Introduction
Hydroceles are pathological collections of fluid in the tunica vaginalis. They may be communicating or non-communicating. In adults, hydroceles are the most common cause of benign scrotal swellings, with an estimated incidence of 1% in the adult population [1]. Adult hydroceles are most often idiopathic, but they may also develop as a result of infection, tumors, trauma, or iatrogenic lymphatic obstruction following varicocelectomy [2].
Hydroceles can usually be managed conservatively. However, surgery may be required in approximately 20% of men diagnosed with hydroceles [3]. Treatment options include open surgical procedures, such as the Jaboulay or Lord techniques, or minimally invasive approaches such as aspiration and sclerotherapy [4,5]. Expected complications after these surgeries include hematoma, infection, chronic pain, recurrence or persistent swelling, trauma to cord structures, or testicular atrophy, with estimated overall complication rates of 20% for open procedures and 5% for minimally invasive techniques [3,6]. Given these risks, some andrologists discourage surgery for hydroceles in young adults who have not yet completed their families.
Conversely, some studies have demonstrated detrimental effects of hydroceles on spermatogenesis, which may result from pressure effects or alterations in testicular temperature [7,8]. Other studies have reported reduced testicular volume in both children and adults with hydroceles [9].
Thus, whether hydroceles should be surgically treated in young men seeking fertility remains a matter of debate among andrologists. To our knowledge, no clinical studies have systematically examined the advantages and disadvantages of hydrocelectomy in infertile men. The present study aimed to evaluate the benefits and risks of hydrocele surgery in this population. The outcome measures were changes in testicular size, semen analysis, and natural pregnancy rate postoperatively.
Methods
This pilot study was conducted between January 2021 and April 2024. Eligibility criteria included male patients with a one-year history of infertility associated with symptomatic hydroceles >100 mL and abnormal semen parameters. Exclusion criteria were patients with azoospermia; severe oligospermia with sperm count <5 million/mL; other causes of male subfertility such as clinical varicoceles, hypogonadism, or low-normal testosterone (total testosterone <12 nmol/L); small-sized testes (testicular volume <10 mL); previous treatment for male infertility; exposure to gonadotoxins or anabolic drugs; prior genital surgery; history of smoking or alcohol consumption; abnormal female factor evaluation; or wife’s age over 35 years.
Patients were referred to our fertility unit for evaluation of potentially correctable causes of male infertility. Two abnormal semen analyses were already available at the time of referral. History-taking included type and duration of infertility, relevant medical and surgical history, history of smoking, alcohol, or drug use, and sexual history. Physical examination was performed in both supine and standing positions. Morning fasting levels of testosterone, follicle-stimulating hormone, and luteinizing hormone were measured in all patients as part of infertility evaluation. Scrotal ultrasonography was performed routinely to assess hydrocele volume, presence of varicoceles, and testicular size.
The procedure, including its risks and benefits, was discussed with all patients. Thirty-one patients elected to undergo hydrocelectomy (study group), while a control group of 30 patients chose conservative follow-up. Both groups were encouraged to adopt a healthy lifestyle, increase physical activity, and avoid excessive heat exposure and tight clothing. Both groups were also prescribed a male fertility supplement (L-carnitine, zinc, selenium, coenzyme Q10, vitamin C, and folic acid), administered as sachets twice daily for 4 months.
Surgery was performed under spinal anesthesia using a median raphe incision. The testes and epididymis were examined for any gross abnormalities. The color and volume of hydrocele fluid were recorded. The surgical technique involved eversion with or without excision of excess tunica, followed by plication of the edges. Patients were discharged 2 hours after surgery unless a drain was required. Postoperative follow-up was performed 6 weeks later to assess wound healing and complications.
Repeat semen analysis and testicular ultrasonography were performed 6 months after surgery. Patient satisfaction was assessed using the Surgical Satisfaction Questionnaire (SSQ-8) [10]. The natural pregnancy rate was documented 1 year after surgery. Patients who did not achieve natural pregnancy were referred for in vitro fertilization.
The study was approved by the Institutional Review Board of South Valley University (Code SVU/MED/URO016/1-21) and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants.
1. Statistical analysis
Data were analyzed using the SPSS ver. 27 (IBM Co.). Normality was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests, and all continuous variables were found to be non-normally distributed. Continuous data were expressed as mean±standard deviation (SD) for parametric variables or as median and interquartile range for non-parametric variables.
Differences between the two groups were analyzed using the Mann-Whitney U test for non-parametric data. The Wilcoxon signed-rank test was used to compare baseline values with 6-month postoperative values, as the data were not normally distributed. Nominal data were expressed as percentages, and differences between groups were analyzed using the chi-square test. A two-tailed p<0.05 was considered statistically significant.
Results
A total of 61 patients were recruited for the study. The mean±SD age of men in the hydrocele surgery group (study group) and the follow-up group (control group) was 34.97±8.19 and 35.40±6.93 years, respectively. The mean±SD age of their wives was 24.84±4.04 and 26.07±4.53 years, respectively. The hydrocele volume ranged from 100 to 500 mL in both groups, with a mean±SD of 251.61±135.7 mL. Primary infertility was reported in more than 65% of patients, and two-thirds presented with unilateral hydroceles. No statistically significant differences were found between the two groups in demographic data, hydrocele volume, testicular size, or semen parameters (Table 1).
At 6 months postoperatively, there were no statistically significant differences between the two groups regarding testicular size and semen parameters. The natural pregnancy rate was higher in the hydrocelectomy group compared with the conservative group (7 [22.58%] vs. 5 [16.67%]), respectively, although the difference was not statistically significant (Table 2).
Within the hydrocelectomy group, no statistically significant changes were observed in semen parameters (semen volume; total sperm count/ejaculate; sperm count; percentage of total motility; percentage of progressive motility; and percentage of normal forms) 6 months after surgery. However, testicular size showed a statistically significant reduction from 14.52±4.04 mL preoperatively to 12.77±3.99 mL postoperatively (p<0.001). This reduction was mild and remained within the normal range (Table 3). By contrast, there were no statistically or clinically significant changes in semen parameters or testicular size in the conservative follow-up group (Table 4).
Subgroup analysis stratified patients according to hydrocele volume: <200 mL (n=11) and ≥200 mL (n=20). Testicular size decreased significantly in both subgroups, but there were no statistically significant changes in semen parameters (Table 5). At 6 months postoperatively, all patients (n=20) with hydrocele volume ≥200 mL were satisfied with surgery. Among patients with hydrocele volume <200 ml, three were dissatisfied, three were neutral, and five were satisfied.
Regarding complications, three patients (9%) experienced recurrence of hydrocele at 6 months, but these recurrences were small, painless, and managed conservatively. Hematoma occurred in two patients (6%); one of these required surgical drainage.
Discussion
We recruited patients with symptomatic hydroceles >100 mL in size. Although hydroceles <200 mL are often considered mild, young and active patients with hydroceles >100 mL were frequently found to be symptomatic. In another study, hydroceles >100 mL were also classified as large hydroceles [11]. Our study showed that more than 80% of patients were satisfied following hydrocelectomy, while 9% reported neutral satisfaction. Semen parameters were comparable to those of patients managed conservatively. Although testicular size decreased significantly after surgery, this reduction was not clinically significant. In contrast, the pregnancy rate was slightly higher in the surgery group.
It is well established that hydroceles can significantly alter testicular morphology by reducing the number of seminiferous tubules, primarily spermatids, and by disturbing the structure and arrangement of seminiferous tubules [12]. Histopathologic changes associated with hydroceles include interstitial fibrosis, basement membrane thickening, and disorganization of spermatogenic cells [7,13]. These alterations may result from the pressure exerted by the hydrocele on the testis, the detrimental effects of highly proteinaceous hydrocele fluid, or other mechanisms underlying hydrocele formation. Indeed, the hydrostatic pressure of hydroceles has been shown to exceed the pressure within scrotal blood vessels [14].
In this study, testicular volume decreased significantly after surgery. This finding is consistent with Mihmanli et al. [15], who reported that postoperative testicular volume was significantly lower than preoperative values. They attributed this to hydrocele-related compression obstructing testicular vessels, which in turn causes stasis of venous and lymphatic outflow. Such stasis results in swelling and increased testicular size preoperatively, while postoperative volume reduction reflects relief of pressure and regression of testicular swelling.
We employed the eversion and excision technique. The overall complication rate was 15%, with most events managed conservatively. Only one patient (3%) required surgical drainage of a postoperative hematoma (Clavien-Dindo grade III). This complication rate was notably lower than that reported in previous studies using the same technique, which ranged between 19% and 54% [4,6]. Most of our patients expressed satisfaction after surgery. This finding aligns with the results of Ahorlu et al. [16], who reported that hydroceles negatively impact comfort, work performance, sexual function, social interaction, and relationships, and that patients experience substantial improvements in these domains following hydrocelectomy.
To our knowledge, this is the first study to evaluate both the benefits and risks of hydrocelectomy in infertile men. Although the small sample size limited our ability to demonstrate a superior effect of hydrocelectomy on semen parameters and pregnancy rates, the study confirmed that surgery is not contraindicated in young infertile men. Moreover, surgery was associated with high satisfaction, primarily due to relief of pain and discomfort related to scrotal swelling. The main limitations of this study are the small sample size, short follow-up period, and non-randomized design.
In summary, hydrocele surgery in infertile men with large symptomatic hydroceles was associated with high patient satisfaction and minimal complications. Larger randomized controlled trials with extended follow-up are necessary to assess the effects of hydrocelectomy on spermatogenesis and natural pregnancy outcomes.
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