Monday, October 20, 2014

Definition

A hydrocele is an accumulation of fluid in any sac-like cavity or duct - specifically in the tunica vaginalis testis or along the spermatic cord. The condition is caused by inflammation of the epididymis or testis or by lymphatic or venous obstruction of the cord.

The term hydrocele literally means a sac of water.

Description

Scrotal malignancies are rare and of unknown etiology. There are, however, a number of benign scrotal conditions that may present as a scrotal mass and must be differentiated from a malignant process.

A hydrocele is a collection of serous fluid between the two layers of the tunica vaginalis which normally surrounds the testis. This is the most common benign cause of scrotal swelling and has been estimated to occur in as many as 1 percent of the adult male population.

Causes

In the pediatric age group, it is usually due to a patent processus vaginalis.

In older men, any process that acts to stimulate increased production of serous fluid (e.g., tumor, inflammation, trauma) by the tunica or decreases the resorption of this fluid (e.g., inguinal surgery) by the scrotal lymphatics or venous system will result in the formation of a hydrocele.

Symptoms

Men who appear at a physician's office for the evaluation of a scrotal mass are frequently asymptomatic. It is not unusual to elicit an incidental history of scrotal or perineal trauma, which has prompted self-examination and discovery of the mass. The history of frequency, urgency, and dysuria associated with bacteriuria and of painful scrotal swelling suggests an inflammatory cause. There may also be pain in the groin or testicle.

An accurate diagnosis can usually be made solely on the basis of physical findings. A complete examination of the scrotum - consisting of inspection, palpation, and transillumination - is made in every case.

The presence of erythema and edema with loss of the normal scrotal rugae is suggestive of an inflammatory lesion (i.e., epididymitis or epididymo-orchitis.) In the presence of acuteepididymitis, the epididymis is exquisitely tender to palpation and, in the absence of orchitis, easily separated from the normal testicle. Pain is aggravated by standing and should be relieved when the testicle is elevated (Prehn's sign).

A smooth, cystic feeling mass completely surrounding the testicle and not involving the spermatic cord is characteristic of a hydrocele. A cystic, non-tender mass arising from the head of the epididymis and distinct from the testicle is characteristic of a spermatocele.

Treatment

When they are small and asymptomatic, hydroceles, spermatoceles, and varicoceles require no therapy other than reassurance. Indications for intervention include scrotal discomfort or disfigurement due to the sheer size of the mass. Treatment options include needle aspiration, aspiration with injection of a sclerosing agent, and surgical excision.

Simple needle aspiration is seldom therapeutic because the cause of the problem is not addressed and the fluid typically reaccumulates.

Excellent results are possible with either surgical excision or needle aspiration combined with injection of a sclerosing agent. Success rates ranging from 33 to 100 percent have been reported.

When intervention is indicated, surgical excision is perhaps the most effective form of treatment. In surgery, the bulk of the hydrocele sac is cut away, and what remains is turned inside out. As a result, the fluid-secreting surface is now in contact with the inner skin of the scrotum rather than that of the testicle with which it made previous contact. The scrotal tissue blots up any fluid that is secreted, unlike the testicular tissue that cannot absorb fluid.

Questions

Is it a hydrocele?

Are any further testing needed for a definitive diagnosis?

What is the probable cause?

Is aspiration indicated?

Is a surgical excision necessary?

Will there be a complete recovery?