Hydrocoele of Testis denotes pathological accumulation of fluid in tunica vaginalis surrounding the testis.
Communicating hydrocele, caused by the failure of the processus vaginalis closure.
A hydrocele can be produced in four ways:
- by excessive production of fluid within the sac, e.g. secondary hydrocele.
- through defective absorption of fluid
- by interference with lymphatic drainage of scrotal structures as in case of elephantiasis.
- by connection with a hernia of the peritoneal cavity in the congenital variety, which presents as hydrocele of the cord.
The swelling is soft and non-tender, large in size on examination and the testis cannot usually be felt. The presence of fluid is demonstrated by trans illumination. These hydrocoeles can reach a huge size, containing large amount of fluid, as these are painless and are often ignored. They are otherwise asymptomatic, other than size and weight, causing inconvenience. However the long continued presence of large hydroceles causes atrophy of testis due to compression or by obstructing blood supply.
Secondary hydrocele due to testicular diseases, can be the result of, cancer, trauma, or orchitis. Secondary hydrocele is most frequently associated with acute or chronic epididymo-orchitis. It is also seen with torsion of the testis and with some testicular tumors. A secondary hydrocele is usually lax and of moderate size: the underlying testis is palpable. A secondary hydrocele subsides when the primary lesion resolves. Causes of secondary hydrocoeles
- Acute/chronic epididymo-orchitis
- Torsion of testis
- Testicular tumor
- Filarial hydrocele
- Post herniorrhaphy
- Hydrocele of an hernial sac
In infants and children, a hydrocoele is usually an expression of a patent processus vaginalis (PPV). The tunica and the processus vaginalis are distended to the inguinal ring but there is no connection with the peritoneal cavity.
The processus vaginalis is patent and connects with the general peritoneal cavity. The communication is usually too small to allow herniation of intra-abdominal contents. Digital pressure on the hydrocele does not usually empty it, but the hydrocele fluid may drain into the peritoneal cavity when the child is lying down. Ascites or even ascitic tuberculous peritonitis should be considered if the swellings are bilateral.
Encysted hydrocele of the cord
There is a smooth oval swelling near the spermatic cord which is liable to be mistaken for an inguinal hernia. The swelling moves downwards and becomes less mobile if the testis is pulled gently downwards. Rarely, a hydrocoele develops in a remnant of the processus vaginalis somewhere along the course of the spermatic cord. This hydrocoele also transilluminates, and is known as an encysted hydrocoele of the cord. In females, a related region in females, a multicystic hydrocoele of the canal of Nuck sometimes presents as a swelling in the groin. It probably results from cystic degeneration of the round ligament. Unlike a hydrocele of the cord, a hydrocele of the canal of Nuck is always at least partially within the inguinal canal.
A primary hydrocoele is described as having the following characteristics:
- Transillumination positive
- Fluctuation positive
- Impulse on coughing negative (positive in infantile hydrocele)
- Reducibility absent. A hydrocele cannot be reduced into the inguinal canal and gives no impulse on coughing unless a hernia is also present.
- Testis cannot be palpated separately. (exception - funicular hydrocele, encysted hydrocele)
Most hydroceles appearing in the first year of life seldom require treatment as they resolve without treatment. Hydroceles that persist after the first year or occur later in life require treatment through open operation for removing surgically. Method of choice is open operation, under general, spinal or local anesthesia which is sufficient in adults. General anesthesia is the choice in children. If a testicular tumor is suspected, a hydrocele must not be aspirated as malignant cells can be disseminated via the scrotal skin to its lymphatic field. This is excluded clinically by Ultrasonography. If a tumor is not present, the hydrocele fluid can be aspirated with a needle and syringe. Clear straw colored fluid (mostly contains albumin and fibrinogen). If the fluid is allowed to drain in a collecting vessel, it does not clot but can be coagulated if small amounts of blood comes in contact with the damaged tissue. In long standing cases, hydrocele fluid may be opalescent with cholesterol and may contain crystals of tyrosine.
The scrotum should be supported post-operatively. Regular changes of surgical dressings, observation of drainage and looking for other complications may be necessary to prevent re-operation.
Aspiration and Sclerotherapy
Sclerotherapy is an alternative; after aspiration, 6% aqueous phenol (10-20 ml) together with 1% lidocaine for analgesia can be injected and this often inhibits re accumulation. Several treatments may be necessary. Aspiration of the hydrocele contents and injection with sclerosing agents sometimes with Tetracyclines is effective but it can be very painful. These alternative treatments are generally regarded as unsatisfactory treatment because of the high incidence of recurrences and the frequent necessity for repetition of the procedure.
Before doing Jaboulay's Procedure (Eversion of sac) it is important to exclude testicular tumor as the scrotal approach is contra-indicated in testicular tumors.
Patient in supine position, the parts are cleaned and draped. If the hydrocoele is large it is recommended to do the surgery in spinal or general anaesthesia. In case of small hydrocoeles it can done in local anaesthesia. Local anaesthesia is infiltrated at the proposed incision site and cord block is also given. It is important to use only plain lignocaine without adrenaline. Adrenaline is contra-indicated for cord block at the testicular arteries are the end arteries.
1. Vertical paramedian incision is given
2. Incision is deepened and sub-dartos plane developed.
3. Hydrocoele sac delivered from the incision.
4. Hydrocoele fluid drained and excess sac excised
5.Eversion of the tunica vaginalis sac
6. Wound is closed in layers after achieving hemostasis
7. Scrotal bandage or coconut bandage applied for scrotal support.
The scrotum is firmly grasped by the assistant to make the skin tense. The incision is given in paramedian plane to the median raphe anteriorly. The testis lies posterio-inferior. In small hydrocoeles transverse incision can also be given. The transverse incision has advantage of less bleeding and more cosmetic (Langer's line run transversely over the scrotum). Around 5 to 6 cm long incision is given depending on the size of the hydrocoele. Skin, dartos and thin cremasteric fascia are incised and reflected back together as a single layer from the underlying parietal layer of the tunica vaginalis which is the outer wall of the hydrocoele. If this plane is not developed prior to the fluid removal and delivering of the testis it become difficult to evert the sac and reposition the testis back after surgery. The hydrocoele sac is delivered out of the incision. When hydrocoele well separated laterally and medially from overlying layers, it is grasped with 2 Babcocks forceps and incision is given over the delivered hydrocoele sac to drain the fluid. If the hydrocoele sac has not been completely dissection before the drainge of the fluid, then with one finger inside the sac, dissect it free from the overlying scrotum so that spermatic cord and testicle with attached hydrocoele lie free in operative field.Hydrocoele sac is then opened completely. Testicle is then carefully inspected and palpated. Redundant wall sac is trimmed leaving a margin of 2cm. Great care must be taken with haemostasis. Sac is then everted behind testis with interrupted suture. Wound is closed in layers.
Here the plication of the sac is done without delivering the testis out for small hydrocoeles advantage is less bleeding and hematoma after surgery. Disadvantage is recurrence of hydrocoele in case the edges of the tunica vaginalis grow back.
- Rupture usually occurs as a result of trauma but may be spontaneous. On rare occasions cure results after the fluid has been absorbed.
- Herniation of the hydrocele sac through the dartos muscle sometimes occurs in long-standing cases.
- Transformation into a haematocele occurs if there is spontaneous bleeding into the sac or as a result of trauma. Acute haemorrhage into the tunica vaginalis sometimes results from testicular trauma and it may be difficult without exploration to decide whether the testis has been ruptured. If the haematocele is not drained, a clotted haematocele usually results.
- The sac may calcify. Clotted hydrocele may result from a slow spontaneous ooze of blood into the tunica vaginalis. It is usually painless and by the time the patient seeks help, it may be difficult to be sure that the swelling is not due to a testicular tumour. Indeed, a tumour may present as a haematocele.
- Occasionally, severe infection can be introduced by aspiration. Simple aspiration, however, often may be used as a temporary measure in those cases where surgery is contraindicated or must be postponed.
- Infection which may lead to pyocele.
- Atrophy of testis in long standing cases.