3. AN APPROACH TO THE
MANAGEMENT OF
HYDROCELE
Presented by
Dr Shivakumara Aladakatti BAMS
2nd year PG Scholar
Dept of PG Studies in Shalya Tantra
JSS Ayurveda Medical College,
Mysore-570028
Guided by
Dr Siddesh Aradhyamath MS, Ph.D
Professor and Head
Dept of PG Studies in Shalya Tantra
JSS Ayurveda Medical College,
Mysore-570028 3
4. CONTENTS
Introduction
Anatomy of Scrotum and testes
Definition of Hydrocele
Types of Hydrocele
Vaginal Hydrocele
Composition of Hydrocele
fluid
Clinical Features
Local Examinations
Differential Diagnosis
Complications of Hydrocele
Congenital Hydrocele
Funicular Hydrocele
Infantile Hydrocele
Encysted Hydrocele
Bilocular Hydrocele
Secondary Hydrocele
Investigations for Hydrocele
Surgical treatment
Ayurvedic view of Hydrocele
4
5. INTRODUCTION
Abnormal collection of serous fluid between the visceral and
parietal layers of the tunica vaginalis is termed as Hydrocele. It is
the commonest reason for painless scrotal swelling.
Affects about 1% of men, mostly above forty years of age, and
4.7% neonates
It is common in newborn males. Most hydroceles in newborns are
harmless and will resolve on their own by 12 months of age. The
causes of hydroceles that develop in children are different from
those in adults.
5
6. INTRODUCTION
Hydrocele was described as early as the 15th century by
Ambroise Pare.
Age — Primary hydrocele is common in middle-aged people. It
is not uncommon in children.
Geographical distribution.— Hydrocele is more common in
Tropical countries. And in North India
6
7. ANATOMY OF SCROTUM
The scrotum (Latin bag) is a cutaneous bag
containing the right and left testes, the
epididymes and the lower parts of the
spermatic cords.
7
9. TESTIS
The Testis is the male gonad. It is homologous with the ovary of the
female. It is suspended in the scrotum by the spermatic cord. It lies
obliquely, so that its upper pole is tilted forwards and laterally. The
left testis is slightly lower than the right.
Shape and Size
The testis is oval in shape,
and is compressed from
side-to-side. It is 3.75 cm
long, 2.5 cm broad from
before backwards, and 1.8
cm thick from side-to-side.
An adult testis weighs
about 10 to 15 g.
9
11. NERVE SUPPLY
The testis is supplied by sympathetic nerves
arising from segment T10 of the spinal cord.
They pass through the renal and aortic
plexuses.
11
12. DEFINITION OF HYDROCELE
A hydrocele is an abnormal collection of serous
fluid in the tunica vaginalis of the testis or within
some part of the processus vaginalis.
12
13. TYPES
Congenital Hydrocele Acquired Hydrocele
1. Primary or idiopathic hydrocele
The cause of which is unknown
i.e. there is no associated disease
in the testis or the epididymis.
2. Secondary hydrocele
when hydrocele is secondary
to a disease in the testis and/or in
the epididymis. A secondary
hydrocele is usually small.
13
14. CONTI…
PRIMARY OR IDIOPATHIC HYDROCELE
(i) Vaginal hydrocele — the commonest.
(ii) Encysted hydrocele of the cord.
(iii) Infantile hydrocele.
(iv) Congenital hydrocele,
(v) Funicular hydrocele.
Three very rare varieties are —
(vi) Hydrocele of the canal of Nuck.
(vii) Hydrocele of the hemial sac.
(viii) Hydrocele en bisac.
14
15. COMPOSITION OF THE HYDROCELE FLUID
The hydrocele fluid is amber coloured.
Its specific gravity varies between 1.022 to 1.024
It contains water, inorganic salts, 6% of albumin
and some fibrinogen.
In old standing cases variable amount of
cholesterol and
tyrosine crystals.
15
16. PRIMARY OR IDIOPATHIC HYDROCELE
VAGINAL HYDROCELE — This is by far the commonest
variety of hydrocele. In this condition there is abnormal
accumulation of serous fluid within the tunica vaginalis.
Aetiology — Though there is no associated disease of the testis
or the epididymis, yet there must be some reason why abnormal
accumulation of serous fluid takes place in some individuals and
not in all. The possible reasons are
Interference
with drainage
of fluid by the
lymphatic
vessels of the
cord.
There may be
some connection
with the
peritoneal cavity
as in the
congenital
variety
16
17. SIGNS AND SYMPTOMS
In majority of cases the only complaint is —
swelling of the scrotum.
• Occasionally patient does not seek
Advise till the sac has attained enormous size.
• Normally testes are not palpable unless there is
an infection and Filarial hydrocele.
• Fluctuant
• Initially transilluminant
• Discomfort to the patient
• Inflammatory signs if the secondary infection.
• Can get above the swelling
17
18. LOCAL EXAMINATIONS
(i) Position
Though hydrocele is often unilateral, it may be bilateral as well.
(ii) On inspection one side or both the sides of the scrotum are enlarged
with a notch at the middle of the affected side of the scrotum.
(iii) It is a purely scrotal swelling and one can get above the swelling.
18
19. FLUCTUATION TEST
It is positive, as it is a cystic swelling. The cyst is
often tense in primary hydrocele.
19
21. (vi) On percussion it is always dull.
(vii) Reducibility.— Vaginal hydrocele cannot be
reduced.
(viii) Palpation of the testis.— Though
occasionally testis may be palpable posterior to the
vaginal hydrocele, but the testis cannot be felt
separately as the fluid of hydrocele surrounds the
body of the testis. In case of secondary hydrocele
when it is lax the testis may be palpable through
the fluid.
21
25. COMPLICATIONS OF A HYDROCELE
1. Infection.
2. Atrophy of the testis.
3. Rupture — may be traumatic.
4. Haematocele — may result from trauma,
5. Herniation of the hydrocele sac — occurs
in only long standing cases. The sac
herniates through the dartos muscle due to
tension of the fluid.
6. Calcification of the sac — sometimes
occurs in longstanding cases.
7. Infertility
25
26. CONGENITAL HYDROCELE
In this condition the processus vaginalis remains
patent so there is direct communication of the
tunica vaginalis with the peritoneal cavity.
26
27. FUNICULAR HYDROCELE
In this condition the processus vaginalis remains patent upto the top
of the testis where it is shut off from the tunica vaginalis
DIAGNOSTIC FEATURES.—
The swelling is inguinal rather than scrotal.
(ii) The testis can be felt separately.
(iii) Other features are similar to those of congenital hydrocele
27
28. INFANTILE HYDROCELE
Here tunica and processus
vaginalis (hydrocele) are
distended up to deep inguinal
ring, but sac has no connection
with the general peritoneal
cavity.
28
29. ENCYSTED HYDROCELE OF THE CORD
When the central portion of the processus vaginalis remains
patent, but its upper and lower parts are obliterated, in such
condition Fluid accumulates in the patent portion of the
processus vaginalis and presents a swelling in relation to the
spermatic cord. Such swelling is a localized oval cystic swelling
situated in the scrotal region, inguinoscrotal region or in the
inguinal region.
29
31. HYDROCELE OF THE CANAL OF THE NUCK
It occurs in females, in relation to the round ligament,
always in the inguinal canal.
HYDROCELE OF THE HERNIAL SAC
It is due to adhesions of the content of hernial sac. Fluid secreted
collects in the sac and forms hydrocele of the hernial sac.
31
32. SECONDARY HYDROCELE
Causes
Infection: Filariasis
Tuberculosis of epididymis - 30% cases have secondary
hydrocele
Syphilis
Injury: Trauma, postherniorrhaphy hydrocele
Tumour: Malignancy Secondary hydrocele rarely attains
large size.
It is usually small, lax and testis is usually palpable
Exception is, secondary hydrocele due to filariasis. It can be
very large.
32
34. CONSERVATIVE LINE OF MANAGEMENT
Antibiotics
Analgesics and Anti-inflammatory
if pain is there
Tapping should be done
Sclerotherapy
34
35. TAPPING
This operation, though not a radical treatment, is
often indicated in case of old patients.
A wheal of local anesthetic solution is raised in an
area of the scrotal skin that is free of visible vessels.
Incision is made on this place of the scrotal wall till
the tunica vaginalis is reached
A fine trocar and a cannula are then thrust into the
sac through the scrotal incision
The fluid is evacuated slowly to avoid shock. Once
all the fluid has been evacuated, the cannula is
withdrawn and the wound in the scrotal wall is
sealed.
35
36. SURGERIES FOR HYDROCELE
• Subtotal excision of the sac
• Jaboulay’s operation
• Evacuation and eversion
• Lord’s plication
36
37. INDICATIONS FOR SURGERY
Medical disqualification due to untreated Hydrocele
Interference with work
Interference with sexual function
Interference with Micturition due to the penis getting
buried in the scrotal sac
Negative impact on patient’s family
Dragging pain
Liability to trauma in view of nature of patient’s
work or mode of transportation such as excessive
cycling.
37
38. PRE-OPERATIVE
NBM 6 hours prior to the surgery
Consent taken from the patient
Inj TT 0.5ml stat dose
Inj Xylocaine test dose
blood urine routine investigations
USG Abdomen and Pelvis
Chest x-ray (PA) view if necessary
Physician fitness for surgery
Part preparation
38
39. PROCEDURE
Under G/A or spinal or L/A
after painting and draping
vertical incision of about 6-8 cm in length is made over the scrotum, anteriorly
1 cm lateral to the median raphe
Skin, dartos, external spermatic fascia, internal spermatic fascia are incised
Bluish hydrocele sac is identified, i.e. parietal layer of the tunica vaginalis of
testis.
Fluid is evacuated using trocar and cannula. Sac is opened.
Drain all the collected fluid, Eversion of sac and suturing done
After that put a drain and close the wound
39
40. Subtotal excision
of sac
If the sac is thick, in
large hydrocele and
chylocele, subtotal
excision of the sac is
done ( tunica vaginalis
is reflected on to the
cord structures and
epididymis
posteriorly,)
Jaboulay’s
operation
Often the sac is
excised partially
and then eversion
is done, which is
called as
Jaboulay’s
operation.
Lord’s procedure of
excision of sac
This operation is mainly
indicated for big size
hydrocele. The steps of
operation up to opening of
the tunica vaginalis are same
as those of the previous
operation. The tunica
vaginalis is now sutured
with 10 to 12 catgut sutures
from the out edge of the
tunica to the reflection of the
tunica from the testis and the
epididymis. When these
sutures are tied, the whole
tunica is bunched at the edge
of the testis.
40
41. POST-OPERATIVE
NBM 6 hours after procedure start with sips of
water and followed by liquid diet
Restricted head movements
Proper wound care management
Post op antibiotics to prevent infection
Drain should be removed after 48 hours.
41
42. COMPLICATIONS OF SURGERY
• Reactionary hemorrhage
• Infection
• Pyocele
• Sinus formation
• Recurrent hydrocele
42
44. MUTRAVRDDHI
मुत्रसधरणशीलस्य मुत्रव्रुद्धिर्भवति, सा गच्छिोऽम्बूपूणाभ
द्रुतिररव क्षुभ्यति मुत्रक्र
ु च्छ
र वेदनाम् व्रुषणयोोः श्वयथुुं
कोशयोश्चापादयति, िाुं मुत्रवॄद्धिुं तवध्याि् (su ni 12/6)
Mutrajavruddi occurs in those people who suppress the
urge of Urination habitually, in coarse of time, the
scrotum develops movements like a bag full of water,
Dysuria, pain in the testicles and swelling of the
scrotum. This should be understand as mutrajavrddi.
44
45. CHIKITSA
मूत्रजाुं स्वेदतयत्वा िु वस्त्रपत्तेन वेष्टयेि् ॥१८॥
सेवन्ाोः पाश्वभिोऽधस्तातिध्येद् तव्रतिमुेेन िु ॥
अथात्र तिमुेाुं नाडीुं दत्वा तवस्रावयेद्धिषक
् ॥१९॥
मूत्रुं नातडुंमथोध्रुत्य स्थतगकाबन्धमाचरेि् ॥
शुिायाुं रोपणुं दद्याद् ( su chi 19)
Scrotal enlargement caused by urine should be
fomented and bandaged. Then it should be punctured with
trocar at the lower part on side of the raphe and fluid
should be drained out by surgeon after introducing
cannula with double Opening.Then the cannula should be
removed and stump bandage applied. After the wound is
cleansed. Healing measures should be employed.
45
46. मूत्रजुं स्वेतदिुं तिग्धैवभस्त्रपत्तेन वेतििुं ।
तवध्येदधस्तात्सेवन्ाोः स्रवयेच्च यथोदरम् ॥३९॥
व्रणुं च स्थतगकाबिुं रोपयेि्
( AH chi 1339)
Mutraja vrddhi should be given Fomentation.
Wrapped with cloth soaked in oil.
Punctured below near the Raphea.
Fluid drained out by using vrihimukha shastra.
Applied with Sthagika Bandha and wound should be
Treated.
46
48. PATHYA
Vyayama
Maintain hygiene
Vegetables and fruits
Wearing good and Suitable inner wears
Apathya
Guru, snigdha and sheeta Ahara
Kaphakara Ahara-vihara
Excessive exercise and cycling
Not maintaining Hygiene
48
49. DISCUSSION
Hydrocele is an easily treatable surgical disease and no
acute conditions are noted
A hydrocele is often diagnosed with an ultrasound of the
scrotum and testicles. The sonogram will typically
demonstrate a thin-walled, anechoic fluid collection on
the anterolateral aspect of the testicle.
Hydrocele can be taken as a elective case for surgery
49
50. DISCUSSION
People are afraid of the organ involved in this disease and they
think that it is very serious but it is normal for surgeons
Scrotal swelling can be seen in all age group and in tropical
regions more.in children it will be congenital and resolve by it’s
own up to 1 year of Age. In middle aged people it is primary or
idiopathic , but in old age people one should confirm with
Testicular cancer.
In our classics mutra vrddhi explained under vrddhi roga.The
earliest method of treating this is tapping, Sthagika Bandha and
Gophana Bandha, which even holds good in modern days also.
One should not neglect this condition without taking proper
treatment then it leads to complications. 50
51. CONCLUSION
Hydrocele is not a cumbersome disease
It is more in North Indian people and who are
riding bicycles more in South India its occurrence
is less.
It is common in newborn males. Most hydroceles
in newborns are harmless and will resolve on
their own by 12 months of age
It can be treated by surgical methods more
satisfactorily than conservative line.
51
52. REFERENCES
1. Prof. Sriram Bhat M SRB’s Manual of Surgery.
New Delhi,Jaypee publications,5th Edition,
2017. page no 1017.
2. Somen das, A concise text book of Surgery,
Kolkata, 6th Edition,2010. page no 1180.
3. Bailey & Love, ed; Norman S Williams et al;
Short Practice of Surgery. London: Taylor &
Francis Group, 27th edition, 2018.
4. B D Chaurasia’s Human Anatomy volume 2, 5th
Edition, CBS Publishers and Distributors, 2020.
page no 260
5. Acharya YT, et al; Susruta Samhita with
Nibandha Sangraha and Nyayachandrika
commentary. Varanasi: Chaukhambha
Surbharati Prakashan, 2012 edition. Nidana
sthana, Chapter 12 , Shloka no 6 52
53. REFERENCES
6. Acharya YT, et al; Susruta Samhita with Nibandha
Sangraha and Nyayachandrika commentary. Varanasi:
Chaukhambha Surbharati Prakashan, 2012 edition.
Chikitsa Sthana, Chapter 19 , Shloka no 18-19.
7. Dr. P.V. Tewari Caraka Samhita English Translation of
text with Ayurveda Dipika commentary of cakrapani datta,
Varanasi: Chaukhambha Vishvabharati. Student Edition,
2020. Chikitsa Sthana, Chapter 12 , Shloka no 94-95.
8 Prof. K. R. Srikantha Murthy Vaghata’s Astanga
Hridayam, English Translation, Varanasi,Chowkamba
Krishnadas Academy 2004. chikitsa Sthana 13 chapter,
shloka no 39.
9. An Elsevier journal of Infertility seconadary to an infected
hydrocele; A case report, by Moayid Fallatah, Alfaisal
University, Riyadh, Saudi Arabia. 8 November 2019.
53
57. मुत्रेण पूणं म्रुदु मेदसा चेि् तिग्धुं च तवध्याि् कतिनुं च शोथम् ॥ ९४ ॥
तवरेचनाभ्यङ्गतनरुिलेपाोः पक्व
े षु चैव व्रणवद्धच्चतकत्सा।
स्यन्मूत्रमेदोःकफ़जुं तवपाट्य तवशोध्य सीव्येद् व्रणवच्च पक्वम् ॥ ९५ ॥
( cha chi 1294)
The scrotum filled with urine is soft, while if it is filled
with medas the swelling will be unctuous and hard.
these should be treated with
Virechana
Abhyanga
Niruha basti
Lepa
The scrotal swelling caused by mutra, medas and kapha
should be incised, after cleansing the morbidity it shoud be
sutured. 57
58. DIAGNOSTIC FEATURES
(i) Congenital hydrocele is present since birth.
(ii) When the patient lies horizontal, the hydrocele
disappears as the fluid in the tunica vaginalis drains
into the abdominal cavity. In the erect posture
hydrocele appears again.
(iii) In contradistinction to assumption, congenital
hydrocele is not easily reducible due to narrowness
of the deep inguinal ring.
58
59. INFANTILE HYDROCELE
DIAGNOSTIC FEATURES.—
Not necessarily it is seen in infants, it is often seen in
adults.
(ii) It gives rise to an inguinoscrotal swelling, very
much similar to the inguinal hernia. It is not
reducible and there is no impulse on coughing.
(iii) It is a cystic swelling.
(iv) Fluctuation test is positive.
(v) Transillumination test is positive.
(vi) It does not disappear when the patient lies down.
59
60. DIAGNOSTIC FEATURES ENCYSTED
Oval cystic swelling in relation to the spermatic
cord.
(ii) Such cystic swelling is seen in the inguinal,
inguino-scrotal or scrotal region depending on
which part of the processus vaginalis is patent.
(iii) The testis can be felt separate from the
swelling.
(iv) In the swelling fluctuation test and
transillumination test are positive.
60
61. CONTI..
(v) As the upper part of the processus vaginalis
is obliterated — the swelling is not reducible
and cough impulse is absent.
(vi) Traction test.— This important test is
pathognomonic of this condition. When gentle
traction is exerted on the testis the swelling
moves downwards and becomes less mobile.
61
62. FILARIAL HYDROCELE AND CHYLOCELE
• Occurs commonly in coastal region, and in and
around the equator.
• Usually occurs after repeated attacks of filarial
epididymitis.
• Hydrocele is usually of large size and the sac is
thickened.
• Fluid contains fat, rich in cholesterol, and is derived
from ruptured lymph varix into the tunica.
• It is often difficult to differentiate from primary
hydrocele.
62
63. DRAINAGE
Unnecessary drainage is not at all advised. Drainage is
only indicated
(i) When the hydrocele is a big one.
(ii) When the surgeon is not sure about haemostasis.
(iii) In case of haematocele.
(iv) In case of filariasis.
(v) In case of infected sac. Drainage is provided with a
corrugated rubber sheet which is fixed to the skin with
nylon or silk. The drainage must be removed within 48
hours or earlier if the soakage is much less
63
