Hydrocele (Fluid Hernia) Surgery in Turkey

Hydrocele (water hernia) surgery is the surgical drainage of the fluid accumulated around the testicle and the correction of the sac structure. It is generally performed in cases causing pain, swelling, or cosmetic discomfort and aims to provide a permanent solution.

How hydrocele surgery is performed is based on the principle of reaching the fluid sac through a small incision made over the scrotum and draining the fluid. Then, the sac is removed or turned inside out to prevent fluid from accumulating again, and the procedure is carried out under sterile conditions.

The recovery process after hydrocele surgery is generally short depending on the patient’s general health condition, and most individuals can return to their daily activities within a few days. Mild pain, edema, and tenderness may be seen after surgery, and they regress rapidly with appropriate care.

Although the risks and complications of hydrocele surgery are rare, they may include conditions such as infection, hematoma, or reaccumulation of fluid. Surgical technique and the choice of a specialist physician play a decisive role in reducing the risk of complications.

What Are Hydrocele and Hernia and How Do They Develop?

To understand the basis of these disorders, it is necessary to look at the miraculous developmental process in the womb. While the baby is in the womb, the testicles initially form in the abdominal cavity, in a region just below the kidneys. As the pregnancy progresses and birth approaches, the testicles embark on a long journey downward from inside the abdomen. This journey ends when they pass through a narrow tunnel called the inguinal canal and reach their final destination, the scrotum.

The testicles are not alone during this downward migration; they also pull down with them an extension of the abdominal membrane. In the medical literature, this thin membranous tube-like structure is called the processus vaginalis. In a healthy and normal developmental process, shortly after the testicles settle into the scrotum, this membranous tunnel is expected to contract completely, close, and disappear. However, in the functioning of nature, sometimes this process remains incomplete or never occurs.

If this tunnel does not close at all and remains as a wide, open tube between the inside of the abdomen and the scrotum, the organs inside the abdomen begin to slide downward through this space. The condition in which usually the intestines or the intra-abdominal fatty tissue protrude through this canal is called an inguinal hernia. On the other hand, if the opening of this tunnel remains too narrow for the intestines to pass through, but wide enough for the natural body fluid in the abdomen to leak through, the fluid slowly trickles downward and accumulates around the testicle. This fluid accumulation is called a communicating hydrocele, or in lay terms, an associated water hernia. Sometimes the tunnel closes completely on the abdominal side, but the membranes surrounding the testicle produce and trap excessive fluid between themselves. This condition is called a non-communicating hydrocele and is not directly related to an opening.

Why Are Hydrocele and Hernia Cases Seen More Frequently on the Right Side?

Behind the fact that these anatomical problems appear much more frequently on the right side of the body than on the left lies an interesting developmental reason based entirely on timing. In the process in the womb, the downward journey of both testicles does not begin and end simultaneously. The left testicle starts its journey a little earlier and naturally reaches its place in the scrotum more quickly. Reaching its place earlier provides more time for the closure of that membranous tunnel it leaves behind.

The right testicle, however, completes this journey a little later than the left testicle. Since the descent ends later, the closure process of the tunnel on the right side also begins later. This delay plays a particularly critical role in the final weeks approaching birth. When the baby is born before the tunnel has completely closed, the statistical likelihood of an opening remaining on the right side becomes much higher.

For this reason, when clinical cases are examined, it is seen that the rates of hydrocele and inguinal hernia are much more pronounced on the right side. While cases on the left side are encountered less frequently, bilateral cases seen on both sides have the lowest rate. Especially in babies born early, that is, premature babies, since there is not enough time for the body to complete its development, the risk of the tunnel remaining open is much higher, and this dramatically increases the frequency of both disorders.

How Is the Distinction Between Hydrocele and Hernia Made During Examination?

When a swelling is noticed in the groin area or in the scrotum, a detailed physical evaluation is essential to understand the source of this condition. Although from the outside both may appear simply as a lump or enlargement, the behavior of the mass provides very clear clues for the differential diagnosis.

The main elements evaluated in the physical examination are as follows:

• Timing of the swelling
• Consistency of the mass
• Light transmittance
• Reducibility
• Presence of pain

To elaborate on these elements, in cases of hydrocele, the swelling is generally smaller when waking up in the morning, but increases significantly in the evening hours as intra-abdominal fluid trickles downward throughout the day due to standing. In inguinal hernia, however, the swelling appears suddenly, usually as a result of increased intra-abdominal pressure when the patient lifts a heavy object, coughs violently, or strains. In terms of consistency, while hydrocele gives the sensation of a soft balloon filled with water, hernia has a firmer and more irregular structure depending on the type of organ inside.

The transillumination test, performed in a dark room by shining a strong light on the swelling, is very valuable. If the inside is filled only with a clear fluid, the light passes brightly through the mass. However, if there is intestinal tissue inside, the passage of light is blocked. In addition, in hernia cases, when the swelling is gently pushed upward by hand, it may return into the abdomen, whereas in fluid accumulations it is not possible to achieve such sudden reduction.

Why Is Ultrasonography Important for Hydrocele or Hernia in Diagnosis?

Although physical examination often provides sufficient confidence for diagnosis, it is essential in medical practice not to leave any detail to chance. Scrotal ultrasonography comes into play to definitively rule out the presence of other complex conditions underlying the swelling that cannot be understood from the outside or to confirm the existing diagnosis. Fine details that cannot be noticed by eye or hand can only be revealed by this imaging method.

The main benefits provided by ultrasonography are as follows:

• Measurement of the amount of fluid
• Detection of the contents of the hernia sac
• Control of testicular blood flow
• Examination of surrounding tissues

Whether there is a life-threatening condition requiring emergency intervention, such as the interruption of blood flow due to the testicle rotating around itself (torsion) in the swollen area, can be quickly understood with Doppler ultrasonography. In addition, it is clearly visualized whether the hernia sac contains intra-abdominal fatty tissue or intestine. Besides this, whether the mass is in fact not a fluid accumulation but rather a malignant tumor originating from the testicle or a serious infection is also definitively clarified in this way.

How Is the Process of Hydrocele and Hernia Managed in Infants and Children?

These two conditions encountered in childhood require two completely opposite approaches in terms of the natural course of the disease and the urgency of the condition. Families naturally become greatly concerned when they see a swelling in their children, but not every situation means an urgent operation.

When fluid accumulation, that is, hydrocele, is detected in infants, it is generally not rushed. The tunnel that remains open may also continue to close gradually in the months after birth. Therefore, a waiting period until one or two years of age is allowed. Most of the time, during this period, the opening closes on its own and the accumulated fluid is absorbed by the body, causing the swelling to disappear completely. During this waiting period, families are explained in detail how to monitor the swelling. If the child is older than two years and the swelling still continues, surgical planning is made from that point onward because the possibility of spontaneous closure has disappeared.

However, when it comes to inguinal hernia, there is absolutely no luxury of waiting. The moment a hernia is diagnosed, surgery is planned as soon as possible regardless of the child’s age. The reason for this is the risk of the intestine protruding downward through the inguinal canal becoming trapped and strangulated in a narrow space. When the blood circulation of the trapped intestine is impaired, the tissue begins to decay, and at the same time it may put pressure on the vessels going to the testicle, causing the testicle to atrophy. The principle of surgery in children is quite simple; with a tiny incision made in the groin region, the open membrane is found and tied off at its root. Since the abdominal muscles are strong in children, there is no need for synthetic meshes as in adults.

Why Does Hydrocele Occur in Adults and Does It Cause Infertility Like Hernia?

The causes of hydrocele development in adult men are based on environmental and physical factors that arise later rather than on a congenital anatomical opening as in infants. In later periods of life, the balance of fluid production and absorption of the membranes around the testicle may be disrupted for various reasons.

The main factors that disrupt this fluid balance in adults are as follows:

• Testicular inflammations
• Trauma to the area
• Scrotal region surgeries
• Lymphatic drainage disorders

Especially after varicocele surgeries, damage to the microscopic lymph vessels in that area may cause fluids not to be reabsorbed and to accumulate around the testicle. These fluid accumulations that occur in adults may reach very large sizes over time, creating a serious feeling of heaviness and turning into a chronic discomfort that even makes wearing trousers difficult.

One of the most critical consequences of this condition is its effect on reproductive health. The testicles must be in an environment cooler than body temperature in order to produce healthy sperm. However, a large mass of fluid surrounding the testicle acts almost like an insulation layer and disrupts the heat balance in the area. The increased heat and the high pressure created by the fluid directly compress the sperm production centers. This situation may lead to a decrease in sperm count, impairment of motility, and ultimately infertility. This is why it is very important for men who are planning to have children and are experiencing this problem to seek a surgical solution without losing time.

How Are Open Surgical Methods Applied in the Treatment of Hydrocele and Hernia?

In adults, the permanent and definitive solution to the problem of fluid accumulation is surgical intervention. Over the years, various open surgical techniques have been developed and applied in the medical world to solve this problem. The main purpose of these methods is to drain the accumulated fluid and reconstruct the diseased membrane producing the fluid in such a way that it cannot collect water again.

In classical open methods, a noticeable incision is made externally on the scrotum. After the fluid is completely drained, different approaches are displayed according to the condition of the membranes. Sometimes these membranes are cut, turned inside out toward the back of the testicle, and sutured; sometimes the excessive parts of the membranes are completely cut out with scissors and removed. In some techniques, however, the membrane is not cut, but is gathered around the testicle by being plicated.

Although these classical methods have been used as standard treatment for many years, they come with some difficulties. The complete removal of the testicle during surgery and the cutting of large tissue areas make the recovery process difficult. Due to the flexible structure of the scrotum, even the slightest blood leakage that may occur inside can cause major bruising and excessive swelling. While large incision areas increase the risk of infection, the return of the patient to normal life may require a painful recovery period that can last for weeks.

What Do Modern and Minimally Invasive Methods Offer in the Treatment of Hydrocele?

To overcome the difficulties of classical open surgery and maximize the patient’s postoperative comfort, innovative methods that are minimally invasive, that is, causing the least possible tissue damage, have been developed in modern medicine. Thanks to these methods, the destructive effects of the operation have been almost completely eliminated.

The main advantages offered to patients by the modern approach are as follows:

• Very small incision area
• Low risk of bleeding
• Minimum tissue damage
• Near-zero pain
• Possibility of same-day discharge

In the Önol technique, one of the most successful examples of these innovative techniques, the incision made in the scrotum is only one or one and a half centimeters in size. During the surgery, the testicle is not displaced or taken out. With the help of a fine needle, the fluid inside is first completely drained and the tension of the membrane is relieved. Then, entering through that tiny opening, the diseased membrane tissue producing the fluid is gently separated from over the testicle and removed, just as if peeling an onion membrane. Since tissue trauma is almost nonexistent, bruising or swelling is not seen after surgery. Patients can walk home on the day the operation is performed and continue their daily lives in a very short time as if nothing had happened.

How Is Laparoscopic Surgery a Solution for Hernia in Adults?

When it comes to inguinal hernia in adults, technological developments have made laparoscopic, that is, closed surgery, the strongest option. In adult hernias, it is not enough just to push the protruding organ back into place; the muscle weakness in that region must also be supported with a synthetic and durable mesh, otherwise the disease will definitely recur.

In laparoscopic repair, the procedure is carried out by entering through several small holes opened in the abdominal region with a camera and very fine hand instruments. Depending on the situation, surgeons place this mesh either by entering inside the abdominal membrane or by advancing directly through the natural space between the muscle layer and the membrane without perforating the membrane at all.

The fact that this method is performed in a closed manner greatly reduces the risks of unwanted injuries by preventing contact with other organs inside the abdomen. Especially in people who have previously had hernia surgery but whose disease has recurred, in patients who have hernias on both sides, or in people who have undergone prostate surgery in the past and whose groin area has weakened, the closed method gives flawless results. Unlike open surgeries, it does not leave large scars, seriously reduces postoperative pain, and allows the patient to return to a physically active life within just days.

Do Non-Surgical Treatment Options Work for Hydrocele?

Fear of going under the knife naturally pushes many patients to seek non-surgical alternatives. In cases of fluid accumulation, the most commonly wondered-about method is entering from outside with the help of a needle and drawing out that water. This procedure is called fluid aspiration and, at the moment it is performed, it relieves that tension in the scrotum and provides the patient with immediate great physical relief.

However, this relief is a completely temporary illusion. With the needle, only the fluid is taken out; the diseased membrane system that continuously produces that fluid is left inside. Since the factory continues to work, after a very short time that space fills again, sometimes even with more fluid than before. Since it does not provide definitive treatment, fluid aspiration is not a method used alone; it is preferred only for temporary relief in very elderly patients for whom receiving anesthesia is definitely dangerous.

The procedure of injecting adhesive or irritating chemical substances inside to prevent refilling after drawing off the water is called sclerotherapy. The purpose of these chemicals is to glue the membrane walls together. However, these substances have the risk of spreading uncontrollably. If they escape into the sensitive structures inside the testicle or accidentally into the abdomen through the inguinal canal, they can cause serious damage to the intestines, chemical burns, and very severe chronic pain. For this reason, in current treatment approaches, safe surgical techniques are kept at the forefront rather than such temporary and high-risk methods.

What Should Patients with Hydrocele and Hernia Pay Attention to During the Postoperative Recovery Period?

No matter which superior surgical technique is applied, the most important complement to a successful operation is the patient’s conscious and careful attitude after surgery. The recovery process is a delicate period that requires time and patience for the tissues to regain their former strength.

The rules that must definitely be followed in the period after discharge are as follows:

• Taking care to rest
• Avoiding heavy sports
• Protecting against climate conditions
• Not increasing abdominal pressure
• Using the prescribed medications regularly

Since the skin of the scrotum has a very flexible structure, applying ice intermittently to the area in the first days after surgery plays a critical role in preventing possible swelling. In addition, the use of special underwear with supportive and lifting features that do not let the testicles hang downward significantly reduces the pressure and pain created by gravity.

It is essential to stay away from all kinds of activities that will increase intra-abdominal pressure in the first months after surgery. Doing heavy fitness exercises, lifting high-weight objects, coughing severely and chronically, or straining excessively due to constipation can cause great damage to the tissues that are healing. If sudden high fever, foul-smelling discharge in the surgical area, or a sudden onset of severe painful and purple-colored swelling is noticed during the recovery process, it should not be forgotten that the situation needs to be evaluated without delay.