HYDROCOELE

Issah J. kiswagala

(M.B.B.S)

INTRODUCTION

• A hydrocele is a fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord.
• These fluid collections may represent persistent developmental connections along the spermatic cord or an imbalance of fluid production versus absorption.
• In rare cases, similar fluid collections can develop in females along the canal of Nuck.

SURGICAL ANATOMY

• The scrotum is a fibromuscular cutaneous sac, located between the penis and anus. It is dual-chambered, forming an expansion of the perineum.

Contents

• The scrotum contains three major (paired) structures:
• Testis – the site of sperm production.
• Epididymis – situated at the head of each testicle. It functions as a storage reservoir for sperm.
• Spermatic cord – a collection of muscle fibres, vessels, nerves and ducts that run to and from the testes.

A handy mnemonic to recall the layers of the scrotum is:

​

‘Some Damn Englishman Called It The Testes’

​

• S: skin
• D: dartos fascia and muscle
• E: external spermatic fascia
• C: cremasteric fascia
• I: internal spermatic fascia
• T: tunica vaginalis
• T: tunica albuginea

• There are also muscle fibres located within the scrotum. The dartos muscle is a sheet of smooth muscle, situated immediately underneath the skin. It acts to help regulate the temperature of the scrotum, by wrinkling the skin – this decreases surface area, reducing heat loss.
• The scrotum is developmentally homologous to the labia majora.
• It has following cells and their functions are:
• Germ cells -Sperm production
• Leydig cells -Testosterone production
• Sertoli cells - Oestrogen production

​

AETIOLOGY

• Infections - Filariasis, a parasitic infection caused by Wuchereria bancrofti, accounts for most causes of hydroceles worldwide. others are Tuberculosis of epididymis (30%) cases have secondary hydrocele, Syphilis
• Injury - Trauma, postherniorrhaphy hydrocele
• Communication with the peritoneal cavity in which patency of the processus vaginalis allows peritoneal fluid to flow into the scrotum.
• Tumour - Malignancy
• Defective absorption of fluid by the tunica vaginalis, probably due to damage to the endothelial wall by low-grade infection.
• Excessive production of fluid as in secondary hydrocele.
• Interference with drainage of fluid by lymphatic vessels of the cord.

PATHOPHYSIOLOGY

• The pathophysiology of hydroceles requires an imbalance of scrotal fluid production and absorption.
• Alternatively, hydroceles can be divided into those that represent a persistent communication (Children) with the abdominal cavity and those that do not.
• Fluid excesses are from exogenous sources (the abdomen) in communicating hydroceles, whereas noncommunicating hydroceles develop increased scrotal fluid from abnormal intrinsic scrotal fluid shifts i.e. increased production (underlying inflammation) or impaired absorption (filarial infestations decreased lymphatic fluid absorption) .

TYPES

• There two types of hydrocele
• Congenital
• Acquired
• Primary
• Secondary
• Secondary hydrocele rarely attains large size.
• It is usually small, lax and testis is usually palpable (unlike primary hydrocele). Exception is, secondary hydrocele due to filariasis. It can be very large.

​

CONGENITAL

• Vaginal hydrocele
• Infantile hydrocele
• True congenital hydrocele
• Encysted hydrocoele of the cord
• Hydrocoele-en-Bissac (bilocular hydrocoele)
• Hydrocoele of canal of Nuck

ACQUIRED

Primary or idiopathic

• Primary Vaginal Hydrocele

Secondary hydrocoele.

• Recurrent epididymo-orchitis due to filariasis
• Tuberculous epididymo-orcbitis
• Pyocoele
• Haematocoele
• Testicular tumours
• Postherniorrhaphy Hydrocele

CONGENITAL HYDROCELE

• Vaginal hydrocoele
• Occurs when hydrocoele sac is patent only in the scrotum.
• Infantile hydrocoele
• The sac from the scrotum is patent up to the deep inguinal ring.
• Here tunica and processus vaginalis (hydrocele) are distended up to internal ring, but sac has no connection with the general peritoneal cavity.
• True congenital hydrocoele
• The scrotal sac communicates with the peritoneal cavity. It is seen in infants, may be secondary to TB peritonitis. The scrotal swelling appears when the child assumes an erect posture for a long time and it may not reduce due to “inverted ink bottle” effect. Hence, congenital hydrocoele is not reducible. It regresses in size if the child assumes supine position while sleeping.

​

• Encysted hydrocoele of the cord
• the sac is obliterated above (inguinal canal) and below (scrotum) but patent at the root of the scrotum around spermatic cord.
• It presents as a soft, cystic, fluctuant, transilluminant swelling separate from testis, well above the testis.
• Diagnosis is established by traction test: The swelling has got free mobility but when traction is applied to testis gently, the swelling becomes fixed and it moves down when testis is pulled down. This variety of hydrocoele is treated by excision of the sac.
• Hydrocoele-en-Bissac (bilocular hydrocoele)
• The scrotal sac communicates with another sac underneath the anterior abdominal wall musculature. Diagnosis is made by eliciting cross-fluctuation test.

• Hydrocoele of canal of Nuck
• It presents as a swelling in the inguinal region in female.
• In rare cases, similar fluid collections can develop in females along the canal of Nuck.

​

ACQUIRED HYDROCELE

• Primary vaginal hydrocoele
• This is the most common type of hydrocoele which is seen in young adults, middle age and beyond. It is due to following causes:
• Defective absorption of fluid
• Defective lymphatic drainage
• Common in tropical countries
• Testis is not palpable as it usually attains a large size (unlike secondary hydroceles which are small, except in filarial hydrocele).

• Clinical features

​

• Soft, cystic, fluctuant, transillumination positive, swelling confined to the scrotum, Not reducible, No impulse on cough, Getting above the swelling is possible.
• Fluctuant (elicited by, fixing the hydrocele with hand and feeling for the fluid movement using fingers placed in two perpendicular directions).
• Note: A relaxed muscle can demonstrate fluctuation in one direction even though there is no fluid in it.

• Initially transilluminant, (elicited in front of the swelling, side to side), but long-standing hydrocele is non-transilluminant (due to thickened dartos, thickened spermatic fascia, thickened hydrocele sac, infected content, chylous fluid, often filarial hydrocele, haematocele).
• Can get above the swelling (you can feel only cord structures and nothing else at the root of the scrotum, unlike in hernia).

TRANSILLUMINATION POSITIVE.

Get above the swelling is possible

in case of hydrocele.

SECONDARY HYDROCOELE

• Recurrent epididymo-orchitis due to filariasis
• Fluid that accumulates is due to obstruction of lymphatics. The fluid is milky white. Such hydrocoeles are called chylocoeles and often do not exhibit transillumination.
• Occurs commonly in coastal region, and in and around the equator.
• Usually occurs after repeated attacks of filarial epididymitis.
• Hydrocele is usually of large size and the sac is thickened.
• Fluid contains fat, rich in cholesterol, and is derived from ruptured lymph varix into the tunica.
• It is often difficult to differentiate from primary hydrocele.

Chylocele

• Tuberculous epididymo-orcbitis
• Retrograde infection from the seminal vesicles.
• Craggy epididymis refers to rough, hard, irregular surface. This involves the epididymal head and causes fibrosis. So, the epididymis feels craggy.
• Vas deferens feels like beads, called as beaded vas. Secondary hydrocoele occurs in 30% of the cases. Eventually it forms cold abscess which ruptures and results in sinus posteriorly, in the scrotum.
• It never involves the testis proper.

Tuberculous epididymo-orchitis

• Pyocoele
• Infected hydrocoele. Infection in a hydrocoele is rare because of the tunica vaginalis sac which is relatively avascular. However, few cases may get infected resulting in pyocoele. These patients present with fever, chills and rigors.
• Haematocoele
• Trauma to the hydrocoele or spontaneous bleeding into the sac.
• Testicular tumours
• They can present with a swelling of the scrotum, often diagnosed as hydrocoele. Any young patient with a rapidly growing scrotal swelling could be a testicular neoplasm. Fluid within the sac is haemorrhagic.

• Postherniorrhaphy Hydrocele
• It is a secondary hydrocele occurring after the surgery for inguinal hernia. It is due to the damage to lymphatic vessels of the tunica vaginalis and is 0.2% common.
• It is treated like any hydrocele but usually after about 6 months.

PHYSICAL EXAMINATION

• General examination
• Local examination
• Systemic examination

​

LOCAL EXAMINATION

INSPECTION�

• Skin and subcutaneous tissue
• The skin of the scrotum is usually wrinkled and freely mobile over the testis.
• Hydrocele - the skin will be tense and subcutaneous veins will be prominent.
• Acute epididymoorchitis - It becomes red and oedematous
• Note the size, shape and extent of the swelling.
• Slight swelling of the scrotum is evident by loss of normal rugosity of the scrotum. small to very big so as to hang up to knee level
• Impulse on coughing.
• Hernia shows impulse on coughing but Hydrocele doesn’t

​

​

PALPATION

• That the swelling is purely scrotal is confirmed by getting above the swelling.
• Skin
• Warmth, Edema, ulcer
• Swelling
• Noting temperature,
• Tenderness,
• Extent,
• Size,
• Shape, Surface (Smooth/nodular), margin and consistency.
• Get above the swelling

• Fluctuation.
• This test cannot be performed in the traditional way, as the whole scrotum is very much mobile. So this test is performed by holding the upper pole of the scrotal swelling between the thumb and the fingers of one hand to make the swelling tense and steady, while intermittent pressure is applied at the lower pole with the thumb and the fingers of the other hand.
• This will push the fluid inside the tunica vaginalis upwards, the thumb and the fingers holding the upper pole of the swelling will be pushed apart from each other making this test positive.

​

Showing the method of eliciting

fluctuation in a case of hydrocele.

• Translucency
• The test is best performed in darkness. A pencil torch is placed laterally over the swollen scrotum. A red glow will be seen throughout the scrotum indicating presence of clear fluid inside the scrotum.
• This can be better visualized through a piece of paper placed on the anterior part the scrotum with the pencil torch laterally.
• The common mistake most students make is to place the pencil torch on the posterior part and a rolled piece of paper anteriorly. The testis comes in the way of the light and this test becomes false negative.
• Uncomplicated hydrocele and the cyst of the epididymis are translucent but spermatocele is not translucent as the fluid it contains is not clear. Hernia is as well is not translucent

Showing the right method of performing the translucency test.

Shows the wrong method of performing the translucency test.

The torch is placed behind the testis which will stand in the way of the light and will make the test negative even in presence of hydrocele

• Reducibility
• This is tested by raising the scrotum and compressing the swelling gently.
• Congenital hydrocele and a varicocele are reducible. In case of the former always examine the abdomen for ascites as congenital hydrocele is often associated with tuberculous peritonitis
• Impulse on coughing
• Many a time scrotal swelling may be associated with a hernia, varicocele or lymph varix. The root of the scrotum is held and the patient is asked to cough.
• An impulse either expansile in nature (hernia or congenital hydrocele) or thrill like (varicocele or lymph varix) may be obtained.

INVESTIGATIONS

• Complete Blood count should be examined for eosinophilia
• Blood Microscopy for microfilaria in filariasis.
• Ultrasonography is extremely helpful not only to know the position of the testis, but also to know whether they are normal or not. This investigation is helpful in hydrocele, haematocele, secondary hydrocele, torsion of testis etc.
• Aspiration of a cystic swelling. In hydrocele an amber colour fluid may be obtained whose specific gravity remains in the range of 1.022 to 1.024; it contains water, inorganic salts, cholesterol, fibrinogen and 6% of albumin. In case of secondary hydrocele from testicular tumour the fluid will be blood stained.

DIFFERENTIAL DIAGNOSIS

• Inguinal hernia
• Epididymal cyst
• Spermatocele
• Testicular tumour
• Scrotal oedema

COMPLICATIONS OF HYDROCELE

• Infection
• Pyocele
• Haematocele
• Atrophy of testis, hernia of hydrocele (rare)
• Infertility
• Hernia of hydrocele sac (rare)

TREATMENT FOR HYDROCELE

• Surgery
• Lord's plication - is indicated in small hydrocoeles. The sac is opened and the cut edge of the sac is plicated to tunica albuginea. As a result, the sac gets crumpled up near the testis. The testicular secretions get absorbed by subcutaneous lymphatics and venous system.
• Partial excision and eversion (Jabouley’s operation) - This is indicated in large hydrocoeles. The thick, large, sac is excised and is sutured behind testis.
• Aspiration - is a temporary method and there is a chance of introducing infection. It can be done only in high-risk patients. This is a procedure to be condemned.
• Evacuation and eversion
• Sub-total excision

​

​

COMPLICATIONS OF SURGERY

• Haematocoele (Reactionary haemorrhage ): Occurs due to a minor trauma
• Infection
• Pyocele (Infected haematocoele)
• Sinus formation
• Recurrent hydrocele
• Calcification of hydrocoele sac
• Rupture of hydrocoele sac-very rare
• Hernia of the hydrocoele sac - occurs when there is a small tear in the sac resulting in accumulation of fluid in the subcutaneous planes