Medicine:Hydrocele

A hydrocele is an accumulation of serous fluid in a body cavity. A hydrocele testis, the most common form of hydrocele, is the accumulation of fluids around a testicle. It is often caused by fluid collecting within a layer wrapped around the testicle, called the tunica vaginalis, which is derived from peritoneum. Provided there is no hernia present, it goes away without treatment in the first year. Although hydroceles usually develop in males, rare instances have been described in females in the canal of Nuck.

Primary hydroceles may develop in adulthood, particularly in the elderly and in hot countries, by slow accumulation of serous fluid. This is presumably caused by impaired reabsorption, which appears to be the explanation for most primary hydroceles, although the reason remains obscure. A hydrocele can also be the result of a plugged inguinal lymphatic system caused by repeated, chronic infection of Wuchereria bancrofti or Brugia malayi, two mosquito-borne parasites of Africa and Southeast Asia, respectively. As such, the condition would be a part of more diffuse sequelae commonly referred to as elephantiasis, which also affects the lymphatic system in other parts of the body.

Presentation

Complications

• Rupture usually occurs as a result of trauma but may be spontaneous. On rare occasions cure results after the fluid has been absorbed.
• Transformation into a haematocele occurs if there is spontaneous bleeding into the sac or as a result of trauma. Acute haemorrhage into the tunica vaginalis sometimes results from testicular trauma and it may be difficult without exploration to decide whether the testis has been ruptured. If the haematocele is not drained, a clotted haematocele usually results.
• The sac may calcify. Clotted hydrocele may result from a slow spontaneous ooze of blood into the tunica vaginalis. It is usually painless and by the time the patient seeks help, it may be difficult to be sure that the swelling is not due to a testicular tumour. Indeed, a tumour may present as a haematocele.
• Occasionally, severe infection can be introduced by aspiration. Simple aspiration, however, often may be used as a temporary measure in those cases where surgery is contraindicated or must be postponed.
• Postherniorrhaphy hydrocele is a relatively rare complication of inguinal hernia repair. It is possibly due to interruption to the lymphatics draining the scrotal contents.
• Infection which may lead to pyocele.
• Atrophy of testis in long standing cases.

Cause

A hydrocele can be produced in four ways:

• by excessive production of fluid within the sac, e.g. secondary hydrocele
• by interference with lymphatic drainage of scrotal structures as in case of elephantiasis
• by connection with a hernia of the peritoneal cavity in the congenital variety, which presents as hydrocele of the cord

Secondary hydroceles

• Acute/chronic epididymo-orchitis
• Torsion of testis
• Testicular tumor
• Hematocele
• Filarial hydrocele
• Post herniorrhaphy
• Hydrocele of an hernial sac

Congenital hydroceles

Communicating hydrocele, caused by the failure of the processus vaginalis closure.

Encysted hydrocele of the cord

There is a smooth oval swelling near the spermatic cord which is liable to be mistaken for an inguinal hernia. The swelling moves downwards and becomes less mobile if the testis is pulled gently downwards. Rarely, a hydrocele develops in a remnant of the processus vaginalis somewhere along the course of the spermatic cord. This hydrocele also transilluminates, and is known as an encysted hydrocele of the cord. In females, a related region in females, a multicystic hydrocele of the canal of Nuck sometimes presents as a swelling in the groin. It probably results from cystic degeneration of the round ligament. Unlike a hydrocele of the cord, a hydrocele of the canal of Nuck is always at least partially within the inguinal canal.

Diagnosis

• Transillumination positive
• Fluctuation positive
• Impulse on coughing negative (positive in congenital hydrocele)
• Reducibility absent
• Testis cannot be palpated separately. (exception - funicular hydrocele, encysted hydrocele)

Treatment

Most hydroceles appearing in the first year of life resolve without treatment. Hydroceles that persist after the first year or occur later in life require treatment only in selected cases, such as patients who are symptomatic with pain or a pressure sensation, or when the scrotal skin integrity is compromised from chronic irritation; the treatment of choice is surgery and the operation is conducted via an open access technique aiming to excise the hydrocele sac. Anesthesia is required for the operation; general anesthesia is of choice in children, while spinal anesthesia is usually sufficient in adults. Local infiltration anesthesia is not satisfactory because it cannot abolish abdominal pain due to traction on the spermatic cord. In longstanding cases, hydrocele fluid may be opalescent with cholesterol and may contain crystals of tyrosine.

After aspiration of a primary hydrocele, fluid reaccumulates over the following months and periodic aspiration or operation is needed. For younger patients, operation is usually preferred. Sclerotherapy is an alternative; after aspiration, 6% aqueous phenol (10–20 ml) together with 1% lidocaine for analgesia can be injected, and this often inhibits reaccumulation. These alternative treatments are generally regarded as unsatisfactory because of the high incidence of recurrences and the frequent necessity for repetition of the procedure.

External links

Classification	D SNOMED CT: 386152007
External resources	eMedicine: article/777386

• Hydrocele at eMedicine