A) Congenital hydroceles are a special form of indirect inguinal hernia and are treated by herniotomy (see congenital inguinal hernia).
B) Established acquired hydroceles often have thickened walls. A cut is made into the skin over the hydrocele. After draining the liquid, the testicle is examined. In case of a normal testis, the twin coverings of the testicle are stitched up to stop the re-collection of liquid. If the testicle is diseased, it may even be necessary to remove it. Finally, the skin is stitched up. Lord’s operation is suitable when the sac is reasonably thin-walled. There is minimal dissection and the risk of hematoma is reduced. Eversion of the sac with placement of the testis in a pouch prepared within the coverings of the scrotum is an alternative (Jaboulay’s procedure).
Drainage of the hydrocele fluid through a cannula is simple but the condition always recurs within a week or so. It may be suitable for very elderly infirm men who are unfit even for scrotal surgery under regional anasthesia. Also, injection of sclerosants such as tetracycline is sometimes effective but tends to be very painful and can cause infection.
Secondary hydrocele is most frequently associated with acute or chronic epididymo-ochitis (infection of testis). It is also seen with torsion of the testis and with some testicular tumors. A secondary hydrocele is usually lax and of moderate size: the underlying testis is palpable. If a tumor is suspected, the hydrocele should not be punctured for fear of implantation of malignant cells in the needle track. A secondary hydrocele subsides when the primary lesion resolves.