Tension hydrocele as an additional cause of acute scrotum: case series and literature review

  • Jeries P. ZawaidehEmail author
  • Michele Bertolotto
  • Massimo Giannoni
  • Giovanni Piaggio
  • Felice Durand
  • Lorenzo E. Derchi
Special section: Male pelvis



To describe the correlation between acute scrotum pain and tension hydrocele, focusing on US and Doppler features.

Methods and materials

We evaluated retrospectively a series of five patients with a long history of hydrocele who were referred to our institutions for increasing acute scrotal pain. Patients were approached with gray scale US of both testes, as well as with color-Doppler and spectral analysis, comparing the results with those after aspiration and symptoms relief.


All patients had a “simple” hydrocele with no internal septa; the involved testicles had a “flattened” appearance and parenchymal Doppler signals showed increased intratesticular vascular resistance. One patient had a low diastolic flow, compared to the contralateral testis, with an increased RI value, one had no diastolic flow, two patients had retrograde diastolic flow, and the remaining one had no intratesticular flow visible. After decompression, there were disappearance of pain and improved flow with normalization of testicular vascularity; post-ischemic hyperemia was appreciated in the two patients examined immediately after fluid aspiration, while normal flow was seen in three studies carried out the day after.


To conclude, tension hydrocele is a rare condition that produces alterations of form and circulation of testicles, increase of intraparenchymal vascular resistances and strong and continuous pain, mimicking a testicular torsion. The increase in pressure produces an effect similar to that observed in a compartment syndrome. US findings, together with clinical assessment, indicate when emergency decompression may be appropriate to relieve testicular ischemia.


Acute scrotum Hydrocele Doppler ultrasound 



All the authors did not receive any economical founds.


  1. 1.
    Rumack CM, Wilson SR, Charboneau JW: Diagnostic Ultrasound. St Louis, Mosby-Year Book, Inc, 1991, p. 579.Google Scholar
  2. 2.
    Ragheb D, Higgins JL. Ultrasonography of the scrotum: technique, anatomy, and pathologic entities. J Ultrasound Med 2002; 21:171–85. CrossRefGoogle Scholar
  3. 3.
    Turgut AT, Ozden E, Unsal A, et Al. A novel parameter by EFOV US for the quantification and the distinction of a physiological amount of scrotal fluid and hydrocele: Ratio of testis volume/scrotum volume. Eur J Radiol. 2007; 63:414-9. CrossRefGoogle Scholar
  4. 4.
    Leung ML, Gooding GA, Williams RD. High-resolution sonography of scrotal contents in asymptomatic subjects. AJR 1984; 143:161–164. CrossRefGoogle Scholar
  5. 5.
    Woodward PJ, Schwab CM, Sesterhenn IA. Extratesticular scrotal masses: radiologic–pathologic correlation. Radiographics 2003; 23: 215–40. CrossRefGoogle Scholar
  6. 6.
    Acer-Demir T, Ekencu BY, Ozer D, et al. Natural history anc conservative treatment outcomes for hydroceles: a retrospective review of one center’s experience. Urology 2017; 112:155-160. CrossRefGoogle Scholar
  7. 7.
    Schweitzer FAW. Hydrocele. Trop Doct 2001; 31:113–114.CrossRefGoogle Scholar
  8. 8.
    Bertolotto M, Cantisani V, Valentino M et al. Pitfalls in Imaging for Acute Scrotal Pathology. Semin Roentgenol. 2016 Jan;51(1):60-9. CrossRefGoogle Scholar
  9. 9.
    Douglas J, Hicks J, Manners J, et al. A pressing diagnosis—a compromised testicle secondary to compartment syndrome. Ann R Coll Surg Engl. 2008;90:W6–W8. CrossRefGoogle Scholar
  10. 10.
    Nye PJ, Prati RC. Idiopathic hydrocele and absent testicular diastolic flow. J Clin Ultrasound. 1997;25:43–46.<43::AID-JCU8>3.0 CrossRefGoogle Scholar
  11. 11.
    Wright LA, Gerscovich EO, Corwin MT, et al. Tension hydrocele: additional cause of ischemia of the testis. J Ultrasound Med. 2012;31(12):2041-3. CrossRefGoogle Scholar
  12. 12.
    Dagrosa LM, McMenaman KS, Pais VM Jr. Tension Hydrocele: An Unusual Cause of Acute Scrotal Pain. Pediatr Emerg Care. 2015 Aug;31(8):584-5. CrossRefGoogle Scholar
  13. 13.
    Dandapat MC, Padhi NC, Patra AP. Effect of hydrocele on testis and spermatogenesis. Br J Surg 1990; 77:1293–1294 10. Google Scholar
  14. 14.
    Mihmanli I, Kantarci F, Kulaksizoglu H, et al. Testicular size and vascular resistance before and after hydrocelectomy. AJR 2004; 183:1379–1385. CrossRefGoogle Scholar
  15. 15.
    Turgut AT, Unsal A, Ozden E, et Al. Unilateral idiopathic hydrocele has a substantial effect on the ipsilateral testicular geometry and resistivity indices. J Ultrasound Med. 2006;25(7):837-43. CrossRefGoogle Scholar
  16. 16.
    Nevarre DR, Raezer DM. Testicular Vascular Flow Compromise Caused by Compressive Hematocele After Lichtenstein Hernioplasty. Hosp Physician 1999; 35:47–49.Google Scholar
  17. 17.
    Galina P, Dermentzoglou V, Baltogiannis N et Al. Sonographic appearances of the epididymis in boys with acute testicular torsion but preserved testicular blood flow on color Doppler. Pediatr Radiol. 2015;45(11):1661-71. CrossRefGoogle Scholar
  18. 18.
    Bandarkar AN, Blask AR. Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatr Radiol. 2018;48(5):735-744. CrossRefGoogle Scholar
  19. 19.
    RRaff U, Ott C, Stefan John S et Al. Nitric Oxide and Reactive Hyperemia: Role of Location and Duration of Ischemia Am J Hypertens. 2010;23(8):865-9. Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Health Sciences (DISSAL), Radiology SectionUniversity of GenoaGenoaItaly
  2. 2.Department of RadiologyUniversity of TriesteTriesteItaly
  3. 3.Emergency Radiology, Policlinico San Martino HospitalGenoaItaly
  4. 4.University of GenoaGenoaItaly
  5. 5.Department of UrologyPoliclinico San Martino HospitalGenoaItaly
  6. 6.Department of Health Sciences (DISSAL)University of Genoa, Emergency Radiology, Policlinico San Martino HospitalGenoaItaly

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