Primary hydrocele:Processus vaginalis of the spermatic cord fuses at term or within 1-2 years of birth, thus obliterating the communication between the abdomen and scrotum. The distal portion, however, remains patent as the tunica vaginalis covers the testis, creating a potential space where fluid accumulation within it can lead to hydrocele formation. Depending upon the site of the obliteration of processus vaginalis, there are four types of primary hydrocele.
- Congenital hydrocele: Patent processus vaginalis communicating with peritoneal cavity allowing peritoneal fluid but too small to allow intra-abdominal contents to herniate
- Infantile hydrocele: Processus vaginalis obliterated at level of deep inguinal ring while distal segment remains patent and allows fluid accumulation.
- Encysted hydrocele of the Cord: Both proximal and distal portions of processus vaginalis obliterated while central portion remains patent and fluid accumulates within it
- Vaginal hydrocele (M/C): Processus vaginalis remains patent only around the testes, and, as fluid accumulates, it renders the testes impalpable.
Secondary Hydrocele:Occurs as a result of an underlying conditions
- Infection (M/C cause): Epididymo-orchitis, filariasis, tuberculosis of the epididymis, syphilis
- Injury: Trauma, post-herniorrhaphy hydrocele
Painless scrotal swelling rendering the testes impalpable with positive transillumination and fluctuation.
- Secondary hydrocele: Generally smaller, with the exception of filarial hydrocele
- Congenital hydrocele: Non-reducible on pressure and intermittent (lying flat drains hydrocele fluid into peritoneum)
- Encysted hydrocele: Smooth oval-shaped swelling near the spermatic cord
Ultrasonography (USG):Indicated in scrotal pain or failure to delineate the testicular anatomy on palpation
- Hydrocele appears as an anechoic or echolucent area surrounding the testis
Duplex ultrasonography:Provides information regarding testicular blood flow
- Reduced/absent in hydroceles resulting from testicular torsions
- However, in hydroceles secondary to epididymitis, the epididymal flow would be increased
- Inguinal hernia: Negative transillumination and palpable bowel at the deep ring on the digital examination is more consistent with an inguinal hernia.
- Testicular Tumor: Serum α-fetoprotein and human chorionic gonadotropin (hCG) levels are indicated if there is suspicion of malignant teratomas or other germ cell tumors.
- Epididymitis/Orchitis: Can lead to secondary or reactive hydroceles
Surgical management: HydrocelectomyIncisions for scrotal exploration is done through either a midline scrotal incision or a transverse incision. After the incision, the hydrocele is delivered out of the scrotum in its entirety. The sac is emptied of its fluid content through a small incision opposite the testis (to avoid injuring it), followed by lengthening of the sac incision and delivering the testis. The redundant tunica vaginalis can then be everted and closed behind the testicle (Jaboulay’s procedure) or plicated with a series of interrupted absorbable sutures (Lord’s Procedure). In long‐standing hydroceles, the sac is thick and stiff and needs to be cut away leaving a frill around the epididymis, which must be over sewn to achieve perfect haemostasis.
- Lord plication (for thin-walled hydroceles): Tunica bunched into a ruff by applying a series of multiple interrupted chromic catgut sutures for the sac to form fibrous tissue.
- Excision & eversion “Jaboulay procedure” (for large thick-walled hydroceles and chyloceles): Subtotal excision of the tunica vaginalis and everting the sac behind the testes followed by placing the testes in a newly created pocket between the fascial layers of the scrotum
HerniotomyFor congenital hydroceles, as they do not resolve spontaneously.
- Performed within 2 years age