Hydrocele

Question 1

What is hydrocele?

Answer 1

Hydrocele refers to a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis.

Question 2

How does hydrocele present?

Answer 2

Patients present with (typically) a non-tender scrotal swelling. Hydroceles may be associated with (communicating hydrocele) or without (non-communicating hydrocele) a patent processus vaginalis.

Question 3

There are two major types of hydrocele: what are they?

Answer 3

There are two major types of hydrocele: communicating and non-communicating.

Question 4

Communicating hydrocele occur due to what?

Answer 4

These occur due to the failure of normal closure of the processus vaginalis. This allows the passage of peritoneal fluid into the tunica vaginalis. Communicating hydroceles are therefore considered congenital though they may present in older children, adolescents and even adults.

It should be noted that a patent processus vaginalis is relatively common. It is estimated to be present in 80-94% of newborns and 20% of adults.

Question 5

Non-communicating hydrocele occur due to what?

Answer 5

There is no abnormal connection with the peritoneal cavity as seen in communicating hydroceles. Instead, fluid is produced by the mesothelial lining of the tunica vaginalis.

They occur when there is an imbalance between fluid production and absorption. Many are idiopathic but identifiable triggers include trauma, infection (e.g. epididymo-orchitis) and testicular torsion.

Question 6

Communicating or non-communicating hydrocele - which is which?

Answer 6

Question 7

… of the spermatic cord: segmental closure of the processus vaginalis results in an isolated segment of fluid.

Answer 7

Hydrocele of the spermatic cord: segmental closure of the processus vaginalis results in an isolated segment of fluid.

Question 8

…-… hydrocele: rarely a hydrocele enlarges, propagates up the inguinal canal and develops an abdominal component.

Answer 8

Abdomino-scrotal hydrocele: rarely a hydrocele enlarges, propagates up the inguinal canal and develops an abdominal component.

Question 9

What do patients with hydrocele present with?

Answer 9

Patients present with scrotal swelling:

The swelling is typically described as:

Smooth
Non-reducible
Demonstrating transillumination with a pen-torch
Non-tender

Question 10

What is the investigation of choice for hydrocele?

Answer 10

A testicular USS is the investigation of choice.

Question 11

Testicular USS has excellent sensitivity for …

Answer 11

Hydroceles

Question 12

NICE CKS advise urgent USS for hydrocele if: (6)

Answer 12

It is not evident whether the scrotal swelling is testicular, or extra-testicular
Body of testis can’t be distinguished
Men aged 20-40 (where a hydrocele may be the first presentation of a testicular cancer)
A haematocele does not follow trauma, or is chronic
There is a history of trauma and scrotal pain, or persistent testicular symptoms
There is diagnostic uncertainty

Question 13

It should always be remembered that a hydrocele may occur secondary to … (3)

Answer 13

It should always be remembered that a hydrocele may occur secondary to epididymo-orchitis, testicular torsion or testicular cancer.

Question 14

Inguinal hernias can pass into the scrotal sac and present as an …-… swelling. If these diagnoses are suspected the patient should be investigated, managed and referred based on the individual presentation.

Answer 14

Inguinal hernias can pass into the scrotal sac and present as an extra-testicular swelling. If these diagnoses are suspected the patient should be investigated, managed and referred based on the individual presentation.

Question 15

Management of hydroceles depend on the age, underlying …, association with … and symptoms present.

Answer 15

Management of hydroceles depend on the age, underlying cause, association with hernia and symptoms present.

Question 16

Infants - hydrocele
When do they resolve?
Surgical intervention cut offs?

Answer 16

The vast majority of simple hydroceles in infants resolve during the first year of life. Patients should have ongoing observation to ensure resolution occurs and to identify the development of an inguinal hernia. Depending on the resource reviewed different cut-offs are described from where surgical intervention should be considered:

NICE CKS / BMJ Best Practice: advise cut-off of two years of age
European Association of Urology: advise cut-off of one year of age

Concomitant inguinal hernia or underlying testicular pathology are also indications for referral to paediatric surgeons and early surgery. When surgery is indicated, a common procedure for an uncomplicated communicating hydrocele is an open repair with high ligation of patent processus vaginalis.

Question 17

Late-onset hydroceles - what may happen?

Answer 17

In patients with suspected idiopathic non-communicating hydroceles, a period of observation may be taken. Spontaneous resolution may be seen in up to 75% of cases. Scrotal support can help adults with symptoms of discomfort. Surgery is considered where cases are persistent or symptomatic.

Communicating hydroceles that develop above the age of two are somewhat less likely to resolve and may increase the risk of an incarcerated inguinal hernia. Elective surgical management should be considered.

Question 18

Hydroceles secondary to infection or trauma will tend to resolve with time or treatment of the underlying cause. Hydroceles may occur as a complication of … (surgery to treat a varicocele). In this setting conservative management should be trialled as the vast majority will resolve with time.

Answer 18

Hydroceles secondary to infection or trauma will tend to resolve with time or treatment of the underlying cause. Hydroceles may occur as a complication of varicocelectomy (surgery to treat a varicocele). In this setting conservative management should be trialled as the vast majority will resolve with time.

Question 19

Aspiration of a hydrocele is simple and may give initial relief, however, recurrence is very common. When surgery is required in older patients there are a number of options which include:

Answer 19

Lord’s procedure: this involves plication of the sac. Tends to be used for small-medium sized hydroceles with a thin sac. It has a reduced risk of haematoma when compared to the Jaboulay procedure.
Jaboulay procedure: the sac is opened drained, partially excised, everted and sutured behind the testicle. Tends to be used for larger hydroceles with a thick sac. Greater risk of haematoma.

Question 20

What is Lord’s procedure?

Answer 20

this involves plication of the sac. Tends to be used for small-medium sized hydroceles with a thin sac. It has a reduced risk of haematoma when compared to the Jaboulay procedure.

Question 21

What is Jaboulay procedure?

Answer 21

The sac is opened drained, partially excised, everted and sutured behind the testicle. Tends to be used for larger hydroceles with a thick sac. Greater risk of haematoma.

Question 22

The presence of a large non-tender fluid-filled cyst within the scrotum is suggestive of a ….

Answer 22

The presence of a large non-tender fluid-filled cyst within the scrotum is suggestive of a hydrocele.

Question 23

A hydrocele refers to a collection of fluid within the scrotum between the layers of the tunica vaginalis. They may be communicating due to a patent processus vaginalis or non-communicating. … hydroceles are common in neonates and usually resolve spontaneously.

Answer 23

A hydrocele refers to a collection of fluid within the scrotum between the layers of the tunica vaginalis. They may be communicating due to a patent processus vaginalis or non-communicating. Communicating hydroceles are common in neonates and usually resolve spontaneously.

Question 24

Clinically, hydroceles vary in size, typically sit anterior to the testis and feel like a water-filled balloon. It may be difficult to feel the testis and they are usually non-tender. … of the scrotum showing the cystic fluid collection, is performed on clinical examination. This coupled with palpation is usually sufficient to make the diagnosis

Answer 24

Clinically, hydroceles vary in size, typically sit anterior to the testis and feel like a water-filled balloon. It may be difficult to feel the testis and they are usually non-tender. Transillumination of the scrotum showing the cystic fluid collection, is performed on clinical examination. This coupled with palpation is usually sufficient to make the diagnosis

Question 25

The presence of pain may indicate that the hydrocele has arisen from an underlying pathology such as epididymitis, orchitis, testicular torsion, torsion of the appendix testis or reactive from an underlying tumour. In this situation,… is usually performed to determine the underlying pathology.

Answer 25

The presence of pain may indicate that the hydrocele has arisen from an underlying pathology such as epididymitis, orchitis, testicular torsion, torsion of the appendix testis or reactive from an underlying tumour. In this situation, doppler ultrasound is usually performed to determine the underlying pathology.