Ruptured hydrocele: a case report highlighting the diagnostic value of early MRI in acute scrotal pathology

Abstract

Hydroceles are a common cause of scrotal swelling due to the accumulation of fluid between the visceral and parietal layers of the tunica vaginalis. Although typically painless, significant scrotal swelling can negatively impact testicular function and an individual’s quality of life. In rare instances, a hydrocele can rupture, often causing significant pain and complicating the diagnosis of other scrotal conditions. We present a 27-year-old man with a 9.8 × 4.1 cm hydrocele that ruptured, highlighting the lack of established diagnostic and management measures for this infrequent condition.

KEY POINTS

• Hydroceles are abnormal fluid collections between the visceral and parietal layers of the tunica vaginalis.

• Management of hydroceles can range from observation and aspiration with sclerotherapy to hydrocelectomy.

CME

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CASE SUMMARY

A 27-year-old man presented to the emergency department immediately after waking with significant left testicle pain and swelling. He reported a medical history of a treated hydrocele as a child; however, specific interventions remain unknown. On arrival, the patient was afebrile, tachycardic, and mildly hypertensive. His left hemiscrotum was enlarged, swollen, and tender to palpation. An ultrasound revealed a large, complex left hydrocele with significant edema and thickening of the left scrotal wall, measuring 2.6 cm. On computed tomography (CT) of the abdomen and pelvis, there was significant soft tissue swelling and fluid, causing distention of the left hemiscrotum, which extended superiorly within the spermatic cord; however, no defect of the hydrocele sac was appreciated. These findings were consistent with ultrasound and were thought to be due to an infectious process. However, the patient’s urinalysis and labs were within normal limits, and sexually transmitted infection screening results were negative. At this time, urology assessed the patient and believed the presentation and imaging were consistent with a possible hydrocele rupture; however, magnetic resonance imaging (MRI) was ordered to rule out testicular rupture. On MRI, both testicles were intact, but the contour of the left testicle was flattened, secondary to the mass effect of a large ipsilateral hydrocele measuring 9.8 × 4.1 cm with a defect of the tunica vaginalis (Figure 1). The patient was diagnosed with a ruptured hydrocele, thought to be secondary to a crush injury in his sleep, and discharged with instructions to wear supportive underwear and utilize over-the-counter pain medications.

Figure 1.

MRI T1-weighted axial image of the scrotum showing rupture in the left hydrocele sac.

Two days later, the patient was seen in the clinic for follow-up by an advanced practice provider, and his condition had improved. On physical exam, the left posterior testis was swollen. Given that his pain was well controlled, conservative management was recommended at that time, with a follow-up scheduled to discuss hydrocelectomy. Upon follow-up 6 months later, the patient reported no pain, decreased swelling to prerupture size, and no impact on daily function (e.g., urinary symptoms, walking). For management, he initially opted for surveillance, but eventually elected to proceed with hydrocelectomy as definitive management. Since hydrocelectomy, the patient has not had recurrence of his symptoms.

CLINICAL QUESTIONS

1. A 12-year-old boy is brought to the clinic by his parents for intermittent left-sided scrotal swelling. He reports that the swelling appears larger in the evening and smaller in the morning. On physical exam, the left hemiscrotum is enlarged, soft, and nontender. A scrotal ultrasound confirms the diagnosis of communicating hydrocele, showing fluid surrounding the testicle and extending toward the left inguinal canal. Which of the following best explains the pathophysiology of a communicating hydrocele?

   1. Excessive production of fluid by the tunica vaginalis

   2. Defective absorption of fluid by the lymphatics of the scrotum

   3. Persistent patency of the processus vaginalis, which allows peritoneal fluid to enter the scrotum

   4. Infection of the epididymis causing reactive fluid accumulation

2. Which of the following physical exam findings is characteristic of a hydrocele?

   1. “Bag of worms” sensation on palpation

   2. Tender swelling with erythema

   3. Nontransilluminating, hard mass

   4. Fluctuant, transilluminating scrotal swelling

Answers are provided at the end of the article.

DISCUSSION

A hydrocele is a pathological accumulation of fluid between the visceral and parietal layers of the tunica vaginalis. In infants, hydroceles are considered congenital and result from a patent processus vaginalis. By contrast, hydroceles in older children and adults are acquired (e.g., idiopathic, inflammatory, torsion, tumor), leading to a discrepancy between the serous fluid produced and reabsorbed. Hydroceles are typically painless; however, significant swelling can negatively impact testicular function as well as an individual’s quality of life. Specifically, hydroceles have been associated with impaired spermatogenesis, anatomical changes via mass effect, and increased temperature of the testes, leading to infertility. In addition to these functional and physical changes, hydroceles can negatively impact patients’ psychological well-being by impairing mobility and promoting sexual dysfunction due to embarrassment or pseudo-shortening of the penis.¹

Hydroceles are often diagnosed using a combination of clinical diagnosis and color Doppler ultrasound; however, if an ultrasound is inconclusive, MRI is recommended as the next step to increase diagnostic accuracy.¹ Management of hydroceles varies widely and is often dependent on the hydrocele’s etiology and its impact on a patient’s quality of life. Congenital hydroceles in infants are typically treated conservatively with active surveillance, whereas acquired hydroceles can be treated with active surveillance, aspiration and sclerotherapy, or hydrocelectomy.¹

Rupturing of a hydrocele is quite rare. Specifically, <15 cases have been reported in the literature (Table 1). The causes vary between trauma^2–8 and idiopathic causes.^9–12 All documented cases involved patients with known histories of hydrocele, and rupture was diagnosed by a combination of history, physical exam, and ultrasound in most cases.^{4–8,10–12} Two prior cases had presentations similar to our patient’s; specifically, both patients awoke with scrotal pain, were later found to have ruptured hydroceles confirmed by scrotal ultrasound, and failed conservative management, prompting hydrocelectomy.^4,11 However, none of the documented cases reported diagnostic uncertainty that necessitated further imaging (e.g., CT, MRI), as in our case.

Table 1.

Ruptured hydroceles and their respective management as reported in the literature

Reference, year	Cause	Treatment	History/presentation
Senger, 19462	Trauma; fell on blunt object	Early surgery	31-year-old with history of left hydrocele
Flores Belaunde, 19543	Trauma; self-inflicted injury	Conservative measures, including antibiotics and aspiration	23-year-old with 8-year history of left hydrocele
Quint et al, 19924	Trauma; during sleep	Conservative measures → hydrocele reaccumulated → hydrocelectomy	69-year-old with 15-year history of right hydrocele (15 cm), prolonged steroid use to manage a chronic condition (asthma)
Wiwanitkit et al, 20115	Trauma; work injury with blunt object	Active surveillance	24-year-old with 4-year history of right hydrocele
Flores et al, 20156	Trauma; sexual intercourse	Conservative measures, including active surveillance → hydrocele reaccumulated within 1 month → hydrocelectomy	28-year-old with 20-year history of right hydrocele (14.1 × 8.9 cm)
Bolat et al, 20207	Trauma; sexual intercourse	Conservative measures, including antibiotics → hydrocele reaccumulated at 18 months → hydrocelectomy	34-year-old with 1-year history of right hydrocele (10 × 9 cm)
Tang et al, 20228	Trauma, fell	Early surgery	39-year-old with 1-year history of left hydrocele (9.3 cm)
Wolf et al, 19559	Idiopathic	Early surgery	62-year-old with 3-year history of right hydrocele, multiple aspirations to attempt to reduce it
Cuervo Pinna et al, 199810	Idiopathic	Early surgery	55-year-old with gradual, nonpainful enlargement of the right testis over several years
Farina et al, 200211	Idiopathic	Conservative measures → hydrocele reaccumulated within a few days → hydrocelectomy	26-year-old with 5-year history of left hydrocele
Masoumi et al, 202212	Idiopathic	Conservative measures, including antibiotics and active surveillance → mild fluid reaccumulation	64-year-old with history of low-risk prostate cancer under active surveillance and a 3-year history of left hydrocele

The diagnosis of ruptured hydroceles typically involves a combination of history, physical exam, and ultrasound with Doppler. However, if ultrasound reports are inconclusive or there is a discrepancy between the clinical diagnosis and the ultrasound findings, other imaging techniques, such as MRI, are recommended, particularly in cases involving scrotal trauma.¹ Given that the majority of documented cases of hydrocele rupture have occurred after trauma,^2–8 it follows that MRI could provide more diagnostic certainty in an evaluation where scrotal swelling may prevent adequate physical exam and visualization of structures via ultrasound.

Historically, hydrocele ruptures were primarily treated with early surgery;^2,8–10 more recently, however, conservative management has been employed to allow the swelling to subside and to determine whether fluid will reaccumulate. Although conservative management is trending as the mainstay for the acute approach to ruptured hydrocele, some have argued for the utility of immediate surgery to rule out emergent causes of acute scrotum and to provide definitive treatment.⁸ This argument presumes that a ruptured hydrocele will eventually recur, necessitating a hydrocelectomy, as has been the case in most documented instances in which active surveillance was initially applied.^4,6,7,11

In this case, our patient suffered a traumatic crush injury to his scrotum during sleep. Initial imaging (i.e., ultrasound, CT) showed findings suggestive of a hydrocele and an inflammatory process secondary to infection. However, this was inconsistent with the urinalysis and infectious panel. To confirm the patient’s condition was not due to a more urgent cause of acute scrotum, an MRI was conducted in the emergency department prior to discharge. Upon follow-up, the patient’s symptoms had improved, and he opted for initial conservative management, followed by hydrocelectomy several months later.

ANSWERS TO CLINICAL QUESTIONS

Question 1, c. A communicating hydrocele results from the failure of the processus vaginalis to close, creating a connection between the peritoneal cavity and tunica vaginalis, allowing fluid to move freely.

Question 2, d. Hydroceles are smooth, fluctuant, and transilluminate due to clear serous fluid within the tunica vaginalis.

Disclosure statement/Funding

Dr. El Tayeb is an advisor for Storz and a past speaker for Cook. All relevant financial relationships have been mitigated. The planners and other faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. The patient consented to publication of this case report.