Hydrocele

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What is a Hydrocele?

A Hydrocele, also known as Hydrocele testis, is a condition that results when fluid accumulates within the layers of the tunica vaginalis that covers the testis, and it presents as a swelling in the scrotum.

Is Hydrocele a Medical emergency?

A Hydrocele is not a medical emergency.

Types

Hydrocele may be of the following types:

  • Primary Hydrocele: The cause is not known, the Hydrocele is tense
  • Secondary communicating Hydrocele: This occurs when the sac surrounding the testes does not close and continues to communicate with the peritoneum even after the testicles descend into the scrotum after birth. This allows the fluid within the Hydrocele to flow in and out.
  • Secondary non-communicating Hydrocele: The sac surrounding the testes is closed, but the fluid is not absorbed leading to the formation

Some of the other types may include:

  • Microbe induced Hydrocele: As seen with tuberculosis, parasitic such as filariasis, elephantiasis, syphilis
  • Inflammatory and iatrogenic: This is caused by inflammations and after surgeries such as laparoscopic varicocelectomy
  • Trauma or tumor-induced
  • Congenital Hydrocele
  • Giant Hydrocele: When the Hydrocele is larger than the individual’s head or holds more than 1000 ml of fluid
  • Hydrocele in the canal of Nuck: Seen in women

Causes

These are common in the newborn and usually resolve spontaneously. These are usually caused by an imbalance in the production and absorption of a scrotal fluid; this fluid imbalance could be due to external causes such as increased intra-abdominal pressure or increased intra-abdominal fluid production, or it may be an internal problem as seen in viral infections or trauma that causes an increased production of the serous fluid.

The causes of a Hydrocele testis may include:

  • Dislocated testes
  • Testicular infarction
  • Microlithiasis (stones) of testes
  • Sarcoidosis of the testes
  • Retained foreign body and trauma with a sharp object
  • Chronic lung disease (increased intra-abdominal pressure)
  • Children with ventriculoperitoneal shunts (increased intra-abdominal fluid production)
  • Infections
  • Filariasis

Risk factors

The risk factors are may include:

  • Sexually transmitted infections
  • Trauma or infection of the scrotum

Signs & symptoms

Usually, the only symptom is the presence of painless swelling of the scrotum on one side. When illuminated with a focused beam of light from one side the scrotum allows the light to pass through, showing clear fluid around the testis. In the Hydrocele of the canal of Nuck, the soft painless swelling is seen on the inguinal canal or the labia, and the swelling trans-illuminates when light is focused on it.

Investigations

The following tests may be done:

  • Laboratory tests:
    • CBP & ESR: To rule out any infections
  • Imaging tests:
    • X-ray: To rule out incarcerated or strangulated hernia
    • Ultrasound: To rule out inguinal hernia, testicular tumors, spermatoceles, or inflammation of the testes or epididymitis that can cause scrotal swelling
    • Duplex ultrasound: To look for testicular torsion (twisting), epididymitis with a reactive, and varicoceles

Diagnosis

It is based on medical history, clinical evaluation, and the results of the investigations if any.

Treatment options

Usually, this disease resolve within a year and no treatment is generally necessary. The treatment of Hydroceles in older individuals who are asymptomatic and with little chance of progressing to complications is usually watchful waiting.

Interventional including surgery and indications for surgery

A temporary procedure of aspiration of the Hydrocele fluid may be done, but if intervention is advisable then surgical removal is a better option. Surgical intervention for the management of a testis is considered if:

  • It cannot be distinguished from an inguinal hernia
  • The testis cannot be examined
  • It does not resolve spontaneously after watchful waiting
  • There is pain or discomfort
  • If it is causing infertility
  • The individual desires it for cosmetic reasons

Surgical intervention is not done for testis if:

  • The individual is a surgical risk
  • The individual is an anesthetic risk

The following surgical procedure is done:

  • Hydrocelectomy with excision of the Hydrocele sac: Is usually done for large or thick-walled Hydroceles, or for  with multiple partitions within
  • Hydrocelectomy with plication of the sac: This is usually done for small or medium-sized Hydroceles with thin walls. The complications are very less

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Some measure that can be taken to reduce the risk of Hydrocele testes include:

  • Protecting oneself from sexually transmitted infections
  • Wearing protective gear if involved in sporting activity with a risk of injury to the scrotum

Complications

The following complications can occur:

  • Infection of the scrotum
  • Infertility
  • Rupture
  • Hematocele: Blood fills into the Hydrocele
  • Pyocele: The fluid gets infected and is filled with pus
  • Scrotal stones and Hydrocele stones formation
  • Psychological complications such as depression, low body image due to social stigma and embarrassment
  • Sexual dysfunction as the penis may be buried in the scrotal swelling

The complications of surgical intervention may include:

  • Scrotal edema (swelling)
  • Chronic pain
  • Hematoma
  • Decreased fertility
  • Infection and gangrene

Prognosis

The prognosis for Hydroceles that are diagnosed and managed appropriately is generally good. The prognosis is poor if the cause of the Hydrocele is a condition which itself has a poor prognosis.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if there is a swelling in the scrotal area that may or may not be associated with pain. If pain, tenderness, or fever develops in a previously diagnosed case of a Hydrocele, it is advisable to seek immediate medical attention.

Indications for hospitalization if required

Hospitalization is not needed. But maybe required for surgical management.

Suggested clinical specialist/ Departments to consult for this condition

It will be treated by specialists from the Departments of General Surgery, Urology, and/or Pediatrics.

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