Hydrocele : Causes, Etiology, Types, Symptoms, Signs, Examination, Diagnosis, Differential Diagnosis, Complications, Treatment, Surgery, Medicine
- Hydrocele is the abnormal collection of fluid (serous fluid) between the two layers of tunica vaginalis of testis or within some part of the processus vaginalis.
- Defective absorption of fluid by the tunica vaginalis, probably due to damage to the endothelial wall by low-grade infection.
- Excessive production of fluid e.g., secondary hydrocele.
- Lymphatic obstruction causing interference with drainage of fluid by lymphatic vessels of the cord.
- Communication with the peritoneal cavity.
1. Congenital – Primary type
- In this, Processus vaginalis remains patent and it freely & directly communicates with the peritoneal cavity.
- But the communicating orifice at the deep inguinal ring remains too small for bowel descend & the development of a hernia.
- This condition is mainly diagnosed by the fact that the hydrocele gradually disappears when the patient lies down but returns in the erect posture.
- Hydrocoele can not be emptied by digital pressure as it causes “inverted ink bottle” effect.
- This condition may be associated with tuberculous peritonitis in children. Thus, in bilateral cases one must exclude the ascites from tuberculous peritonitis.
- Primary (Idiopathic) : The cause is unknown and no associated disease of the testis or the epididymis is present.
- Secondary : Occurs as secondary to a disease of the testis and/or the epididymis.
Primary hydrocele (congenital or acquired)
- Mostly seen in middle aged men.
- May be uni- or bilateral.
- Chief & only complaint is the swelling of the scrotum & this is why, patient often presents with enormous swelling.
- Get above the swelling positive if it is pure hydrocele except : Infantile hydrocele.
- Swelling is non-tender, dull on percussion.
- Testis is non-palpable because fluid surrounds the testis.
The following varieties of primary hydrocele can be seen:
1. Vaginal hydrocele (commonest type)
- Occurs in middle-aged, common in tropical countries.
- In this condition there is abnormal collection of serous fluid between visceral and parietal layers of tunica vaginalis.
2. Encysted hydrocoele of the cord
- In this condition, the processus vaginalis remains patent in the middle being shut off from the tunica vaginalis below and peritoneum above.
- It is a smooth, soft, cystic, oval, fluctuant and transilluminant swelling associated with the spermatic cord.
- Diagnosis : Traction test i.e. on gentle traction to the testis, the swelling becomes less mobile. The swelling has got free mobility but when traction is applied to testes gently, the swelling becomes fixed and it moves down, when testes is pulled down.
- Differential diagnosis: Epididymal cyst, inguinal hernia, lipoma of cord, varicocele.
- Treatment : Excision of the sac under local anaesthesia.
3. Funicular hydrocoele
- In this, the processus vaginalis is shut off from the tunica vaginalis just above the testis.
- It is very rare condition.
4. Congenital hydrocoele
5. Infantile hydrocoele
- In this, tunica and processus vaginalis (hydrocele) are distended up to the deep inguinal ring, but sac has no connection with the general peritoneal cavity. Thus, This is just opposite of the funicular variety.
- So, unlike the congenital or funicular variety, it does not disappear when the patient lies down.
6. Bilocular hydrocoele (Hydrocele-en-bisac)
- Here the hydrocoele has two intercommunicating sacs one above and one below the neck of the scrotum.
- A cross fluctuations may be elicited since upper one lies superficial or in the inguinal canal or may insinuate
itself between the muscle layers.
7. Hydrocoele of the hernial sac
- It is due to adhesions of the content of hernial sac. Fluid secreted collects in the hernial sac and forms hydroc0ele of the hernial sac.
8. Hydrocoele of the Canal of the Nuck
- It occurs in females, in relation to the round ligament, always in the inguinal canal.
Causes of secondary hydrocele are as following:
- Infection: Filariasis, Tuberculosis, Syphilis
- Injury: Trauma, postherniorrhaphy hydrocele (occurring after the surgery for inguinal hernia due to the damage to lymphatic vessels of the tunica vaginalis).
- Tumour: Malignancy
Secondary hydrocele rarely attains large size thus, testis is usually palpable (unlike primary hydrocele). Exception : Secondary hydrocoele due to filariasis which can be very large.
Treatment : Treatment of the primary cause would cure it.
Vaginal hydrocele (commonest type) patient presents with following features:
- A scrotal swelling which may be uni-or bilateral
- Getting above the swelling is possible (Get above the swelling test positive).
- Fluctuant as it is a cystic swelling ( Fluctuation test positive)
- Initially transilluminant as the hydrocoele fluid is clear but long-standing hydrocoele is non-transilluminant.
- The swelling is not reducible. Testis is not palpable as it usually attains a large size (unlike secondary hydroceles which are small, except in filarial hydrocele).
- Testicular sensation can be elicited in vaginal hydrocele by transmitting the pressure sensation through the fluid.
Patient is examined & inspected thoroughly. Diagnosis of hydrocele is made by following tests:
- Fluctuation test
- Translucency (Transillumination) test
- To get above the swelling
- Traction test
- Inguinal hernia
- Epididymal cyst
- Testicular tumour
- Scrotal oedema
Complications of hydrocoele are following:
- Atrophy of testis
- Calcification of sac wall
- Hernia of hydrocoele (rare)
- Hernia of hydrocoele sac (rare)
Treatment for hydrocele
1. Surgery : Surgeries for hydrocele are:
- Sub-total excision of sac
- Partial excision and eversion (Jabouley’s operation)
- Evacuation and eversion
- Lord’s plication : Indicated in small hydrocoele.
- Sharma and Jhawer’s technique
If the sac is small, thin and contains clear fluid, either Lord’s plication Or Evacuation and eversion of the sac behind the testis is done.
If the sac is thick, in large hydrocele and chylocele, subtotal excision of the sac is done.
Note: Aspiration must be avoided as much as possible as it is only a temporary measure (recurrence occurs very early) and chances of haematocele, infection are higher.
Complications of surgery
- Reactionary haemorrhage
- Sinus formation
- Recurrent hydrocoele