31 uro-hydrocele

Hydrocole is collection of fluid in persistant tunica than 40 years. vaginalis in males. It is collection of serous fluid

Hydrocele is bilateral in 7-10% of cases. Hydrocele resulting from a defect or irritation in the tunica often is associated with hernia, especially on the vaginalis of the scrotum. Hydroceles also may arise right side of the body in infants and children.in the spermatic cord in males or the canal of Nuck in

females.

Most pediatric hydroceles are congenital; however, malignancy, infection, and circulatory compromise Hydrocele is estimated to affect 1% of adult men. are possible causes of hydrocele.More than 80% of newborn boys have a patent

processus vaginalis, but most close spontaneously Hydrocele of the cord is associated with pathologic within 18 months of age. closure of the distal processus vaginalis, which

Most hydroceles are congenital and are noted in allows fluid pooling in the mid portion of the children aged 1-2 years of age. The incidence of spermatic cord.hydrocele is rising with the increasing survival rate of premature infants and with increasing use of the Communicating hydrocele is caused by failed peritoneal cavity for ventriculoperitoneal (VP) closure of the processus vaginalis at the internal ring.shunts, dialysis, and renal transplants. Hydrocele is Noncommunicating hydrocele results from a disease observed only in males. Chronic or pathologic closure of the processus vaginalis and secondary hydroceles usually occur in men older trapping of peritoneal fluid.

ETIOLOGY

FREQUENCY

ETIOLOGY & PATHOPHYSIOLOGY

HYDROCELE

SURGERY - UROLOGICAL PROBLEMS

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Hydrocele (trans illumination test) Hydrocele (ultrasound scan) Hydrocele (ultrasound scan)

Shuja Tahir, FRCS(Edin), FCPS (Hon)

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Adult-onset hydrocele may be secondary to orchitis closure through infancy and childhood. Hydroceles or epididymitis. Hydrocele also can be caused by are classified into three principal types.malignancy, tuberculosis and by tropical infections such as filariasis.

These are also called a communicating (congenital) hydroceles. Patent processus vaginalis permits flow Testicular torsion may cause a reactive hydrocele in of peritoneal fluid into the scrotum. Indirect inguinal 20% of cases. The clinician may be mis-led by hernias are associated with this type of hydrocele.focusing on the hydrocele, which delays the

diagnosis of torsion. Tumor, especially germ cell tumors or tumors of the testicular adnexa may cause It is also called noncommunicating hydrocele. Patent hydrocele. Traumatic (ie, hemorrhagic) hydroceles processus vaginalis is present, but no communi-are common. Ipsilateral hydrocele occurs in as many cation with the peritoneal cavity occurs.as 70% of patients after renal transplantation. Radiation therapy is associated with cases of hydrocele. Closure of the tunica vaginalis is defective. The distal

end of the processus vaginalis closes correctly, but Exstrophy of the bladder may lead to hydrocele. the mid portion of the processus remains patent. The Hydrocele may arise from Ehlers-Danlos syndrome. proximal end may be open or closed in this type of Hydrocele may result from a change in the type or hydrocele.volume of peritoneal fluid, like in patients undergoing peritoneal dialysis and those with a ventri-

Adult hydroceles are usually late-onset (secondary). culoperitoneal shunt.Late-onset hydroceles may present acutely following local injury, infections, and radiotherapy; these may

Embryologically, the processus vaginalis is a present chronically from gradual fluid accumulation. diverticulum of the peritoneal cavity. It descends with Morbidity may result from chronic infection after the testes into the scrotum via the inguinal canal surgical repair. This type of hydrocele can adversely around the 28th gestational week with gradual affect fertility.

CONGENITAL

ACQUIRED

HYDROCELE OF CORD

SECONDARY HYDROCELE

PATHOPHYSIOLOGY

ASYMPHTOMATIC SCROTAL DISCOMFORT

PAINSCROTAL SWEELING

Most hydroceles are asymptomatic or subclinical. Sensation of heaviness, fullness, or dragging may be Onset, duration, and severity of signs and symptoms felt by the patient. Patients occasionally report mild are evaluated. Relevant genitourinary (GU) history, discomfort radiating along the inguinal area to the sexual history, recent trauma, exercise, or systemic mid portion of the back.illnesses are identified.

Hydrocele usually is not painful; pain may be an Most common presentation is a painless enlarged indication of an accompanying acute epididymal scrotum. infection. The size may decrease with recumbency

PRESENTATIONS

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or increase in the upright position. Chronically erythema or scrotal discoloration is observed.formed hydroceles appear to be larger in size than acutely formed ones.

A light source shined through the scrotum causes the hydrocele to illuminate. The bowel also may

Fever, chills, nausea, or vomiting are absent in transilluminate; thus, positive transillumination uncomplicated hydrocele. GU symptoms are absent findings are not diagnostic of hydrocele. Positive in uncomplicated hydrocele. transillumination findings should not stop the

clinician from investigating serious causes or co-Hydroceles are located superior and anterior to the morbid conditions that may be associated with testis, in contrast to spermatoceles, which lie secondary hydrocele. This procedure is not reliable superior and posterior to the testis. for final diagnosis.

Transillumination test is usually positive.The size and the palpable consistency of hydroceles can vary with position. Hydrocele usually becomes

A light source shines brightly through a hydrocele. smaller and softer after lying down, it usually Transillumination is common, and diagnostic for becomes larger and tenser after prolonged standing. hydrocele. Transillumination may be observed with Systemic signs of toxicity are absent. The patient is other etiologies of scrotal swelling (eg, hernia).usually afebrile with normal vital signs. Abdominal or

testicular tenderness is absent. No abdominal distension is present. Bowel sounds cannot be Indirect inguinal hernia auscultated in the scrotum unless an associated Epididymitis hernia is present. Traumatic injury to the testicle

Unless an infection causes an acute hydrocele, no

Transillumination

SYSTEMIC SYMPTOMS

DIFFERENTIAL DIAGNOSIS

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BLOOD EXAMINATION

ULTRASOUND SCAN

DOPPLER ULTRASOUND FLOW STUDY

bowel.A CBC with differential count may indicate the existence of an inflammatory process. Urinalysis Hydrocele appears as a cystic mass within the may detect proteinuria or pyuria. spermatic cord (hydrocele of the cord) or as mass

surrounding the testicle.

It is used to confirm the diagnosis. It may be useful to identify abnormalities in the testis, complex cystic This study is recommended to assess perfusion, masses, tumors, appendages, spermatocele, or even if an acute scrotum is clinically unlikely. This associated hernia. In the context of pain or testicular must be performed urgently if there is suspicion of bleeding after trauma, an imaging test can testicular torsion or of traumatic hemorrhage into a differentiate between a hydrocele and incarcerated hydrocele or testes. Sensitivity of Doppler ultrasound

INVESTIGATIONS

260

is 86-100%; specificity is up to 100%. incomplete torsion, and following detorsion. Specificity for torsion can be 90%, but it is decreased

Limited availability of this test within a clinically useful in the presence of scrotal fluid collections (such as period reduces its usefulness. hydrocele, hernia, abscess and hematocele).

This nuclear scan is particularly useful, especially in Abdominal x-ray findings usually are normal in children, if testicular torsion is suspected. Decreased patients with hydrocele. If films demonstrate an or absent flow to one testis or a testicular pole obstructive gas pattern, they may help to indicates torsion. Sensitivity for torsion can be 90%, differentiate between incarcerated hernia and but it is decreased with infancy, early torsion, hydrocele.

TESTICULAR SCINTIGRAPHY X-RAY ABDOMEN

ASPIRATION

SURGICAL TREATMENT

EMERGENCY CARE

COMPLICATIONS

ACUTE SCROTAL PROBLEMS

hydrocele. Aspiration of a hydrocele reveals a clear amber fluid. Ischemic testicle in childrenAspiration is not therapeutic because the fluid generally reaccumulates quickly. Aspiration of hydroceles is not recommended because it is Hydrocele is treated through inguinal incisions with associated with a high rate of immediate recurrence high ligation of the patent processus vaginalis and with a risk of introducing an infection. If an (herniotomy) and excision of the distal sac.associated hernia is present, risk of perforating a ! Herniotomy loop of bowel also exists. ! Eversion of sac

! Lord’s operation

Differentiating between a hydrocele and an acute Spontaneous closure is unlikely in children older scrotum (eg, testicular torsion, strangulated hernia) than 1 year. Infants with hydrocele are observed for is important. As many as 50% of acute scrotum 1-2 years. Surgical treatment is offered afterwards. cases are initially misdiagnosed.

Transillumination is not diagnostic and cannot rule An extremely large hydrocele may impinge on the out an acute scrotum. testicular blood supply. The resulting ischemia can

cause testicular atrophy and subsequent impairment Ultrasound examination, imaging and Doppler of fertility.evaluation of testicular blood flow is indicated when an acute scrotum is suspected. Hemorrhage into the hydrocele can result from

testicular trauma.

Traumatic hemorrhage into a hydrocele or Incarceration or strangulation of an associated testes hernia may occur. Testicular torsion with or without a secondary

!

!

!

TREATMENT

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SURGICAL COMPLICATIONS

MISCELLANEOUS

PROGNOSIS

SPECIAL CONCERNS

later in life depends upon the etiology of the Accidental injury to the vas deferens can occur hydrocele. during inguinal surgery for hydrocele.

Adult-onset hydrocele is not uncommonly Postoperative wound infections occur in 2% of associated with an underlying malignancy.patients undergoing surgery for hydrocele.

Medical/Legal PitfallsPostoperative hemorrhagic hydrocele is not In a patient with signs and symptoms of an acute uncommon, but it usually resolves spontaneously. scrotum, the presence of a hydrocele and a finding of positive transilluminance does not rule out testicular Direct injury to the spermatic vessels may occur.torsion. Immediate definitive tests are indicated to rule out torsion because testicular survival is poor

The prognosis for congenital hydrocele after surgery after 4 hours of ischemia. A reasonable search for is excellent. possible etiologies should be documented.

Most congenital cases resolve by the end of the first year of life. Pediatric: Most cases resolve without intervention.

Geriatric: Hydroceles in this group rarely resolve Persistent congenital hydrocele is readily corrected without surgical intervention.surgically. The prognosis of hydrocele presenting

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REFERENCES4. Schul MW, Keating MA. The acute pediatric scrotum. J 1. Blaivas M, Brannam L. Testicular ultrasound. Emerg Med

Emerg Med. Sep-Oct 1993;11(5):565-77. [Medline].Clin North Am. Aug 2004;22(3):723-48, ix. [Medline].

5. Skoog SJ, Conlin MJ. Pediatric hernias and hydroceles. 2. Jayanthi VR. Adolescent urology. Adolesc Med Clin. Oct The urologist''s perspective. Urol Clin North Am. Feb 2004;15(3):521-34. [Medline].1995;22(1):119-30. [Medline].

3. McAchran SE, Dogra V, Resnick MI. Office urologic 6. Tanagho EA, McAninch JW. Disorders of the spermatic ultrasound. Urol Clin North Am. Aug 2005;32(3):337-52,

cord. In: Smith's General Urology. 1992;620-3. [Medline]. vii.

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Health & Medicine

31 uro-hydrocele