Hydrocele and Varicocele

Question 1

What is a Hydrocele

Answer 1

collection of fluid between visceral and parietal layers of tunica vaginalis
MCC is idiopathic

Question 2

What inflammatory conditions are associated with a hydrocele

Answer 2

Epididymitis
Torsed appendix testis
-Hydrocele resolves by treating underlying condition

Question 3

How does a hydrocele present

Answer 3

unilateral scrotal enlargement

Question 4

What should the PE for a hydrocele include

Answer 4

palpation
transillumination
-Scrotal US (fluid around testis)

Question 5

How do you treat an asymptomatic or minimally symptomatic hydrocele

Answer 5

Reassurance and monitoring

They are not emergent

Question 6

How can you treat a bothersome hydrocele

Answer 6

Electively:
needle aspiration + sclerosing agent injection (doxy) to minimize recurrence
hydrocelectomy

Question 7

What does a sclerosing agent do

Answer 7

induces an inflammatory reaction causing layers of tunica vaginalis to stick together

Question 8

How is a needle aspiration (hydrocele Tx) done

Answer 8

in office, awake pt, with local anesthesia for spermatic cord block
after inserting needle into hydrocele and aspirating fluid, inject doxy into empty hydrocele sac
S/E: can possibly lead to infection, hematoma, and pain

Question 9

How do you preform a hydrocelectomy

Answer 9

In OR with anesthesia, trans-scrotal incision is made, hydrocele sac opened, and fluid drained
Then evert and marsupialize the tunica vaginalis to minimize recurrence
Suture penrose drain to scrotum overnight
S/E: can possibly lead to pain, hematoma, infection, rarely loss of testis

Question 10

What is a varicocele

Answer 10

dilated veins of pampiniform plexus (= low flow= blood build up in testis)

Question 11

What are the effects of a varicocele

Answer 11

pain
fibrosis of testis
decreased spermatogenesis, testis atrophy
infertility (stress pattern on semen)

Question 12

What will you note on PE of a varicocele

Answer 12

Bag of worms!!!

must examine patient supine, standing, and valsalva while standing

Question 13

What are the grades of a varicocele

Answer 13

I: small, palpable on valsalva
II: medium, palpable while standing
III: large, grossly visible

Question 14

Which side is a varicocele MC on

Answer 14

left!
the left gonadal vein drains into the left renal vein, and then into the IVC. so it is a slower system than the right, and more likely to have a varicocele

Question 15

When would you simply surveil a varicocele

Answer 15

If palpable in a young man, with normal semen analysis (do semen analysis q1-2 years)
If normal testis size in children (measure testis annually for atrophy)

Question 16

When would surgery be an option for varicocele treatment

Answer 16

If symptomatic
If palpable with abnormal semen analysis (couple is infertile and female is nl)
If testis is small/atrophied (you can reverse atrophy)

Question 17

What surgeries are available to treat varicocele if necessary

Answer 17

Ligation of gonadal vein to redirect venous outflow (open or laparoscopic)
Percutaneous embolization

Question 18

Are varicocele repairs effective

Answer 18

Yes, 70% of men see improvement in semen quality s/p 3-6 mo after repair