade 4 for a visible scrotal deformity.

Diagnosis

Hydroceles and varicoceles can look a lot like each other as well as other urologic condtions like spermatoceles (caused by the formation of a cyst in the epididymis). Often, a specialist called a urologist is needed to make the correct diagnosis.

Many of the same tests and procedures are used for hydrocele or varicocele. These include a physical exam and imaging studies such as an ultrasound (which creates images with high-frequency sound waves) or computed tomography (which composites multiple X-ray images).

Specific procedures and tools are used to diagnose each condition, including:

• Hydroceles can often be diagnosed by shining a light through the scrotum, which causes the fluid-filled sac to glow brightly. You may also be asked to lie on your back as a hydrocele will often get smaller as the fluid drains from the testicle back into the abdomen.
• Varicoceles can usually be detected by checking visually and feeling for a “bag of worms” around the testicle. You may also be asked to do the Valsalva maneuver (in which you shut your nose and mouth while exhaling forcefully) to expose the varicocele better.

Other tests and procedures may be used to pinpoint the underlying cause, check for possible complications (like low testosterone or sperm count), or rule out other conditions with similar symptoms (such as testicular tumors or epididymal cysts).

Nonsurgical Treatments

Healthcare providers will often take a watch-and-wait approach with hydrocele or varicocele to see if the condition persists or worsens. If treatment is indicated, several minimally invasive procedures may be used, such as:

• Hydroceles can sometimes be treated with a procedure called aspiration with sclerotherapy. This involves extracting fluid with a needle and syringe, followed by injecting a chemical agent to scar the inner lining of the hydrocele sac. The sclerosing agent causes the sac to harden and shrink, preventing the reaccumulation of fluid in the space.
• Varicoceles can often be managed with lifestyle changes, like wearing an athletic supporter (jockstrap) and losing weight. If these measures don’t help, a procedure called varicocele embolization can redirect blood flow around the obstruction by sealing off blood vessels with heat or a sclerosing agent. The vessels are accessed by threading a catheter from a vein in your groin to the PVP.

Mild pain or discomfort may be managed with over-the-counter (nonprescription) pain relievers like Tylenol (acetaminophen) or Advil or Motrin (ibuprofen). Not everyone can take these medications, so speak with your healthcare provider beforehand.

Ice application may also help. But, if the pain is severe enough to require ice or stronger pain medications, it is probably time to seek a more permanent solution with surgery.

Surgical Treatment

Surgery is the treatment of choice for hydrocele or varicocele. It may be pursued if a hydrocele fails to clear on its own or a varicocele causes pain, infertility, or hypogonadism. These surgeries are typically performed on an outpatient basis under general anesthesia. Details are:

• Hydrocele repair (hydrocelectomy) involves an incision in the scrotum or groin to access, drain, and remove part of the hydrocele sac. After stitching the sac, the surgeon may also use stitches or mesh to close a hole in the abdominal wall (called a hernia repair).
• Varicocele repair (varicocelectomy) involves an incision in the groin or lower abdomen to access the varicocele. Select blood vessels are then cut and sealed off to redirect blood flow.

Both surgeries can be performed with either open surgery (involving a large incision) or laparoscopic surgery (involving two or three tiny, keyhole incisions). The choice depends in part on the age and size of the person.

Microsurgery (involving an operating microscope) or robotic surgery may also be used.

Postoperative Care

Recovery from hydrocelectomy or varicocelectomy can take anywhere from two to six weeks depending on the extent of the repair. Most people can return to work within two days to a week.

To speed recovery times:

• Rest for the first couple of days, keeping your feet up and getting enough rest.
• Wait 24 hours before showering. Bathing should be avoided for at least a week.
• Try to walk each day to avoid blood clots, gradually increasing the duration of the walks.
• Avoid heavy lifting or strenuous exercise for two weeks or as directed by your surgeon.

Risk Assessment

Although there are risks associated with any surgery, there are also risks associated with leaving a hydrocele or varicocele untreated. By understanding the risks, you can make informed decisions.

Untreated Hydroceles or Varicoceles

The main risk of leaving a hydrocele untreated is an inguinal hernia. The bulging of the intestine into the inguinal canal can not only cause pain, weakness, and a visible bulge in the groin but may also cause hernial strangulation. This is a potentially life-threatening situation in which blood flow to the intestine is cut off, causing tissue necrosis (death) and an increased risk of sepsis.

The main risk of untreated varicocele is infertility and sexual dysfunction. If a semen analysis indicates poor sperm quality, motility (movement), or count, treatment can potentially reverse this. There is some evidence that varicocele repair can increase pregnancy rates, both in couples who conceive naturally and those who require fertility treatment.

Some studies also suggest that varicocele may increase the risk of erectile dysfunction (ED), low libido (sex drive), and premature ejaculation due to the effects of hypogonadism. This is why varicocele repair is commonly pursued if testosterone levels are especially low.

After Aspiration or Surgery

The surgeries used for hydrocele and varicocele have become increasingly safe and effective. Even so, there are risks associated with the procedures, including serious ones like:

• Postoperative infection and wound dehiscence (the wound starts to reopen)
• Scrotal hematoma (the pooling of clotted blood in the scrotum)
• Scrotal seroma (the accumulation of fluid in the scrotum)
• Damage to the vas deferens (the tube transports sperm to the urethra during ejaculation)
• Testicular artery damage, leading to testicular atrophy and even the loss of a testicle
• Chronic scrotal pain
• Recurrence of a hydrocele or varicocele

Moreover, between 3% and 33% of people who undergo varicocelectomy will develop a hydrocele. Microsurgery is one of the ways to reduce the risk of these and other postoperative complications.

While aspiration with sclerotherapy has fewer risks overall, the procedure can also lead to scrotal pain, hematoma, and seroma in 6% to 31% of cases.

Summary

Hydrocele and varicocele are two conditions affecting the reproductive tract of people with testicles. Hydrocele, most often seen in infants, is the buildup of fluid in the sac surrounding the testicle. Varicocele, more often diagnosed in teens and young adults, is caused by the blockage of veins called the pampiniform venous plexus (PVP).

A hydrocele often requires no treatment and tends to resolve on its own. Treatment may also not be needed for a varicocele if it does not cause pain, infertility, or low testosterone.

If treatment is needed, surgery is usually the treatment of choice. Other nonsurgical procedures are available, including varicocele embolization and hydrocele aspiration with sclerotherapy.