Hydrocele

• A hydrocele is a common cause of scrotal swelling. It results from the collection of excess fluid in the potential space between the parietal and visceral layers of the tunica vaginalis lining of the testes.
• Paediatric hydrocele:

  • testes descend through the inguinal canal into the scrotum - travel with an outpouching of peritoneum called the processus vaginalis - forms the peritoneal lining of the testicle becoming the tunica vaginalis (has potential space between visceral and parietal layer)
  • result of a failure of the processus vaginalis to obliterate correctly (normal to be patent at birth but normally closed within the first 2 years of life)
  • Allows peritoneal fluid to drain from abdomen into space around the testes (can also allow abdominal contents)
• Congenital = communicating hydrocele

  Acquired = non-communicating
• Acquired hydrocele:

  • Can be primary (idiopathic) or secondary (reactive)
  • Idiopathic hydrocele's typically grows slowly over several years and is thought to result from an imbalance between production and reabsorption of fluid within the tunica vaginalis
  • Reactive hydrocele occurs as a result of insult to the testicle: epididymo-orchitis, trauma and testicular cancer
  • Non-communicating
• In children, it is useful to know whether the swelling fluctuates in size to help determine whether the hydrocele is communicating or non-communicating.

  If a child has a patent processus vaginalis (causing a communicating hydrocele) then the swelling typically increases in size during the day as peritoneal fluid drains into the scrotum with gravity and reduces at night when the child lays horizontally.
• Clinical exam:

  • Larger hydroceles can encroach on the contralateral side and extend into the ipsilateral inguinal canal
  • Typically painless unless there is underlying pathology
  • Smooth swelling
  • Transilluminate
  • Able to get above hydrocele (unable for hernia)
  • The underlying testicle is usually impalpable - need USS to rule out underlying cancer in 18-40 year olds
• Investigations:

  • Clinical diagnosis
  • Bloods if suspected underlying inflammatory or malignant cause
  • Scrotal ultrasound
• If the person is 18–40 years of age, or the testis cannot be palpated, arrange an urgent ultrasound scan of the scrotum.
• Congenital hydrocele management:

  • If present since birth, reassure likely to resolve without treatment by 12 months
  • Refer to surgeon if:
  • Not resolved after 12 months
  • Also have inguinal hernia or underlying testicular pathology suspected
  • Develop in someone above the age of 2
• Management of acquired hydrocele:

  • Assess weather due to underlying cause e.g. torsion, cancer, epidiymo-orchitis and treat accordingly
  • If aged 18-40yrs or tested cannot be palpated arrange urgent ultrasound
  • If idiopathy - reassure, observe, advise on sacral support
  • If hydrocele large/symptomatic, refer to urology to consider surgery
• Surgical repair for adult hydrocele:

  • Aims to drain the hydrocele and prevent recurrence
  • Through scrotal incision
  • Drin and either suturing or removing excess tunica vaginalis