Ultrasound-based Evaluation of Postoperative Scrotal Swelling following Jaboulay’s Procedure: A Prospective Observational Study

Abstract

Background:

Postoperative scrotal swelling is a common occurrence following hydrocelectomy and may raise concern regarding complications, such as hematoma, infection, or recurrence. Differentiating physiological postoperative changes from pathological findings based on clinical examination alone can be challenging in the early postoperative period. Ultrasonography provides an objective and noninvasive method for postoperative evaluation; however, prospective data on serial ultrasound-based assessment following Jaboulay’s procedure remain limited.

Materials and Methods:

This prospective observational study included 75 adult patients with vaginal hydrocele who underwent Jaboulay’s procedure at a tertiary care teaching hospital over 18 months. All patients underwent standardized ultrasonographic evaluation on postoperative day 2 (POD 2), POD 10, and at 2 months after surgery. Parameters assessed included scrotal wall thickness and epididymal head, body, and tail dimensions. Continuous variables were expressed as mean ± standard deviation and analyzed using repeated measures analysis of variance, whereas categorical variables were compared using the McNemar test.

Results:

The mean age of patients was 52.4 ± 16.8 years. On POD 2, 48.0% of patients demonstrated moderate swelling, and 36.0% had mild swelling. By POD 10, a significant reduction in swelling was observed, with 60.0% of patients showing minimal swelling and 40.0% demonstrating complete resolution (P < 0.001). The mean scrotal wall thickness decreased significantly from 6.6 ± 1.9 mm on POD 2 to 4.6 ± 1.3 mm at 2 months (P < 0.001). Significant reductions were also observed in epididymal dimensions across follow-up intervals (P < 0.001). Postoperative hematoma occurred in 5.3% of patients and was managed conservatively.

Conclusion:

Postoperative scrotal swelling following Jaboulay’s procedure is predominantly physiological and resolves progressively over time. Serial ultrasonography plays an important role in differentiating normal postoperative changes from complications.

INTRODUCTION

Hydrocele is a common benign scrotal condition characterized by the accumulation of serous fluid between the layers of the tunica vaginalis. It predominantly affects adult males and typically presents as a painless scrotal swelling, although large or long-standing hydroceles may cause discomfort, cosmetic concerns, and interference with daily activities.[1] Surgical management remains the definitive treatment for symptomatic hydroceles, as conservative approaches, such as aspiration and sclerotherapy, are associated with high recurrence rates and complications.[2]

Several operative techniques have been described for the surgical management of vaginal hydrocele, including Lord’s plication, Jaboulay’s eversion procedure, and Bergmann’s excision. Among these, Jaboulay’s procedure is widely practiced for moderate-to-large hydroceles due to its technical simplicity, effective reduction in sac size, and acceptable recurrence rates.[3] Despite favorable surgical outcomes, postoperative scrotal swelling is frequently encountered and often causes concern for both patients and surgeons.

Postoperative scrotal swelling following hydrocelectomy may result from physiological causes such as tissue edema, inflammatory response, and residual serous collections. However, similar clinical presentations may also indicate complications, including hematoma, infection, or early recurrence.[4] Clinical examination alone may not reliably distinguish between expected postoperative changes and pathological conditions, particularly in the early postoperative period, leading to uncertainty in management and unnecessary interventions.

Ultrasonography is the imaging modality of choice for evaluating scrotal pathology and is routinely used in the preoperative assessment of hydrocele. High-resolution ultrasound allows detailed visualization of scrotal wall thickness, epididymal changes, spermatic cord status, and residual fluid collections, whereas Doppler imaging provides assessment of testicular perfusion.[5] In the postoperative setting, ultrasound can objectively differentiate normal postoperative edema from complications such as hematoma or infection, thereby aiding timely and appropriate management.[6]

Despite its proven diagnostic value, the role of routine or structured postoperative ultrasound follow-up after hydrocelectomy is not well defined. Most published studies focus on surgical techniques, recurrence rates, and immediate complications, with limited emphasis on serial ultrasound-based evaluation of postoperative changes and recovery timelines.[7] There is a paucity of prospective data documenting the natural course of postoperative scrotal swelling following Jaboulay’s procedure and the time required for return to normal scrotal size.

The present prospective observational study was therefore undertaken to evaluate postoperative scrotal changes following Jaboulay’s procedure using serial ultrasonographic assessment at predefined intervals. By correlating ultrasound findings with clinical outcomes, this study aimed to identify the causes of postoperative scrotal swelling, determine the expected duration of recovery, and detect the true postoperative complications. Such objective data may help optimize postoperative follow-up protocols, improve patient counseling, and reduce unnecessary interventions following hydrocele surgery.

MATERIALS AND METHODS

Study design and setting

This prospective observational follow-up study was conducted in the Department of General Surgery at a tertiary care teaching hospital in South India over 18 months. The study was designed to evaluate postoperative scrotal changes and complications following Jaboulay’s procedure for vaginal hydrocele using serial ultrasonographic assessment. The role of ultrasonography in postoperative evaluation of scrotal surgeries has been emphasized in previous radiological and urological studies.[5,6]

Study population

A total of 75 adult patients diagnosed with vaginal hydrocele and scheduled to undergo Jaboulay’s procedure were consecutively enrolled. All patients underwent a detailed clinical and radiological evaluation before surgery. Written informed consent was obtained from all participants before inclusion in the study.

Inclusion and exclusion criteria

Patients aged 20 years and above with a clinical and ultrasonographic diagnosis of vaginal hydrocele who were willing to undergo surgical management and comply with postoperative follow-up were included. Patients with systemic conditions known to cause generalized edema, such as chronic kidney disease, decompensated liver disease, nephrotic syndrome, or autoimmune disorders, were excluded, as these conditions could influence postoperative scrotal swelling and confound assessment. Patients with other inguinoscrotal pathologies, including inguinal hernia, testicular tumors, or varicocele, as well as those unwilling to participate or adhere to follow-up, were also excluded.

Ethical considerations

The study protocol was reviewed and approved by the institutional ethics committee (IEC no: VMMC/2023/APR/19) before commencement. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Patient confidentiality was strictly maintained, and all participants were informed of their right to withdraw from the study at any stage without affecting their standard of care.

Preoperative evaluation

All patients underwent routine preoperative evaluation, including complete blood count, renal function tests, and random blood sugar estimation. Baseline scrotal ultrasonography was performed in all cases to confirm the diagnosis of hydrocele, assess its extent, and evaluate testicular morphology and surrounding structures, in line with established recommendations for scrotal imaging.[5]

Surgical technique

All patients underwent Jaboulay’s eversion procedure under appropriate anesthesia. A scrotal incision was made, and the hydrocele sac was carefully dissected and opened to drain the fluid. Partial excision of the tunica vaginalis was performed where required, followed by eversion of the sac behind the testis and hemostatic suturing. A corrugated drain was placed at the discretion of the operating surgeon, and scrotal support was applied postoperatively. The operative steps followed standard surgical principles described for hydrocele management in the literature.[2,3]

Postoperative follow-up and ultrasonographic assessment

Postoperative evaluation consisted of serial clinical and ultrasonographic assessments performed on postoperative day (POD) 2, POD 10, and at 2 months after surgery. High-resolution scrotal ultrasonography was performed using a linear high-frequency transducer. Parameters assessed included scrotal wall thickness, epididymal head, body, and tail dimensions, spermatic cord status, presence of residual fluid collection or hematoma, and testicular size and echotexture. Color Doppler imaging was used when indicated to assess testicular perfusion, particularly in patients presenting with significant postoperative swelling or pain, as recommended in previous studies.[6]

Outcome measures

The primary outcome measure was the cause and duration of postoperative scrotal swelling following Jaboulay’s procedure, as determined by serial ultrasound findings and clinical correlation. Secondary outcome measures included postoperative complications such as hematoma, infection, or recurrence, which have been reported as common concerns following hydrocele surgery.[4]

Pain assessment

Postoperative pain was assessed using the Visual Analog Scale, with pain scores recorded on PODs 2, 5, and 7 to document the progression and resolution of postoperative discomfort.

Statistical analysis

All data were entered into a structured pro forma and analyzed using Statistical Package for the Social Sciences (SPSS) software version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD), whereas categorical variables were presented as frequencies and percentages.

Normality of distribution for continuous variables was assessed using the Shapiro–Wilk test. Serial ultrasonographic measurements obtained at POD 2, POD 10, and at 2 months were compared using repeated measures analysis of variance (RM-ANOVA) to assess changes over time within the same study population. Post hoc pairwise comparisons were performed using Bonferroni correction where applicable. Categorical variables assessed at different postoperative time points, such as the severity of scrotal swelling, were compared using the McNemar test to evaluate changes in proportions over time in paired observations. Postoperative complication rates were evaluated using a one-sample proportion test. P < 0.05 was considered statistically significant for all analyses.

RESULTS

Patient demographics and baseline characteristics

Seventy-five patients undergoing Jaboulay’s procedure for vaginal hydrocele were included in the study. The mean age was 52.4 ± 16.8 years. Right-sided hydrocele was more common than left-sided disease. Baseline clinical characteristics are summarized in Table 1.

Table 1.

Baseline demographic and clinical characteristics (n=75)

Variable	Value
Age (years), mean±SD	52.4±16.8
BMI (kg/m2), mean±SD	24.1±3.2
Side of the hydrocele
Right	49 (65.3)
Left	26 (34.7)
Pallor present	20 (26.7)
Lymphadenopathy	1 (1.3)

BMI=Body mass index, SD=Standard deviation

Ultrasound-detected postoperative scrotal swelling

Ultrasonographic evaluation performed on POD 2 demonstrated that the majority of patients exhibited varying degrees of scrotal swelling [Table 2], with 48.0% of patients showing moderate swelling and 36.0% demonstrating mild swelling. Only 16.0% of patients had no evidence of swelling at this early postoperative stage. In contrast, by POD 10, a marked reduction in swelling was observed across the study population, with 60.0% of patients exhibiting minimal swelling and 40.0% showing complete resolution. None of the patients had persistent mild or moderate swelling at POD 10. Statistical analysis using the McNemar test revealed a highly significant reduction in postoperative scrotal swelling between POD 2 and POD 10 (P < 0.001), indicating progressive resolution of postoperative edema during the early recovery period.

Table 2.

Ultrasound-detected postoperative scrotal swelling

Ultrasound finding	POD 2, n (%)	POD 10, n (%)	P
No swelling	12 (16.0)	30 (40.0)	<0.001*
Mild swelling	27 (36.0)	0
Moderate swelling	36 (48.0)	0
Minimal swelling	0	45 (60.0)

*indicates significant, POD=Postoperative day

Comparison of mean scrotal wall thickness over time

Serial ultrasonographic assessment demonstrated a progressive reduction in mean scrotal wall thickness across postoperative follow-up intervals. The mean scrotal wall thickness was 6.6 ± 1.9 mm on POD 2 [Table 3a], which showed a slight reduction to 6.3 ± 1.8 mm on POD 10. A more pronounced decrease was noted at the 2-month follow-up, with a mean value of 4.6 ± 1.3 mm, approaching baseline anatomical thickness. RM-ANOVA revealed a statistically significant reduction in scrotal wall thickness over time (P < 0.001), suggesting gradual resolution of postoperative inflammatory edema.

Table 3a.

Comparison of mean scrotal wall thickness over time

Time interval	Mean±SD (mm)	P
POD 2	6.6±1.9	<0.001*
POD 10	6.3±1.8
2 months	4.6±1.3

*indicates significant, SD=Standard deviation, POD=Postoperative day

Comparison of mean epididymal head size over time

The mean epididymal head dimension measured 13.8 ± 2.6 mm on POD 2 and showed a mild reduction to 13.4 ± 2.7 mm by POD 10. At the 2-month postoperative follow-up, a substantial decrease in epididymal head size was observed, with a mean measurement of 10.8 ± 2.1 mm. Analysis using RM-ANOVA demonstrated a statistically significant reduction in epididymal head dimensions across the three postoperative intervals (P < 0.001), indicating resolution of postoperative tissue changes and edema [Table 3b].

Table 3b.

Comparison of mean epididymal head size over time

Time interval	Mean±SD (mm)	P
POD 2	13.8±2.6	<0.001*
POD 10	13.4±2.7
2 months	10.8±2.1

*indicates significant, SD=Standard deviation, POD=Postoperative day

Comparison of mean epididymal body size over time

The epididymal body showed a similar trend of postoperative reduction in size [Table 3c]. On POD 2, the mean epididymal body dimension was 10.9 ± 3.2 mm, which decreased marginally to 10.6 ± 3.2 mm by POD 10. By the end of 2 months, a notable reduction was observed, with the mean value declining to 8.3 ± 2.5 mm. RM-ANOVA confirmed that this reduction was statistically significant over the postoperative follow-up period (P < 0.001), reflecting progressive normalization of epididymal morphology.

Table 3c.

Comparison of mean epididymal body size over time

Time interval	Mean±SD (mm)	P
POD 2	10.9±3.2	<0.001*
POD 10	10.6±3.2
2 months	8.3±2.5

*indicates significant, SD=Standard deviation, POD=Postoperative day

Comparison of mean epididymal tail size over time

The mean epididymal tail dimension was found to be 9.6 ± 3.6 mm on POD 2 and demonstrated a slight decrease to 9.3 ± 3.5 mm on POD 10 [Table 3d]. At the 2-month follow-up, the mean epididymal tail size further reduced to 7.4 ± 2.8 mm. Statistical analysis using RM-ANOVA showed a significant reduction in epididymal tail dimensions across the three-time intervals (P < 0.001), indicating resolution of postoperative inflammatory changes in the epididymal structures.

Table 3d.

Comparison of mean epididymal tail size over time

Time interval	Mean±SD (mm)	P
POD 2	9.6±3.6	<0.001*
POD 10	9.3±3.5
2 months	7.4±2.8

*indicates significant, SD=Standard deviation, POD=Postoperative day

Postoperative complications following Jaboulay’s procedure

Postoperative complications were minimal in the present study cohort [Table 4]. The majority of patients (94.7%) had an uneventful postoperative course without any complications. Scrotal hematoma was observed in 5.3% of patients, all of whom were managed conservatively without the need for surgical intervention. No cases of postoperative infection or hydrocele recurrence were identified during the follow-up period. One-sample proportion testing demonstrated that the observed complication rate was statistically low (P < 0.001), suggesting a favorable safety profile of Jaboulay’s procedure in the studied population.

Table 4.

Postoperative complications following Jaboulay’s procedure

Complication	n (%)	P
None	71 (94.7)	<0.001*
Hematoma	4 (5.3)
Infection	0
Recurrence	0

*indicates significant,

DISCUSSION

The present prospective observational study evaluated postoperative scrotal changes following Jaboulay’s procedure using serial ultrasonographic assessment. The findings demonstrate that postoperative scrotal swelling is common in the early postoperative period but is predominantly physiological and resolves progressively over time. Ultrasound evaluation showed that most of the patients exhibited mild-to-moderate swelling on POD 2, with a marked shift toward minimal or resolved swelling by POD 10, as illustrated in Figure 1. Complete or near-complete resolution was observed in the majority of patients within 4–6 weeks, with a mean time to return to normal scrotal size of approximately 33 days.

Figure 1.

Comparison of postoperative scrotal swelling resolution over time. POD = Postoperative day

Postoperative scrotal swelling following hydrocelectomy is a well-recognized clinical concern and is often a source of anxiety for patients and surgeons alike. In the current study, early postoperative swelling was largely attributable to scrotal wall edema, epididymal enlargement, and spermatic cord thickening rather than pathological collections. Serial ultrasonography demonstrated progressive reduction in scrotal wall thickness [Figure 2], supporting the interpretation that postoperative edema is a transient and self-limiting phenomenon. These findings align with previous reports indicating that postoperative swelling after hydrocele surgery is usually inflammatory rather than indicative of complications.[8,9]

Figure 2.

Longitudinal reduction in mean scrotal wall thickness. POD = Postoperative day

Ultrasonography proved to be a valuable tool in the objective assessment of postoperative changes. While clinical examination alone may be insufficient to differentiate between normal postoperative edema and complications such as hematoma or infection, ultrasound allows precise evaluation of scrotal wall thickness, residual fluid collections, and epididymal changes. Prior studies have emphasized the importance of high-resolution ultrasound and Doppler imaging in evaluating scrotal pathology and postoperative changes.[10,11] In the present study, Doppler assessment confirmed preserved testicular perfusion in all evaluated cases, providing reassurance regarding testicular viability even in patients with significant early swelling.

The low complication rate observed in this study is comparable to previously published data. Postoperative hematoma was observed in 5.3% of patients, all of whom were managed conservatively, with no cases of infection or recurrence during follow-up. This finding is consistent with the multicenter study by Mäki-Lohiluoma et al., which reported hematoma and scrotal edema as the most common complications following hydrocele surgery.[4] The absence of recurrence in the present study further supports the effectiveness of Jaboulay’s procedure when performed using standard surgical techniques.

The results of this study have important clinical implications. Understanding that postoperative scrotal swelling is usually physiological and follows a predictable course can help surgeons provide accurate preoperative counseling and postoperative reassurance. Incorporation of selective ultrasound follow-up, particularly in patients with exaggerated swelling or pain, can reduce unnecessary interventions and improve patient satisfaction. Routine ultrasound for all patients may not be required; however, targeted imaging in symptomatic individuals appears to be a practical and cost-effective approach.

The strengths of this study include its prospective design, standardized surgical technique, and serial ultrasound evaluation at predefined intervals. The use of objective radiological parameters adds robustness to the assessment of postoperative changes. However, the study has certain limitations. It was conducted at a single center with a relatively short follow-up period, which may limit the detection of late recurrences. In addition, the absence of a comparison group undergoing alternative surgical techniques restricts direct comparison of outcomes.

Future studies with larger sample sizes, longer follow-up durations, and comparative evaluation of different hydrocele repair techniques would provide further insight into postoperative recovery patterns. Incorporation of patient-reported outcome measures alongside ultrasound findings may also enhance the understanding of functional recovery following hydrocele surgery.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.