Original question.
Distinguish between Hydrocele and Scrotal Hernia.
A hydrocele contains fluid around the testis; a scrotal hernia contains abdominal contents that have descended through the inguinal canal. Their distinction rests on a combination of location, continuity with the inguinal canal, behaviour and light transmission.
The usual acquired hydrocele is a collection between the layers of the tunica vaginalis. A scrotal hernia is generally an indirect inguinal hernia: a sac of peritoneum, often containing intestine or omentum, follows the spermatic cord into the scrotum. Persistence of the processus vaginalis can permit either a communicating hydrocele or an indirect inguinal hernia, depending on the communication and its contents. Thus the underlying developmental route is related even though the usual clinical appearances differ.[ref]
Hydrocele by MedlinePlus. “Exams and Tests”: examination, light transmission, changes in swelling and imaging
- An uncomplicated hydrocele is typically smooth, fluctuant or tense, and confined to the scrotum. One can usually feel normal spermatic cord above it: one can “get above” the swelling. The testis may be difficult to feel separately and is usually behind the fluid collection. A scrotal hernia extends upwards toward the inguinal canal; its upper limit cannot usually be encircled within the scrotum.[ref]The Ship Captain's Medical Guide by the Maritime and Coastguard Agency. Chapter 7, p. 155, distinguishing continuity into the groin from a swelling confined to the scrotum
- A typical acquired hydrocele has neither an expansile cough impulse nor ready reduction into the abdomen. A reducible scrotal hernia enlarges on standing, coughing or straining, and diminishes on lying down or with gentle clinical reduction; intestine may give a gurgle. An irreducible hernia is an important exception, so failure of reduction does not establish hydrocele.
- For transillumination, a bright light is applied to one side of the swelling in a darkened setting while the examiner views the other side. Clear fluid in a thin-walled hydrocele usually transmits a diffuse glow. Most scrotal hernias do not. Blood, thick walls or an underlying tumour can prevent a hydrocele from transmitting light; apparent transmission alone cannot exclude a hernia, especially in a child.
- A longstanding uncomplicated hydrocele commonly produces heaviness rather than acute systemic illness. A painful, tender, irreducible scrotal hernia with vomiting or abdominal distension raises concern for intestinal obstruction or strangulated hernia, in which the blood supply of the trapped contents is compromised. That requires urgent surgical assessment.
If examination leaves doubt, ultrasonography can establish whether the swelling contains fluid, intestine or a solid tumour, assess the testis and show continuity with the inguinal canal. A collection may obscure a diseased testis; demonstrating fluid does not finish the diagnostic task. Blind puncture is not an appropriate diagnostic shortcut when a hernia remains possible. Even an established hydrocele usually reaccumulates after simple aspiration, which also risks infection.[ref]
Repair of a scrotal hydrocele by the British Association of Urological Surgeons. September 2024 leaflet, “Key points” and “What are the alternatives?”
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