A seminar on Hydrocele.

1. D R . H A R M A N D E E P S I N G H
G U I D E D B Y – D R . D . D . W A G H S I R
P R O F E S S O R & H E A D ,
D E P T . O F G E N E R A L S U R G E R Y ,
D . M . I . M . S . , S A W A N G I ( M )
HYDROCELE

2. INTRODUCTION
 Hydrocele is an abnormal fluid collection between
the visceral and parietal layers of the tunica
vaginalis.
 In infants it is usually the result of incomplete
closure of the processus vaginalis. It may or may not
be associated with inguinal hernia. In older boys and
men it may be idiopathic but more likely to be
secondary to another pathologic process in the
scrotum or adjacent structures

3. DEVELOPMENTAL ANATOMY
Testis descends from the posterolateral genitourinary
ridge at the beginning of the third trimester of fetal
gestation, a saclike extension of peritoneum descends
in concert with the testis. As descent progresses, the
sac envelops the testis and epididymis. The result is a
serosal-lined tubular communication between the
abdomen and the tunica vaginalis of the scrotum.
The peritoneum-derived serosal communication is the
processus vaginalis, and the serosa of the hemiscrotum
becomes the tunica vaginalis.

4.  At term, or within the first 1-2 years of life, the
processus vaginalis of the spermatic cord fuses,
obliterating the communication between the
abdomen and the scrotum. The processus fuses
distally as far as the lower epididymal pole and
anteriorly to the upper epididymal pole. Failure of
complete fusion may result in communicating
hydroceles, indirect inguinal hernias, and the bell-
clapper deformity of abnormal testicular fixation in
the scrotum.

7. Layers of Scrotum
 SKIN
 DARTOS MUSCLE
 EXTERNAL SPERMATIC FASCIA
 CREMASTRIC MUSCLE
 INTERNAL SPERMATIC FASCIA
 TUNICA VAGINALIS

8. Relevant Anatomy

12. Lymphatic Drainage
 Scrotal lymphatics drain into the corresponding
superficial inguinal lymph nodes.
Anastomoses to the lymphatics of the contralateral
network across the median raphe occur.
 Testicular lymphatics via the spermatic cord drain to
the paraaortic nodes.

13. Risk factors
 Most hydroceles are present at birth (congenital),
and babies who are born prematurely have a higher
risk of having a hydrocele.
 Incidence : 3.5 to 5.0% in full term infants and 44 to
55% in premature and Low birth weight babies
(Groff D, Nagaraj HS, Pietsch JB, Inguinal hernias in premature infants who were operated on before their
discharge from the neonatal intensive care unit Arch Surgery 1985)
 Risk factors for developing a hydrocele later in life
include: Scrotal injury (Traumatic/Iatrogenic),
Infection including sexually transmitted infections,
Tumours.

14. CLASSIFICATION
 CONGENITAL
 ACQUIRED
I) PRIMARY
II) SECONDARY

15. CONGENITAL HYDROCELE
 NONCOMMUNICATING HYDROCELE - patent
processus vaginalis obliterates but fluid remains.
 COMMUNICATING HYDROCELE - the sac remains
open in communication with the peritoneal cavity.

17. CONGENITAL HYDROCELE:
PROCESSUS VAGINALIS
COMMUNICATES WITH PERITONEAL
CAVITY

18. INFANTILE HYDROCELE:
TUNICA &PROCESSUS
VAGINALIS DISTENDED UPTO
INTERNAL RING BUT SAC HAS
NO CONNECTION WITH
PERITONEAL CAVITY

19. ENCYSTED HYDROCELE OF
CORD:
PART OF FUNICULAR PROCESS
PATENT, & IS CLOSED FROM
THE TUNICA VAGINALIS BELOW &
PERITONEAL CAVITY ABOVE.
SMOOTH,OVAL SWELLING
ASSOCIATED WITH SPERMATIC
CORD.
 TRACTION TEST

20. HYDROCELE EN BISSAC
TWO INTERCOMMUNICATING
SACS ABOVE & BELOW NECK
OF SCROTUM

21. Hydrocele En Bissac
Operated at Midnapur Medical College, West Bengal (2008)

22. HYDROCELE OF CANAL OF NUCK:
OCCURS IN FEMALES IN RELATION ROUND LIGAMENT
ALWAYS IN THE INGUINAL CANAL

23. HYDROCELE OF HERNIAL
SAC:
NECK OF THE HERNIAL SAC
BECOMES CLOSED BY
ADHESIONS OR PLUGGED BY
OMENTUM.
RESULTS IS RETENTION OF
FLUID SECRETED BY
PERITONEUM OF HERNIAL
SAC

24.  INFECTIONS:
FILARIASIS
TUBERCULOSIS OF EPIDIDYMIS
SYPHILIS
 INJURY
POST HERNIORRHAPHY HYDROCELE
POST VARICOCELECTOMY HYDROCELE
TRAUMA
 TUMOUR
MALIGNANCY
SECONDARY HYDROCELE

25. ETIOLOGY
 In older men, any process that acts to stimulate increased production of
watery fluid by the tunica or decrease the absorption of this fluid by the
scrotal lymphatics or venous system will result in the formation of a
hydrocele.
 Increased production of fluid could be due to:
Inflammation of the testis (orchitis) or epididymis (epididymitis) caused by
tuberculosis and by tropical infections such as filariasis.
Testicular torsion (rotation of the testis) may cause a reactive hydrocele in
20% of cases.
Tumors of the testis, especially germ cell tumors or tumors of the testicular
adnexa may cause hydrocele.
 Decreased resorption of fluid could be due to:
Surgery in the inguinal region or a renal transplantation can affect the
lymphatics or venous system causing decreased absorption.
Radiation therapy is associated with cases of hydrocele.
Peritoneal dialysis and ventriculoperitoneal shunts.

26.  COMMON IN COASTAL/TROPICAL REGIONS ,
ACCOUNTS FOR 80 % OF ALL HYDROCELES IN
TROPICAL REGIONS, CAUSED BY Wucheria bancrofti
 REPEATED ATTACKS OF FILARIAL EPIDIDYMITIS
 SIZE- LARGE SIZE WITH THICKENED SAC
 OCCASIONALLY CONTAINS CHOLESTEROL RICH
FLUID – CHYLOCELE
DUE TO RUPTURED LYPMH VARIX WITH DISCHARGE
OF CHYLE IN TO THE HYDROCELE
 RESEMBLES PRIMARY HYDROCELE
 MAY BE ASSOCIATED WITH FILARIAL
ELEPHANTIASIS.
FILARIAL HYDROCELE

27. Filarial Hydrocele

28. SIGNS & SYMPTOMS
 In the early stages hydroceles are usually asymptomatic. As they
enlarge they bulge out and can become a cosmetic problem.
 Symptoms can develop, as the swelling increases in size, which
include: Heaviness, fullness, or dragging sensations due to an
enlarged scrotum.
 There may be mild discomfort radiating along the inguinal area to
the mid portion of the back.
 If pain develops in a Hydrocele it is usually an indication of acute
epididymal infection or due to overstretched scrotal skin in huge
hydroceles.
 The size may decrease with recumbency or increase in the upright
position.
 Fever, chills, nausea, or vomiting indicate an infection of a
hydrocele.

29. 1. INFECTION
2. PYOCELE,HEMATOCELE/CLOTTED
HEMATOCELE
3. CALCIFICATION OF SAC (D/D FOR TESTICULAR
TUMOUR)
4. INFERTILITY
5. ATROPHY OF TESTIS
6. HERNIATION OF HYDROCELE SAC (rare)
7. RUPTURE (rare)
COMPLICATIONS OF HYDROCELE:

30. PHYSICAL ASSESSMENT
 Smooth, cystic mass completely
surrounding the testis and not
involving the spermatic cord(Possible
to get above the swelling) is
characteristic of a hydrocele.
 The consistency of hydroceles can
vary with position. Sometimes a
hydrocele can become smaller and
softer on lying down and become
larger and tenser after prolonged
standing.
Getting above the Swelling

31.  When the fluid in the hydrocele
is clear, Transillumination is
positive.
 Transillumination may be
negative in filarial hydrocele
due to prescence of chyle,
calcification or in complicated
hematocele/pyocele

32.  Hydroceles are generally painless. The presence of
pain, redness and edema with loss of the normal
scrotal rugae is suggestive of an inflammatory lesion
like epididymitis or epididymo-orchitis or filarial
relapses.

33. PRIMARY
 TESTIS NOT PALPABLE
 TENSE,FLUCTUANT
 TRANSILLUMINANT
 CAN GET ABOVE
SWELLING
FEATURES : PRIMARY VS SECONDARY
HYDROCELE
SECONDARY
TESTIS MAY BE PALPABLE
SOFT,FLUCTUANT,
MAYBE TENSE IN CASE OF
FILARIAL SCROTUM
TRANSILLUMINANT
CAN GET ABOVE
SWELLING

34. LABORATORY STUDIES
 Laboratory evaluation is generally not essential to
the evaluation of hydroceles.
 Leukocytosis with a higher percentage of neutrophils
suggests an infectious and/or inflammatory process
(eg, epididymo-orchitis).

35. IMAGING STUDIES
 Uncomplicated hydroceles do not require
radiographic studies. Findings from USG can help
evaluate for an underlying process, such as a tumour
or torsion.

36. 1. TESTICULAR TUMOUR
2. EPIDIDYMAL CYST
3. SPERMATOCELE
4. SCROTAL EDEMA
5. IRREDUCIBLE INGUINAL HERNIA
DIFFERENTIAL DIAGNOSIS

37. In Children,
 A Non-communicating Hydrocele usually resolves
spontaneously by the time the child reaches the age
of 1 year.
 A hydrocele that persists longer than 12 to 18
months is usually a Communicating Hydrocele &
requires Herniotomy
TREATMENT

38. TREATMENT
In Adults,
 Treatment depends upon the age of the patient and the
degree of discomfort caused by the hydrocele. Surgical
excision forms the definitive therapy for hydroceles.
 When they are small and asymptomatic, hydroceles require
no treatment other than reassurance.
Indications for surgery –
 Scrotal discomfort or pain
 Cosmetic - disfigurement due to the sheer size of the
hydrocele.

39. Principle of Surgery
Techniques include –
 LORDS PLICATION
used for small to medium hydroceles with thin sac. Benefits - reduced risk of
hematoma.. Some articles suggest a slight incidence of recurrence of the hydrocele
following this procedure.
 JABOULEYS OPERATION
the sac & everted and sutured behind the testis, associated with a reduced risk of
recurrence, may have an increased risk of hematoma.
 SUBTOTAL EXCISION or HYDROCELECTOMY
In cases of large sac, where there is risk of a large redundant swelling post
operatively, excision of the sac with 1 cm margin around the testis & epididymis.
?Filarial Sac
 SHARMA & JHAWERS TECHNIQUE
 ASPIRATION WITH/WITHOUT INJECTION OF SCLEROSING AGENT
 CONGENITAL HYDROCELE ARE TREATED BY HERNIOTOMY.

40. LORD’S PLICATION
JABOULAY’S PROCEDURE

41. JABOULAY’S PROCEDURE

42.  INJURY TO VAS DEFERENS
 INJURY TO URETHRA
 INJURY TO TESTIS/EPIDIDYMIS
 REACTIONARY HAEMORRHAGE
 INFECTION
 SINUS FORMATION
 RECURRENT HYDROCELE
COMPLICATIONS OF SURGERY

43. COMPARISON

44. COMPARISON