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 rupture of a lymphatic varix with discharge of chyle into the hydrocele. Adult worms of the Wuchereria bancrofti have been found in the epididymis removed at operation or at necropsy. In long-standing chyloceles, there are dense adhesions between the scrotum and its contents. Filarial elephantiasis supervenes in a small number of cases.

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).