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Internal Medicine

Hydrocele

Abnormal collection of serous fluid between the two layers of tunica vaginalis of testis.

Abnormal collection of serous fluid between the two layers of tunica vaginalis of testis.

Embryology

Diagram of the embryologic development of the IC. A, At 7 weeks gestation, the gubernaculum passes through the developing anterior abdominal wall at the site of the future IC. The gubernaculum is attached to the lower pole of the extraperitoneally located testes. B, At 7–12 weeks gestation, the gubernaculum shortens and pulls the testes to the level of the deep inguinal ring. The PV invaginates through the anterior abdominal wall along a path formed by the gubernaculum. Extensions of the layers of the abdominal wall accompany the PV and form the walls of the IC. C, At 26–28 weeks gestation, with androgenic stimulation and increased intra-abdominal pressure, the PV and testes begin to pass through the IC. It takes 2–3 days for the testes to reach the scrotum. D, At 32–40 weeks gestation, the IC is formed, and there is downward gradual obliteration of the PV. The scrotal portion of the PV remains patent, forming the tunica vaginalis. | Revzin, M. V, Ersahin, D., Israel, G. M., Kirsch, J. D., Mathur, M., Bokhari, J., & Scoutt, L. M. (2016). US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation. RadioGraphics, 36(7), 2028–2048. https://doi.org/10.1148/rg.2016150181
Diagram of the IC and scrotum shows obliteration of the superior portion of the PV. During development, extensions of all layers of the abdominal wall accompany the PV and contribute to the formation of the walls of the IC and scrotum. The PV is anterior (ventral) to the spermatic cord and developing testis. The parietal and visceral layers of the tunica vaginalis are formed from the patent scrotal portion of the PV. The testes and spermatic cord remain retroperitoneal throughout their descent. | Revzin, M. V, Ersahin, D., Israel, G. M., Kirsch, J. D., Mathur, M., Bokhari, J., & Scoutt, L. M. (2016). US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation. RadioGraphics, 36(7), 2028–2048. https://doi.org/10.1148/rg.2016150181

Classification

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.
Johnathan Boettcher. (2020) Human Biology Online Lab / Hydrocele JB. Retrieved October 11, 2020, from http://humanbiologylab.pbworks.com/w/page/67481518/Hydrocele%20JB

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
  • Malignancy

Pathophysiology

Clinical features

Painless scrotal swelling rendering the testes impalpable with positive transillumination and fluctuation.

(a) Right hydrocoele before 640 ml of straw colored fluid removed (b) Straw colored fluid removed with significant deflation of scrotum | Parks, K., & Leung, L. (2013). Recurrent hydrocoele. Journal of family medicine and primary care, 2(1), 109–110. https://doi.org/10.4103/2249-4863.109972

Specific features:

  • 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

Diagnosis

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
Antenatal hydrocele shows the fluid in the scrotal sac with echogenic testis. | Patil, V., Shetty, S. M., & Das, S. (2015). Common and Uncommon Presentation of Fluid within the Scrotal Spaces. Ultrasound international open, 1(2), E34–E40. https://doi.org/10.1055/s-0035-1555919

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
An increase in the resistive index (RI) of the testicular artery is seen due to a compressive effect on the vessels. | Patil, V., Shetty, S. M., & Das, S. (2015). Common and Uncommon Presentation of Fluid within the Scrotal Spaces. Ultrasound international open, 1(2), E34–E40. https://doi.org/10.1055/s-0035-1555919

Differential diagnosis:

  • 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
Anatomical similarities between a complete inguinal hernia and a communicating hydrocoele | Parks, K., & Leung, L. (2013). Recurrent hydrocoele. Journal of family medicine and primary care, 2(1), 109–110. https://doi.org/10.4103/2249-4863.109972

Management

Surgical management: Hydrocelectomy

Incisions 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

Herniotomy

For congenital hydroceles, as they do not resolve spontaneously.
  • Performed within 2 years age

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