Hydrocele

Question 1

Define hydrocele. What are the two types?

Answer 1

Hydrocele is a collection of serous fluid between the layers of the tunica vaginalis that surrounds the testis or along the spermatic cord.

There are 2 types of hydroceles: communicating and non-communicating (simple).

Question 2

What is the difference between a communicating and non communicating hydrocele?

Answer 2

Communicating - patent processus vaginalis connects the peritoneum with the tunica vaginalis which allows peritoneal fluid to flow freely between both structures. IF the collection is large, abdo contents can enter the groin –> inguinal hernia

Non-communicating - processus vaginalis is closed and more fluid is produced by the tunica vaginalis than is being absorbed.

Question 3

Name 3 types of hydroceles that can occur in the testicles.

Answer 3

Can be difficult to tell whether it is a mass or tense hydrocele. Use light to distinguish.

Question 4

How common are hydroceles and who is usually affected?

Answer 4

Common in male infants and the newborn - most resolve within the first year of life.

May occur in adult men - secondary to minor trauma, infection, testicular torsion, epididymitis, varicocele operation, or testicular tumour.

Question 5

What is the aetiology of hydroceles?

Answer 5

Congenital - in paediatric cases most are congenital and resolve within 1year

Acquired - most are adults.

• Non-communicating - trauma, infection, torsion, epididymitis, varicocele operation or testicular tumours
• Communicating - raised abdo pressure/fluid e.g. shunts, peritoneal dialysis or ascites

Connective tissue disease increases risk of communicating hydroceles

Filariasis may cause lymphatic obstruction –> hydroceles

Question 6

What are the signs/symptoms of a hydrocele?

Answer 6

Scrotal mass, non-tender - soft in communicating, tense in little communication. May extend to inguinal canal

Transillumination - most are easily transilluminated when a focused beam of light is shone on the scrotum. Omentum or bowel is not easily transilluminated (septations may be seen if bowel)

Enlargement of scrotal mass after activity - increased IAP makes peritoneal fluid flow into scrotal sac so increased mass in coughing, straining, crying, raising arms.

Variation in size of scrotal mass during the day - smaller in morning than evening

NB: non-communicating hydroceles are more common in adults and present with scrotal swelling and vague sensation of heaviness.

Question 7

What are the risk factors for hydrocele?

Answer 7

• male sex - 85%
• prematurity and low birth weight - x20 risk if <1500g at birth
• infants <6 months of age - account for 30% of all paediatric hernias/hydroceles
• infants whose testes descend relatively late
• increased intraperitoneal fluid or pressure
• inflammation or injury within the scrotum
• testicular cancer - 10% of testicular malignancies present with hydroceles
• connective tissue disorders
• varicocelectomy
• filariasis
• maternal exposure to polybrominated biphenyl (a brominated flame retardant and endocrine disruptor)

Question 8

What is a spermatocele?

Answer 8

A spermatocele is an often pain-free benign cyst that occurs close to a testicle. It may also be known as a spermatic or epididymal cyst. The cyst forms in the epididymis. The epididymis is a coiled tube behind each testicle

Question 9

What investigations would you do for hydrocele?

Answer 9

History and exam are usually sufficient for diagnosis but do USS if diagnosis is uncertain

Question 10

Should you treat varicoceles?

Answer 10

No, only if symptomatic.

Question 11

What is the management of a hydrocele?

Answer 11

• Infantile hydroceles = generally repaired if they do not resolve spontaneously by the age of 1-2 years
• Adults:
  
  • Conservative approach
  • +/- Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
  • +/- Surgical hydrocelectomy, excision or plication of the hydrocele - if large and uncomfortable

Question 12

What are the complications of a hydrocele?

Answer 12

• Haematoma
• Inguinal hernia
• Pain in inguinal area radiating to abdomen
• Lower extremity oedema
• Testicular atrophy - due to incarcerated or strangulated hernia due to vascular obstruction
• Hydronephrosis

Surgical complications:

• Infertility - if the epididymis and vas deferens are injured
• Testicular injury after surgery

Question 13

What is the prognosis with hydrocele?

Answer 13

Most non-communicating hydroceles resolve within 2yrs of life - persistence may indicate need for surgical correction

Recurrence is low

2% develop inguinal hernia within 5yrs of surgery - if the processus vaginalis is not adequately dissected and ligated at initial repair