It usually occurs from birth and progresses over time. Physical examination shows that when the abdominal mass is compressed, the scrotal mass is enlarged and vice versa.
Table of Contents
What is hydrocele?
It is the collection of fluid between the visceral and parietal layers of the tunica vaginalis of the testicle, which may or may not be with the peritoneal cavity. The testicles have this serous membrane, which is made up of two layers, in which there is a fluid with lubricating and shock-absorbing functions. In the hydrocele, an abnormal accumulation of fluid is produced in this pseudocavity.
It is a benign process, very common in newborns but it also occurs in the adult population.
Congenital: within the congenital hydroceles we have:
It is produced by an incomplete closure of the tunica vaginalis during growth, maintaining communication with the peritoneal cavity. This causes the liquid to flow from the abdomen into the scrotum and vice versa.
On examination, it can be seen how this accumulation of fluid can increase in size during crying, Valsalva manoeuvre or straining and fluctuates during the day and night.
It usually appears in children older than one year, after some action that has increased their intra-abdominal pressure. It does not heal spontaneously, for this reason, the solution is surgical since its persistence could alter the testicle by compression or become an inguinal-scrotal hernia.
This is the most frequent hydrocele, it is produced when the tunica vaginalis closes with a large amount of liquid from the peritoneal cavity and this is not absorbed, it is typical of newborns, in most children it heals spontaneously before the first year of life since the liquid trapped between the two layers of the testicular tunica vaginalis is reabsorbed and there is no communication with the peritoneal cavity.
This is an idiopathic hydrocele that has no known cause. It is attributed to an imbalance between the capacity of the visceral and parietal layers of the tunica vaginalis to secrete and reabsorb; it usually occurs in older adults.
it occurs as a consequence of a traumatic or infectious event at the testicular level, such as inguinal hernia, inguinal surgery, Filariasis, epididymitis, orchitis and other traumatic causes.
It is formed by a very thin persistence of the peritoneal vaginal duct, which causes a collection of liquid in the inguinal duct, which does not affect the testicle. Clinically, it is observed as a mobile, round, irreducible and painless mass in the upper part of the scrotum or in the inguinal canal, and generally appears during the first months of life.
this is a type of hydrocele with a very low incidence, which consists of a collection of fluid at scrotal level but which is continued through the inguinal canal and the abdominal cavity.
It is usually present from birth and progresses over time. Upon physical examination, it can be seen that compression of the abdominal mass produces enlargement of the scrotal mass and vice versa.
Its solution is surgical, due to the compressive nature of the hydrocele to the testicular mass.
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Risk factors and causes
The most common symptoms of this condition are:
For the diagnosis of hydrocele, it is important to begin with the interview and physical examination.
The patient’s traumatic and pathological history and the presence of risk factors should be known.
On examination, the scrotum will be observed to be enlarged, tightened, and with shiny skin, the involvement may be of the entire scrotal sac or of a single hemi-scrotum, palpation of the testicle may be very difficult due to the amount of fluid accumulated.
Non-communicating hydrocele is suspected when on physical examination, we find an increase in scrotal volume that is painless, irreducible and when the transillumination test is positive.
The technique of testicular transillumination consists of applying a source of light beneath the scrotal sac and observing whether or not there is transparency of the scrotal sac. In this way, it is possible to differentiate between solid tumours and liquid collections, when light easily passes through the testicle and is considered positive, suggesting that the contents are liquid, giving an image of red illumination. However, when the contents are solid tumours, it does not allow the passage of light and is considered negative. To carry out this exploration, it is recommended that the lights in the room be switched off.
A communicating hydrocele may be considered when there is a history of fluctuation in the size of the testicular mass. This is usually greater during the day, while activities are being performed, and decreases with nighttime rest.
On physical examination, a reducible scrotal fluid is found, which is bright, translucent and non-painful. As the diagnosis of hydrocele in infants and children is suspected, the presence of indirect inguinal hernia must also be ruled out, since it is very common for these pathologies to coexist.
When a painless and transilluminable mass is observed along the path of the spermatic cord, it should be considered a hydrocele or cord cyst.
In cases of abdominal-scrotal hydrocele, it is recommended to investigate the presence of other testicular pathologies since this is associated in many cases with lymphedema, cryptorchidism, appendicitis, testicular ectopy and malignant paratesticular mesothelioma. In addition to evaluating the damage to other adjacent organs by compression, it is recommended to perform an ultrasound in the abdominal and scrotal region, where you will find a cystic mass with homogeneous anechoic content and hourglass appearance
Scrotal ultrasound remains an excellent complementary tool which can be used by a trained medical team at a primary care level, this study will help in the following cases:
Conventional ultrasound combined with Doppler has shown great utility in evaluating different testicular lesions and perfusion, and also helps to distinguish the hydrocele from varicocele and testicular torsion, since these conditions can occur alone and associated with hydrocele.
There are other pathological conditions that can simulate the same signs and symptoms of hydrocele, and for which the doctor will have to establish a differential diagnosis, being these
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TECHNIQUES AND TREATMENTS
The therapeutic options and behaviours will depend on the type of hydrocele that the patient presents and its condition. In cases of non-communicating congenital hydrocele, it is recommended a watchful waiting if there is no discomfort and no aesthetic repercussions, as the hydrocele usually disappears and the liquid is reabsorbed before the age of two in 80% of cases.
Watchful waiting can also be used in those cases of asymptomatic idiopathic hydrocele.
Like patients with asymptomatic idiopathic hydrocele, who have a minimum volume of fluid and are not under stress.
Surgical solution is recommended in the following cases:
The surgical approach will also depend on the type of hydrocele, the inguinal approach is recommended in cases of spermatic cord hydrocele and communicating hydrocele associated with inguinal hernia and abdominal-scrotal hydrocele, otherwise, the scrotal route is suggested when dealing with non-communicating hydrocele.
In the majority of cases local anaesthesia is used, making an incision at scrotal level, preferably transversal when the involvement is in a single testicle, no larger than 3 or 4 centimetres, trying to respect the scrotal vessels, which are visible through transparency. In cases of bilateral hydrocele, a longitudinal incision is recommended on the medial raphe, which allows a single access and bilateral approach. The transverse scrotal incision, made in the skin folds, helps to minimize bleeding and has better aesthetic results, as it is hidden by the folds.
During surgery the surgeon can perform the following techniques:
Through the scrotal route, the tunica vaginalis is accessed, dissected and resected. It is used in long evolution hydroceles with thick walls.
A plication of the tunica vaginalis is performed after partial eversion, liquid aspiration and coagulation of the surface of the tunica vaginalis are performed.
in this technique, the tunica vaginalis is dissected and inverted.
The laparoscopic technique has the advantage of offering better direct observation of the internal inguinal ring, reducing the risk of iatrogenic damage to the cord and scrotal contents, which reduces recurrence. It is recommended to be used in hydrocele with persistence of the vaginal peritoneum process, recurrent hydrocele and suspected bilateral hydrocele.
Sclerotherapy: It is a minimally invasive technique, which does not require anaesthesia, where transillumination is used to locate an area of the scrotum that is not very vascularized, the puncture of the sac is performed with a needle and all the liquid is carefully evacuated, and then about 2ml polidocanol at 3% is inoculated. It is a method that has gained acceptance for having a rapid recovery, low morbidity, besides being economical.
Other sclerosing agents have also been used, such as Tetracycline, Quinacrine, Fibrin, Tetradecyl Sulfate, Rolitetracycline, Talc, Phenol, Ethanolamine Oleate, Antazoline, and lately those that have shown better results, Iodopovidone and Polidocanol.
There are few complications that can occur with a hydrocelectomy, such as:
Some cases of hypospadias may reappear a few months after being operated on, with the appearance of fistulas usually the main setback. It is possible to re-intervene with a good prognosis in most of such cases, but we must always assess the patient’s condition carefully because each new intervention adds instability in the tissues of the affected area. You can only enter the operating room again after a substantial period of time and the reasons why the previous one was not successful must be well analyzed. This explains why the knowledge and analytical capacity of an experienced team such as ours are basic aspects to be taken into account by the parents. In other words, it is a surgery that must be performed by a medical team of proven ability.
In Spain, all the cases usually have public medical coverage by the state or regional service. However, there are many parents who prefer to go to private medical centers (whether they have medical insurance or not) regardless of the price. This choice which often involves a cost on the family finances is usually guided by two main reasons. The first is the freedom to choose the professional doctor and the second is to shorten the waiting periods which are sometimes quite lengthy. Both are important issues to take into account since the successful correction of hypospadias depends a lot on the expertise and experience of the surgeon, and it is a condition that needs to be addressed with some urgency i.e. in the first months of the child’s life (before 15 months).
After a well planned and executed intervention, the resulting phalloplasty leaves the penis of the child without any present or future sexual or urinary problems. So, it is perfectly prepared for its development at puberty without any type of sequela. This further highlights the importance of choosing the surgical team since it is a very sensitive operation that could end up with setbacks in the future if not executed perfectly.