A hydrocele is a fluid collection in the tunica vaginalis surrounding the testes, commonly seen in newborns and categorized into communicating and non-communicating types. Diagnosis involves physical examination and imaging to differentiate it from other scrotal conditions, with management strategies based on symptoms and persistence, ranging from observation to surgical intervention. Complications may arise from surgery, and alternative treatments like sclerotherapy are reserved for high-risk patients.

1. HYDROCELE
Presenter :Udite Vukicanavanua
Student ID: 20180233

2. INTRODUCTION
● A hydrocele is a collection of serous fluid between the parietal and visceral layers of
the tunica vaginalis which directly surrounds the testes and the spermatic cord
● Range from small soft collections that still permit palpation of scrotal contents, to tense
collections of several litres.
● Hydroceles are common in newborns, the majority of which in neonates resolve
spontaneously, usually by the first or second birthday
● In older children ,adolescents or adults hydroceles may be idiopathic or may occur
secondary testicular pathology
● Most cases are non- painful( pain generally correlated with the size, inflammatory
processes)

3. Normal testicular anatomy Hydrocele

4. Anatomic structures that may be involved in scrotal conditions :
● Testis (testicle): is the male gonad responsible for production of sperm and androgens (primarily
testosterone). The normal testis is ovoid, about 3 to 5 cm in length, and firm with smooth surfaces.
One testis may be slightly larger than the other, and one testis (usually the left) may hang slightly
lower.
● Tunica vaginalis: is a fascial layer which encapsulates a potential space encompassing the
anterior two-thirds of the testis. Different types of fluid may accumulate within the tunica vaginalis
(eg, peritoneal or serous fluid with a hydrocele, blood with a hematocele, pus with a pyocele).
● Epididymis: is a tightly coiled tubular structure located on the posterior aspect of the testis
running from its superior to inferior poles. Sperm travels from the tubules of the rete testis into
the epididymis, which joins the vas deferens distally. The function of the epididymis is to aid in
the storage and transport of sperm cells that are produced in the testes, as well as to facilitate
sperm maturation.

5. • Spermatic cord: consists of the testicular blood vessels, ilioinguinal nerve
branches,cremasteric muscle fibers, fat, and the vas deferens. Is connected to the superior
pole of the testis and epididymis and traverses cephalad into the retropubic space.

6. HYDROCELE TYPES :
1. Communicating hydroceles (congenital): usually develop as a result of failure of the processus
vaginalis to close during development thus babies who are born prematurely are high risk. The fluid
around the testis and cord is peritoneal fluid. Are often associated with inguinal hernias (complication).
- Collection of fluid can occur anywhere along the path of descent of the testis.
Embryology
Testes — The testes appear on the ventromedial aspect of the urogenital ridge on the posterior
abdominal wall during the fifth to sixth week of gestation. By the 10th week, they have descended
through the coelomic cavity and can be found close to the groin. The processus vaginalis forms during
the third month of gestation from an outward protrusion of the peritoneum that lines the ventral
abdominal wall and forms a diverticulum at the internal inguinal ring. Between the seventh and ninth
months of gestation, the testes descend through the inguinal canal and into the scrotum, pushing the
processus vaginalis ahead and protruding into its cavity. Once this process is complete, the processus
vaginalis obliterates spontaneously, usually by age two years .

8. INGUINAL HERNIA TYPES :
Indirect inguinal hernia - Indirect inguinal
hernias are the most common type of hernia
in both males and females . Are classified as
lateral hernias by the European Hernia
Society groin hernia classification
system .Indirect hernias protrude at the
internal inguinal ring ( the site where the
spermatic cord in males and the round
ligament in females exit the abdomen) .The
origin of the hernia sac is located lateral to
the inferior epigastric artery
Direct inguinal hernia - protrude medial to
the inferior epigastric vessels within
Hesselbach's triangle( formed by the inguinal
ligament (Poupart's ligament) inferiorly, the
inferior epigastric vessels laterally, and the
rectus abdominis muscle medially)

9. 2. Non-communicating hydroceles ( acquired) : have no connection to the peritoneum; the fluid comes
from the mesothelial lining of the tunica vaginalis( or from fluid remnants after the proximal aspect
closes). Are also belived to arise from imbalance of secretion and reabsorption of fluid from the tunica
vaginalis ( idiopathic/ primary) or secondary to epididymitis, orchitis, testicular torsion, torsion of the
appendix testis or epididymis, trauma, or tumor (reactive hydroceles). These conditions must be excluded
. Idiopathic hydrocele is the most common type and arises over a long period of time. Inflammatory
conditions of the scrotal contents can produce an acute reactive hydrocele ( treat the underlying
condition).

10. Spermatic cord hydrocele ( congenital) — A hydrocele of the spermatic cord occurs when fluid
accumulates along the cord in the inguinal canal or upper scrotum, but is separated from the testes. A
cord hydrocele occurs from an abnormal closure of the processus vaginalis where the distal portion
closes and midportion remains patent along the cord.
-Are typically classified into one of two types:
a) Non-communicating (encysted) – This is the most common variety and is characterized by fluid
pooling along the length of the cord but not communicating with the peritoneal cavity or tunica vaginalis.
Since the encysted type does not communicate with the peritoneal cavity, the size does not change with
increases in intra-abdominal pressure, such as crying fits or coughing, nor is this type reducible.
b) Communicating (funicular) – Unlike the encysted type, the funicular type communicates freely with
the peritoneal cavity at the internal ring. Therefore, the swelling in the inguinal area can enlarge with
increased intra-abdominal pressure, and can decrease in size when the patient relaxes. Communicating
cord hydroceles can be difficult to distinguish from indirect inguinal hernias on physical examination, and
ultrasound is frequently required to establish the diagnosis.
Regardless of type, children with spermatic cord hydroceles warrant referral to a surgeon with pediatric
and genitourinary expertise. Herniotomy is frequently performed to prevent later development of an
indirect inguinal hernia.

11. Encysted non-communicating (B) Funicular communicating

12. CLINICAL PRESENTATION
- Patients present with a heavy cystic scrotal mass of one or both testis.
-A hydrocele that communicates with the peritoneal cavity may increase in size during the
day or with the Valsalva maneuver. In contrast, non- communicating hydroceles are not
reducible and do not change in size or shape with crying or straining.
-Although rare, large, non-communicating hydroceles may extend through the inguinal ring
and into the abdomen creating an abdominal scrotal hydrocele. This condition is suspected
when abdominal extension of the hydrocele into the abdominal cavity is present on
examination and confirmed by sonogram
-In patients with testicular pain and scrotal swelling, the hydrocele may arise from
epididymitis, orchitis, testicular torsion, torsion of the appendix testis, testicular rupture,
testicular hematoma, or tumor as the primary etiology (reactive hydroceles); Doppler
ultrasonography is usually necessary to evaluate these patients further.

13. DIAGNOSTIC EVALUATION:
- Physical examination: Hydrocele fluid in the scrotal sac generally transilluminates well and
demonstrates a cystic fluid collection ( differentiates it from a possible hematocele, hernia, or
solid mass). Communicating hydroceles are often reducible; non-communicating hydroceles are
not.
- Imaging modality : Doppler ultrasonography may be necessary to evaluate the testicle and rule
out a primary cause or to determine if an abdominoscrotal hydrocele is present.
- A scrotal ultrasound should be considered if the diagnosis is uncertain since a reactive hydrocele
can occur in the presence of a testicular neoplasm or with acute inflammatory scrotal conditions
(orchitis, epididymitis).
- blood or urine test may be used to rule out infection.

14. MANAGEMENT:
- Most hydroceles do not require intervention. Treatment is only indicated in patients who are
symptomatic. For asymptomatic patients with hydroceles, there is no need for routine follow-up.
- The management of asymptomatic hydroceles in a neonate or child younger than one to two years
of age usually is supportive. Hydroceles that are present in newborns, whether communicating or
non-communicating, usually resolve spontaneously by the second birthday, unless they are
accompanied by an inguinal hernia or are large
- Surgical repair is indicated for communicating hydroceles that persist beyond one to two years of
age and for idiopathic, non-communicating hydroceles that are symptomatic or compromise the
skin integrity
-Communicating hydroceles in patients older than two years of age rarely resolve and pose a risk
for development of incarcerated inguinal hernia. Surgical repair of communicating hydroceles is
usually undertaken on an elective basis
- Idiopathic non-communicating hydroceles are often asymptomatic. Surgical repair may be
indicated for symptomatic complaints and for abdominal scrotal hydroceles
-Reactive hydroceles usually resolve with treatment of the underlying condition

15. - Scrotal surgery : The most common surgical procedure is excision of the hydrocele sac--
hydrocelectomy (can also perform sac eversion). Recommended for chronic non-communicating
hydroceles.
- Inguinal surgery: incision in the groin or inguinal area, draining the fluid, hernia repair if present
and closing off the opening between the scrotum and abdomen.
Complications of surgery:
• injury to testis, urethra, testis/ epididymis, to spermatic cord structures
• Infections
• Recurrent hydrocele
• Bleeding or scrotal hematoma
• Illioinguinal/ genitofemoral nerve injury
• Wound infection.
- Alternative to surgery : Simple aspiration is generally unsuccessful because of the rapid
re-accumulation of fluid but may be effective if combined with instillation of a sclerosing agent--
sclerotherapy ( tetracycline , alcohol) into the sac. The potential risks of this approach are a low
incidence of reactive orchitis/epididymitis and a higher rate of recurrence, which may then make open
surgery more difficult because of the development of adhesions between the hydrocele sac and the
scrotal contents. Performed on men who are high risk for complications during surgery.

16. CONCLUSION
A hydrocele is a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis
which directly surrounds the testes and the spermatic cord. Hydrocele are classified into
communicating, non-communicating based on whether or not they communicate with the peritoneum.
Pain is generally associated with size and inflammation. Diagnostic evaluation is based on
transillumination, on whether the hydrocele is reducible or not, by ultrasonography , blood and urine
tests. Management is based on whether or not the hydrocele is symptomatic or persistent , thus surgery
may be indicated or simple aspiration with sclerotherapy may be indicated for patients that are high risk
for surgical complications.

17. REFERENCE
● Www-uptodate-com.unifiji.idm.oclc.org. 2022. [online] Available at: <https://www-uptodate-
com.unifiji.idm.oclc.org/contents/nonacute-scrotal-conditions-in-adults.
● Www-uptodate-com.unifiji.idm.oclc.org. 2022. [online] Available at: <https://www-uptodate-
com.unifiji.idm.oclc.org/contents/causes-of-painless-scrotal-swelling-in-children-and-adolescents.
● Www-uptodate-com.unifiji.idm.oclc.org. 2022. [online] Available at: <https://www-uptodate-
com.unifiji.idm.oclc.org/contents/inguinal-hernia-in-children.