Hydrocele and other conditions of inguino scrotal area. how to differentiate between common confusing pathologies on basis of clinical examination.

1. HYDROCELE
Dr. Ashok Kumar
Professor
Department of Surgery
LHMC & SSK Hospital

2. Why is it Hydrocele ?
• Can get above the swelling
• Fluctuation present
• Transillumination present
• Testis not palpable
• Non reducible swelling
• Impulse on coughing absent

3. Definition ?
• Abnormal collection of serous fluid in some
part of the processus vaginalis usually tunica.

4. TYPES OF HYDROCELE ?
• Primary
• Secondary

5. PRIMARY HYDROCELE ?
• Congenital
• Vaginal
• Infantile
• Hydrocele of the cord

6. SECONDARY HYDROCELE ?
• Causes :-
1. Epididymorchitis
2. Torsion
3. Tumor
4. Post herniotomy

7. Characterstics of secondary
hydrocele ?
1. Lax
2. Moderate size
3. Testis palpable

8. CHARACTERSTICS OF
HYDROCELE FLUID ?
• Amber colour
• Specific gravity – 1.022 – 1.024
• Water, salts , Albumin, Fibrinogen
• Cholesterol and tyrosine crystals

9. CYST WHICH CONTAINS
CHOLESTEROL CRYSTALS ?
• Vaginal hydrocele
• Branchial cyst
• Dentigerous cyst

10. Conditions in which we cant get
above the swelling ?
• Congenital hydrocele
• Infantile hydrocele

11. Can hydrocele present as purely
inguinal swelling ?
YES
Encysted hydrocele of the cord.

12. Conditions in which hydrocele
presents as inguinoscrotal swelling
?
• Congenital hydrocele
• Infantile hydrocele

13. Can hernia present as purely
scrotal swelling ?
• Herniation of hydrocele through dartos
muscle.

14. SWELLING WHICH REDUCE ON
LYING DOWN ?
• Reducible Hernia
• Varicocele
• Lymph varix
• Congenital hydrocele

15. Hydrocele in females ?
• Hydrocele of the canal of nuck.

16. Conditions in which there is loss of
testicular sensations ?
• Syphilitic gumma
• Lepromatous orchitis
• Advanced testicular tumor

17. SWELLINGS SHOWING CROSS
FLUCTUATION ?
• Plunging ranula
• Compound palmar ganglion
• Psoas abscess
• Hydrocele en bisac (Bilocular hydrocele)

18. SWELLING WHICH ARE
BRILLIANTLY TRANSILLUMINANT
?
• Vaginal Hydrocele
• Epididymal cyst
• Cysto hygroma
• Ranula
• Meningocele

19. ABSENT TRANSILLUMINATION ?
• Pyocele
• Hematocele
• Spermatocele
• Chronic hydrocele

20. INTERMITTENT HYDROCELE ?
• Congenital hydrocele

21. Role of ultrasonography ?
• Testis not palpable ; Vaginal hydrocele.
• Palpable but suspicious
• Acute hydrocele

22. How will you differentiate between inguinal
hernia and encysted hydrocele of the cord ?
• Traction test
• Reducibility
• Impulse on coughing

23. Edward Gibbon

24. COMPLICATIONS ?
• Pyocele
• Hematocele
• Testicular atrophy
• Rupture
• Herniation of hydrocele sac
• Infertility

25. Treatment ?
• Congenital hydrocele –
Herniotomy
• Acquired - VAGINAL HYDROCELE –
1. Small size – Lord’s Operation
2. Moderate size – Jaboulay’s Operation
3. Large size – Excision of sac + Jaboulay’s operation
4. Very Large size – Scrotoplasty + Excision of sac +
Jaboulay’s operation

26. LAYERS OF SCROTUM
1. Skin
2. Dartos
3. External spermatic fascia <- External oblique
4. Cremastic fascia <- Internal oblique
5. Internal spermatic fascia <- Fascia
transversalis
6. Tunica Vaginalis

27. Differences between epididymal cyst and
spermatocele ?
CYST OF EPIDIDYMIS
• Bilateral
• Behind the testis
• Irregular surface
• Multilocular
• Transillumination present
SPERMATOCELE
• Usually unilateral
• Behind and above the testis
• Smooth surface
• Unilocular
• Transillumination absent

28. How to differntiate between hematocele and
testicular malignancy ?
HEMATOCELE
• History of trauma present
• Long duration
• Non progressive swelling
• Weight loss absent
• Surface smooth
• Testicular sensation present
• Lymph node absent
MALIGNANCY
• History of trauma absent
• Short duration
• Progressive swelling
• Weight loss present
• Hard / Variable surface
• Testicular sensation absent
• Lymph node present

29. DISEASE and PARTS involved
• FILARIASIS – Epididymorchitis
• TUBERCULOSIS – Epididymitis
• SYPHILIS - Orchitis

30. Q 1. In reaching hydrocele sac
which of the following layer is not
incised ?
1. Dartos muscle and superficial fascia
2. Tunica Albugenia
3. Internal spermatic fascia
4. Cremastic fascia

31. Q 2. Which one of them is not a
recommended procedure for
hydrocele ?
1. Lord’s procedure
2. Jaboulay’s procedure
3. Herniotomy
4. Tapping / Aspiration

32. JABOULAY’S PROCEDURE