Hydrocele
A hydrocele is an abnormal collection of serous
fluid in some part of the processus vaginalis, usually the tunica. Four types of
congenital hydrocele are encountered (Fig. 68.8). Acquired hydroceles are primary or idiopathic, or
secondary to testicular disease.
Aetiology
A hydrocele can be produced in four ways:
•
by excessive production of fluid within the sac, e.g. secondary hydrocele;
•
by defective absorption of fluid. This appears to be the explanation for
most primary hydroceles although the reason why the fluid is not absorbed is
obscure;
•
by interference with lymphatic drainage of scrotal structures;
•
by connection with a hernia of the peritoneal cavity in the congenital
variety.
Hydrocele fluid is amber coloured and sterile, and contains albumin and fibrinogen. If the contents of a hydrocele are allowed to drain into a collecting vessel, the liquid does not clot, but the fluid coagulates if it is mixed with even a small quantity of blood that has been in contact with damaged tissue. In long-standing cases, hydrocele fluid is sometimes opalescent with cholesterol and may occasionally contain crystals of tyrosine
Clinical
features
Hydroceles are almost invariably translucent
and it is
possible to ‘get above the swelling’ on examination of the scrotum.
Primary
vaginal hydrocele
Primary vaginal hydrocele is most common in middle and later
life but can also occur in early childhood. The condition is particularly common
in hot countries. Because the swelling is usually painless it
may reach a
prodigious size before the man presents for treatment. The testis may be
palpable within a lax
hydrocele but an
ultrasound may be necessary to visualise the testis
if the hydrocele sac is tense. Be wary of an acute hydrocele in a young man; there
may be a testicular tumour (Fig. 68.9).
About
5 per
cent of inguinal hernias are associated with a vaginal hydrocele on the same
side1.
Infantile
hydrocele
Infantile hydrocele does not necessarily appear
in infants. The tunica and processus vaginalis ate distended to the inguinal
ring but there is no connection with the peritoneal cavity.
Congenital
hydrocele
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.
Hydrocele of the canal of Nuck is a similar condition. It occurs
in females and the cyst lies in relation to 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.
Complications
of hydrocele
•
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.
•
The sac may calcify.
Treatment
A variety of surgical procedures is available. Congenital
hydroceles are a special form of indirect inguinal hernia and are treated by
herniotomy. The thin sac of an infantile hydrocele should be excised.
Established
acquired hydroceles often have thickened walls. Unless great care is taken to
stop bleeding after subtotal excision of the wall, haemorrhage from the cut
edge is liable to cause a large scrotal haematoma, even if the wound is drained.
Lord’s
operation is
suitable when the sac is reasonably thin-walled (Fig.
68.10). There is minimal
dissection and the risk of haematoma is reduced. Evertion of the sac with
placement of the testis in a pouch prepared by blunt dissection in the fascial
planes of the scrotum is an alternative (Jaboulay’s
procedure) (Fig.68.11).
Drainage
of the hydrocele fluid through a cannula is simple but the condition always
recurs within a week or so. It may be suitable for very elderly infirm men who are
unfit even for scrotal surgery under regional anaesthesia. Injection of
sclerosants
such as tetracycline is sometimes effective but tends to be very painful.
Secondary
hydrocele is most frequently associated with acute or chronic epididymo-ochitis.
It is also seen with torsion of the testis and with some testicular tumours. A
secondary hydrocele is usually lax and of moderate size: the underlying testis
is palpable. If a tumour is suspected, the hydrocele should not be punctured for
fear of implantation of malignant cells in the needle track. A secondary
hydrocele subsides when the primary lesion resolves.
Postherniorrhaphy
hydrocele
Postherniorrhaphy hydrocele is a relatively
rare complication of inguinal hernia repair. It is possibly due to interruption
to the lymphatics draining the scrotal contents.
Hydrocele
of a hernial sac
Hydrocele of a hernial sac occurs when the neck
is plugged with omentum or occluded by adhesions.
Filarial
hydroceles and chyloceles
Filarial hydroceles and chyloceles account for
up to 80 per cent of hydroceles in some tropical countries where the parasite is
endemic. Filarial hydroceles follow repeated attacks of filarial
epididymo-orchitis. They vary in size and may develop slowly or very rapidly.
Occasionally the fluid contains liquid fat which is rich in cholesterol. This is
due to
Treatment is by rest and aspiration. The more
usual chronic cases are treated by excision of the sac.
Haematocele
Haematocele usually results from damage to a
small vessel during tapping of a hydrocele. Prompt refilling of the sac with
pain, tenderness and poor or absent transillumination leave no doubt about the
diagnosis. 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.
Clotted hydrocele
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.
Treatment is by orchidectomy unless the testis is indubitably benign. As a rule it is impossible to be certain of this until the mass has been bisected. The testis is often compressed and relatively useless (Fig. 68.12).