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HYDROCELE - IN ADULTS

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Description

Hydrocele is an accumulation of watery fluid in the scrotum, causing it to swell. 

 

Types

Hydrocele may be 1.  Congenital (since birth)
This kind of Hydrocele occurs by virtue of its connection with a hernia of the peritoneal cavity in the congenital variety. A Hydrocele can develop in the womb and continue after birth. Normally, the testicles descend from the developing baby's abdominal cavity into the scrotum. In most cases, each sac closes and the fluid is absorbed. Occasionally, the fluid remains even after the sac is closed. In cases where the fluid persists after a year or the sac remains open, surgery is required.
2.  Acquired Hydrocele:
a)  Primary or idiopathic: The causes of primary Hydrocele include:
i) By excessive production of fluid within the sac, e.g. secondary hydrocele.
ii) By defective absorption of fluid.
iii) By interference with lymphatic drainage of scrotal structures.
b)  Secondary to testicular disease
In older males, a hydrocele can develop as a result of inflammation, infection including sexually transmitted diseases, trauma or radiation injury within the scrotum. Inflammation may be the result of infection of the small coiled tube at the back of each testicle (epididymitis) or of the testicle itself.

Hydrocele Fluid
Hydrocele fluid is amber colored and sterile, and contains albumin and fibrinogen. In long-standing cases, hydrocele fluid is sometimes opalescent with cholesterol and may occasionally contain crystals of tyrosine.

 

Epidemiology

The watery fluid that collects in the scrotum can cause various complications such as rupture, pain or sudden bleeding following trauma. Surgery is performed to prevent these complications and also to prevent re-collection of this fluid.
A Hydrocele may occur due to any one of the reasons discussed below. They are classified into different types based on how they are formed.

 

Symptoms

  • Scrotal swelling either on one side or both sides
  • Slowly growing in size
  • Initially painless
  • Adults experience discomfort & heaviness in the scrotum
  • On examination, Hydrocele appears as a fluctuant swelling in the scrotum. They are almost translucent and it is possible to ‘get above the swelling’ on examination of the scrotum.
 

Other types of Hydrocele

1. Encysted hydrocele of the cord

There is a smooth oval swelling near the spermatic cord which can be mistaken for an inguinal hernia. The swelling moves downwards and becomes less mobile if the testis is pulled gently downwards.

2. Hydrocele of the canal of Nuck

This type of Hydrocele is a rare condition that occurs in females. The cyst lies in relation to the round ligament. Hydrocele of the canal of Nuck may cause inguinal swelling in women, though it is a rare occurrence.

 

Other causes of Hydrocele

Postherniorrhaphy Hydrocele

This kind of Hydrocele occurs as a rare complication of inguinal hernia surgery. It is possibly due to interruption to the lymphatics draining the scrotal contents.

Hydrocele of a hernial sac occurs when the neck of the sac is plugged with omentum or occluded by adhesions.

Filarial hydroceles and chyloceles account for up to 80 % of hydroceles in some tropical countries where the parasite is endemic. Filarial hydroceles follow repeated attacks of filarial epididymo-orchitis. They vary in size and may develop slowly or very rapidly. Treatment is by rest and aspiration. The more usual chronic cases are treated by excision of the sac.

Hematocele usually results from damage to a small vessel during taping of a hydrocele. Prompt refilling of the sac accompanied by pain, tenderness and poor or absent transillumination leads to the diagnosis. Acute hemorrhage into the tunica vaginalis sometimes results from testicular trauma. If the hematocele is not drained, a clotted hematocele usually results.

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 tumor. Indeed a tumor may present as a hematocele. Treatment is by orchidectomy unless the testis is benign. As a rule, it is impossible to be certain unless the testis has been bisected. Often, the testis is compressed and rendered relatively useless.

 

Treatment

A) Congenital hydroceles are a special form of indirect inguinal hernia and are treated by herniotomy (see congenital inguinal hernia).

B) Established acquired hydroceles often have thickened walls. A cut is made into the skin over the hydrocele. After draining the liquid, the testicle is examined. In case of a normal testis, the twin coverings of the testicle are stitched up to stop the re-collection of liquid. If the testicle is diseased, it may even be necessary to remove it. Finally, the skin is stitched up. Lord’s operation is suitable when the sac is reasonably thin-walled. There is minimal dissection and the risk of hematoma is reduced. Eversion of the sac with placement of the testis in a pouch prepared within the coverings of the scrotum is an alternative (Jaboulay’s procedure).
Drainage of the hydrocele fluid through a cannula is simple but the condition always recurs within a week or so. It may be suitable for very elderly infirm men who are unfit even for scrotal surgery under regional anasthesia. Also, injection of sclerosants such as tetracycline is sometimes effective but tends to be very painful and can cause infection.
Secondary hydrocele is most frequently associated with acute or chronic epididymo-ochitis (infection of testis). It is also seen with torsion of the testis and with some testicular tumors. A secondary hydrocele is usually lax and of moderate size: the underlying testis is palpable. If a tumor is suspected, the hydrocele should not be punctured for fear of implantation of malignant cells in the needle track. A secondary hydrocele subsides when the primary lesion resolves.

 

Complications

Rupture usually occurs as a result of trauma but may be spontaneous. On rare occasions, cure results after the fluid has been absorbed.

Herniation of the hydrocele sac through the dartos muscle of scrotum sometimes occurs in long-standing cases.

Transformation into a haematocele occurs if there is spontaneous bleeding into the sac or as a result of trauma.

The sac may also calcify.

Typically, a hydrocele isn't dangerous and usually doesn't affect fertility. However, it may be associated with an underlying testicular condition that may cause serious complications like 

a)     Infection or tumor: Either may reduce sperm production or function.

b)     Inguinal hernia: A loop of intestine could become trapped in the weak point in the abdominal wall (strangulated), a life-threatening condition.

 
 
 
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