HYDROCELE 02  HYDROCELE  Shuja Tahir, FRCS(Edin), FCPS (Hon)                                     ETIOLOGY & PATHOPHYSIOLOG...
HYDROCELE 03Adult-onset hydrocele may be secondary to orchitis        closure through infancy and childhood. Hydrocelesor ...
HYDROCELE 04or increase in the upright position. Chronically           erythema or scrotal discoloration is observed.forme...
HYDROCELE 05is 86-100%; specificity is up to 100%.                         incomplete torsion, and following detorsion.   ...
HYDROCELE 06SURGICAL COMPLICATIONS                                        later in life depends upon the etiology of theAc...
31 uro-hydrocele
Upcoming SlideShare
Loading in...5

31 uro-hydrocele


Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

31 uro-hydrocele

  1. 1. HYDROCELE 02 HYDROCELE Shuja Tahir, FRCS(Edin), FCPS (Hon) ETIOLOGY & PATHOPHYSIOLOGYHydrocole is collection of fluid in persistant tunica than 40 years.vaginalis in males. It is collection of serous fluidresulting from a defect or irritation in the tunica Hydrocele is bilateral in 7-10% of cases. Hydrocelevaginalis of the scrotum. Hydroceles also may arise often is associated with hernia, especially on thein the spermatic cord in males or the canal of Nuck in right side of the body in infants and children.females. ETIOLOGYFREQUENCY Most pediatric hydroceles are congenital; however,Hydrocele is estimated to affect 1% of adult men. malignancy, infection, and circulatory compromiseMore than 80% of newborn boys have a patent are possible causes of hydrocele.processus vaginalis, but most close spontaneouslywithin 18 months of age. Hydrocele of the cord is associated with pathologic closure of the distal processus vaginalis, whichMost hydroceles are congenital and are noted in allows fluid pooling in the mid portion of thechildren aged 1-2 years of age. The incidence of spermatic cord.hydrocele is rising with the increasing survival rate ofpremature infants and with increasing use of the Communicating hydrocele is caused by failedperitoneal cavity for ventriculoperitoneal (VP) closure of the processus vaginalis at the internal ring.shunts, dialysis, and renal transplants. Hydrocele is Noncommunicating hydrocele results froma disease observed only in males. Chronic or pathologic closure of the processus vaginalis andsecondary hydroceles usually occur in men older trapping of peritoneal fluid. Hydrocele (trans illumination test) Hydrocele (ultrasound scan) Hydrocele (ultrasound scan)SURGERY - UROLOGICAL PROBLEMS 258
  2. 2. HYDROCELE 03Adult-onset hydrocele may be secondary to orchitis closure through infancy and childhood. Hydrocelesor epididymitis. Hydrocele also can be caused by are classified into three principal types.malignancy, tuberculosis and by tropical infectionssuch as filariasis. CONGENITAL These are also called a communicating (congenital)Testicular torsion may cause a reactive hydrocele in hydroceles. Patent processus vaginalis permits flow20% of cases. The clinician may be mis-led by of peritoneal fluid into the scrotum. Indirect inguinalfocusing on the hydrocele, which delays the hernias are associated with this type of hydrocele.diagnosis of torsion. Tumor, especially germ cell ACQUIREDtumors or tumors of the testicular adnexa may cause It is also called noncommunicating hydrocele. Patenthydrocele. Traumatic (ie, hemorrhagic) hydroceles processus vaginalis is present, but no communi-are common. Ipsilateral hydrocele occurs in as many cation with the peritoneal cavity occurs.as 70% of patients after renal transplantation.Radiation therapy is associated with cases of HYDROCELE OF CORDhydrocele. Closure of the tunica vaginalis is defective. The distal end of the processus vaginalis closes correctly, butExstrophy of the bladder may lead to hydrocele. the mid portion of the processus remains patent. TheHydrocele may arise from Ehlers-Danlos syndrome. proximal end may be open or closed in this type ofHydrocele may result from a change in the type or hydrocele.volume of peritoneal fluid, like in patients undergoingperitoneal dialysis and those with a ventri- SECONDARY HYDROCELEculoperitoneal shunt. Adult hydroceles are usually late-onset (secondary). Late-onset hydroceles may present acutely followingPATHOPHYSIOLOGY local injury, infections, and radiotherapy; these mayEmbryologically, the processus vaginalis is a present chronically from gradual fluid accumulation.diverticulum of the peritoneal cavity. It descends with Morbidity may result from chronic infection afterthe testes into the scrotum via the inguinal canal surgical repair. This type of hydrocele can adverselyaround the 28th gestational week with gradual affect fertility. PRESENTATIONSASYMPHTOMATIC SCROTAL DISCOMFORTMost hydroceles are asymptomatic or subclinical. Sensation of heaviness, fullness, or dragging may beOnset, duration, and severity of signs and symptoms felt by the patient. Patients occasionally report mildare evaluated. Relevant genitourinary (GU) history, discomfort radiating along the inguinal area to thesexual history, recent trauma, exercise, or systemic mid portion of the back.illnesses are identified. PAINSCROTAL SWEELING Hydrocele usually is not painful; pain may be anMost common presentation is a painless enlarged indication of an accompanying acute epididymalscrotum. infection. The size may decrease with recumbencySURGERY - UROLOGICAL PROBLEMS 259
  3. 3. HYDROCELE 04or increase in the upright position. Chronically erythema or scrotal discoloration is observed.formed hydroceles appear to be larger in size thanacutely formed ones. Transillumination A light source shined through the scrotum causes theSYSTEMIC SYMPTOMS hydrocele to illuminate. The bowel also mayFever, chills, nausea, or vomiting are absent in transilluminate; thus, positive transilluminationuncomplicated hydrocele. GU symptoms are absent findings are not diagnostic of hydrocele. Positivein uncomplicated hydrocele. transillumination findings should not stop the clinician from investigating serious causes or co-Hydroceles are located superior and anterior to the morbid conditions that may be associated withtestis, in contrast to spermatoceles, which lie secondary hydrocele. This procedure is not reliablesuperior and posterior to the testis. for final diagnosis.The size and the palpable consistency of hydroceles Transillumination test is usually positive.can vary with position. Hydrocele usually becomessmaller and softer after lying down, it usually A light source shines brightly through a hydrocele.becomes larger and tenser after prolonged standing. Transillumination is common, and diagnostic forSystemic signs of toxicity are absent. The patient is hydrocele. Transillumination may be observed withusually afebrile with normal vital signs. Abdominal or other etiologies of scrotal swelling (eg, hernia).testicular tenderness is absent. No abdominal DIFFERENTIAL DIAGNOSISdistension is present. Bowel sounds cannot be Indirect inguinal herniaauscultated in the scrotum unless an associated Epididymitishernia is present. Traumatic injury to the testicleUnless an infection causes an acute hydrocele, no INVESTIGATIONSBLOOD EXAMINATION bowel.A CBC with differential count may indicate theexistence of an inflammatory process. Urinalysis Hydrocele appears as a cystic mass within themay detect proteinuria or pyuria. spermatic cord (hydrocele of the cord) or as mass surrounding the testicle.ULTRASOUND SCANIt is used to confirm the diagnosis. It may be useful to DOPPLER ULTRASOUND FLOW STUDYidentify abnormalities in the testis, complex cystic This study is recommended to assess perfusion,masses, tumors, appendages, spermatocele, or even if an acute scrotum is clinically unlikely. Thisassociated hernia. In the context of pain or testicular must be performed urgently if there is suspicion ofbleeding after trauma, an imaging test can testicular torsion or of traumatic hemorrhage into adifferentiate between a hydrocele and incarcerated hydrocele or testes. Sensitivity of Doppler ultrasoundSURGERY - UROLOGICAL PROBLEMS 260
  4. 4. HYDROCELE 05is 86-100%; specificity is up to 100%. incomplete torsion, and following detorsion. Specificity for torsion can be 90%, but it is decreasedLimited availability of this test within a clinically useful in the presence of scrotal fluid collections (such asperiod reduces its usefulness. hydrocele, hernia, abscess and hematocele).TESTICULAR SCINTIGRAPHY X-RAY ABDOMENThis nuclear scan is particularly useful, especially in Abdominal x-ray findings usually are normal inchildren, if testicular torsion is suspected. Decreased patients with hydrocele. If films demonstrate anor absent flow to one testis or a testicular pole obstructive gas pattern, they may help toindicates torsion. Sensitivity for torsion can be 90%, differentiate between incarcerated hernia andbut it is decreased with infancy, early torsion, hydrocele. TREATMENTASPIRATION hydrocele.Aspiration of a hydrocele reveals a clear amber fluid. ! Ischemic testicle in childrenAspiration is not therapeutic because the fluidgenerally reaccumulates quickly. Aspiration of SURGICAL TREATMENThydroceles is not recommended because it is Hydrocele is treated through inguinal incisions withassociated with a high rate of immediate recurrence high ligation of the patent processus vaginalisand with a risk of introducing an infection. If an (herniotomy) and excision of the distal sac.associated hernia is present, risk of perforating a ! Herniotomyloop of bowel also exists. ! Eversion of sac ! Lord’s operationEMERGENCY CAREDifferentiating between a hydrocele and an acute Spontaneous closure is unlikely in children olderscrotum (eg, testicular torsion, strangulated hernia) than 1 year. Infants with hydrocele are observed foris important. As many as 50% of acute scrotum 1-2 years. Surgical treatment is offered afterwards.cases are initially misdiagnosed. COMPLICATIONSTransillumination is not diagnostic and cannot rule An extremely large hydrocele may impinge on theout an acute scrotum. testicular blood supply. The resulting ischemia can cause testicular atrophy and subsequent impairmentUltrasound examination, imaging and Doppler of fertility.evaluation of testicular blood flow is indicated whenan acute scrotum is suspected. Hemorrhage into the hydrocele can result from testicular trauma.ACUTE SCROTAL PROBLEMS! Traumatic hemorrhage into a hydrocele or Incarceration or strangulation of an associated testes hernia may occur.! Testicular torsion with or without a secondarySURGERY - UROLOGICAL PROBLEMS 261
  5. 5. HYDROCELE 06SURGICAL COMPLICATIONS later in life depends upon the etiology of theAccidental injury to the vas deferens can occur hydrocele.during inguinal surgery for hydrocele. Adult-onset hydrocele is not uncommonlyPostoperative wound infections occur in 2% of associated with an underlying malignancy.patients undergoing surgery for hydrocele. MISCELLANEOUSPostoperative hemorrhagic hydrocele is not Medical/Legal Pitfallsuncommon, but it usually resolves spontaneously. In a patient with signs and symptoms of an acute scrotum, the presence of a hydrocele and a finding ofDirect injury to the spermatic vessels may occur. positive transilluminance does not rule out testicular torsion. Immediate definitive tests are indicated toPROGNOSIS rule out torsion because testicular survival is poorThe prognosis for congenital hydrocele after surgery after 4 hours of ischemia. A reasonable search foris excellent. possible etiologies should be documented.Most congenital cases resolve by the end of the first SPECIAL CONCERNSyear of life. Pediatric: Most cases resolve without intervention. Geriatric: Hydroceles in this group rarely resolvePersistent congenital hydrocele is readily corrected without surgical intervention.surgically. The prognosis of hydrocele presentingREFERENCES1. Blaivas M, Brannam L. Testicular ultrasound. Emerg Med 4. Schul MW, Keating MA. The acute pediatric scrotum. J Clin North Am. Aug 2004;22(3):723-48, ix. [Medline]. Emerg Med. Sep-Oct 1993;11(5):565-77. [Medline].2. Jayanthi VR. Adolescent urology. Adolesc Med Clin. Oct 5. Skoog SJ, Conlin MJ. Pediatric hernias and hydroceles. 2004;15(3):521-34. [Medline]. The urologists perspective. Urol Clin North Am. Feb 1995;22(1):119-30. [Medline].3. McAchran SE, Dogra V, Resnick MI. Office urologic ultrasound. Urol Clin North Am. Aug 2005;32(3):337-52, 6. Tanagho EA, McAninch JW. Disorders of the spermatic vii. cord. In: Smiths General Urology. 1992;620-3. [Medline].SURGERY - UROLOGICAL PROBLEMS 262