Hydrocele Testis

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Definition and Classification of Hydroceles

Hydrocele testis

A hydrocele testis is an accumulation of serous fluid in the cavity of the tunica vaginalis of the testis, without communication of the hydrocele with the abdominal cavity [hydrocele testis].

Hydrocele of the Cord

A hydrocele of the cord is an accumulation of serous fluid in a non-obliterated part of the processus vaginalis without communication with the abdominal cavity or tunica vaginalis of the testis.

Communicating Hydrocele

An open processus vaginalis leads to varying amounts of serous fluid in the cavum vaginalis testis.

Abdominoscrotal Hydrocele

The inguinal portion of a large hydrocele is pushed into the low pressure compartment of the abdomen. An obliteration of the hydrocele develops in the area of the internal inguinal ring.

Hydrocele of the testis: serous fluid in the cavity of the tunica vaginalis.

Etiology of Hydroceles

Congenital Hydroceles

With the descent of the testis, the parietal peritoneum forms the processus vaginalis and the cavity of the tunica vaginalis of the testis. The processus vaginalis normally obliterates till the fourth month of life. Congenital hydroceles occur mostly through lack of closure of the processus vaginalis (= communicating hydrocele).

Acquired Hydroceles

Usually, there is a balance between fluid production and outflow in the cavity of the tunica vaginalis. The following diseases disturb this balance: inflammation, tumors, testicular trauma, torsion of the testis or testicular appendages, defective lymphatic drainage (after surgery for varicoceles or inguinal hernias).

Signs and Symptoms

• Painless testicular swelling, positive transillumination
• Communicating hydrocele: size is changing depending on activity (small in the morning small, large in the evening).

Diagnosis of Hydrocele

Ultrasound Imaging

The typical ultrasound image is the anechoic fluid collection in the cavity of the tunica vaginalis of the testis [fig. ultrasound of a hydrocele]. It is important to carefully examine the testes and spermatic cord (signs for torsion? tumor? size of the epididymis? abdominal parts of the hydrocele?).

Ultrasound imaging: hydrocele of the testis

Differential Diagnosis of a Scrotal Swelling

The most important reasons for a painless scrotal swelling are:

• Hydrocele
• Spermatocele
• Varicocele
• Hematocele
• Scrotal hernia
• Testicular cancer

Treatment of Hydroceles

Please see section hydrocelectomy: surgical techniques and complications.

Surgery for Communicating Hydroceles

Treatment of communicating hydroceles starts with an inguinal incision for exposure of the testis. The processus vaginalis is isolated from the spermatic cord, divided and ligated at the internal inguinal ring. The distal sac is resected as far as possible, the end of the sac can be left open.

The contralateral exploration is not a standard therapy, but is sometimes performed. The probability for an open contralateral processus vaginalis in unilateral communicating hydrocele is 50%, but only about 15–22% become clinically significant.

Surgery for Hydroceles of the Cord

Treatment of hydroceles of the cord starts with an inguinal incision for exposure of the spermatic cord. After excision of the hydrocele of the cord, the processus vaginalis is ligated at the internal inguinal ring.

Surgery for Hydroceles of the Testis

After scrotal incision for exposure of the scrotal hydrocele, two surgical techniques are available. The recurrence rate should be below 5% with either technique, Lord's technique has probably the lowest complication rate:

• Hydrocelectomy with excision of the hydrocele sac: Winkelmann's technique or Jaboulay's technique
• Hydrocelectomy with plication of the hydrocele sac: Lord's technique

Sclerotherapy for Hydroceles of the Testis

Sclerotherapy is a therapeutic alternative to surgery for simple hydroceles of the testis and patients unfit for surgery. The recurrence rate is higher than with surgical therapy. After treatment failure of sclerotherapy, the surgical treatment is more difficult due to scarring and adhesions. Phenol 2.5% is used as a sclerosant.