Hydrocele- All types & treatment options

Hydrocele covered all types & treatment options for Medical professionals,Medical Students

1. HYDROCELE By:- Pawan Kurliye MBBS Student(Intern) Moderator:- Dr Sabin Yadav

2. Content What is hydrocele? Definiton? Developmental Anatomy Risk factors & Etiology Classification & Types Signs & symptoms Physical assessment & Dx Complication of Hydrocele Differential Dx Management (Surgical Tx & complications) Mind Map Clinical case Scenario Reference

3. INTRODUCT I ON Hydrocele is an abnormal collection of serous fluid between the visceral and parietal layers of the tunica vaginalis.

4. DEVELOPMENTAL ANATOMY

5. Layers of Scrotum SKIN DARTOS MUSCLE EXTERNAL SPERMATIC FASCIA (external oblique) CREMASTRIC MUSCLE (internal oblique) INTERNAL SPERMATIC FASCIA (Facia Transversalis) TUNICA VAGINALIS

6. Arteries and veins of testis Testicular Artery It is a branch of abdominal aorta Descends on the posterior abdominal wall It traverses the inguinal canal and supplies the testis and the epididymis Testicular Veins These are the extensive venous plexus, the pampiniform plexus Leaves from the posterior border of the testis As the plexus ascends, it becomes reduced in size so that at about the level of deep inguinal ring, a single testicular vein is formed Drains into left renal vein on left side and inferior vena cava on right side

7. Risk factors Most hydroceles are present at birth (congenital), and babies who are born prematurely have a higher risk of having a hydrocele. H ydrocele generally affects men 40 or older : Scrotal injury (Traumatic/Iatrogenic), Infection including sexually transmitted infections, Tumours & Radiation Therapy

8. ETIOLOGY For baby boys, a hydrocele can develop m the womb. Normally, the test icles descend from the developing baby's abdominal cavity into scrotum. A sac (proce s sus vaginalis) accompanies each testicle, allowing fluid to surround the testicles. In most cases, each sac closes and the fluid is absorbed. However, if the fluid remains acer the sac closes, the condition is known as a NONCOMMUNICATING HYDROCELE. Because the sac is closed, fluid can't flow back into the abdomen. Usually the fluid gets absorbed within a year. In some cases, however, the sac remains open. With this condition, know n as COMMUNICATING HYDROCELE,the sac can change size or,if the scrotal sac is compressed, fluid can flow back into the abdomen. In older males, a hydrocele can develop as a result of inflamma ti on or injury within the scrotum.Inflammation may be result of infection of the small coiled tube at the back of each testicle (epididymi ti s) or of the testicle.

9. CLASSIFICATION CONGENITAL ACQUIRED PRIMARY SECONDARY

10. CONGENITAL HYDROCELE NONCOMMUNICATING HYDROCELE - patent processus vaginalis obliterates but fluid remains. COMMUNICATING HYDROCELE - the sac remains open in communication with the peritoneal cavity.

11. CONGENITAL HYDROCELE : PROCESSUS VAGINALIS COMMUNICATES WITH PERITONEAL CAVITY ..... INFANTILE HYDROCELE : TUNICA & PROCESSUS VAGINALIS DISTENDED UPTO INTERNAL RING BUT SAC HAS NO CONNECTION WITH PERITONEAL CAVITY

12. ENCYSTED HYDROCELE OF CORD: PART OF FUNICULAR PROCESS PATENT, & IS CLOSED FROM THE TUNICA VAGINALIS BELOW & PERITONEAL CAVITY ABOVE. SMOOTH,OVAL SWELLING ASSOCIATED WITH SPERMATIC CORD. TRACTION TEST +ve

13. HYDROCELE EN BISSAC TWO INTERCOMMUNICATING SACS ABOVE & BELOW NECK OF SCROTUM Operated at Midnapur Medical College, West Bengal (2008)

14. HYDROCELE OF CANAL OF NUCK: OCCURS IN FEMALES IN THE INGUINAL CANA L THE CYST LIES IN RELATION ROUND LIGAMENT SIMILAR TO HHYDROCELE OF THE CORD(ENCYSTED HYDROCELE)

15. HYDROCELE OF HERNIAL SAC : NECK OF THE HERNIAL SAC BECOMES CLOSED BY ADHESIONS OR PLUGGED BY OMENTUM. RESULTS IS RETENTION OF FLUID SECRETED BY PERITONEUM OF HERNIAL SAC

16. Primary Hydrocele - Clinical Pictures

17. I NFECTIONS : FILARIASIS TUBERCULOSIS OF EPIDIDYMIS SYPHILIS I NJURY POST HERNIORRHAPHY HYDROCELE POST VARICOCELECTOMY HYDROCELE TRAUMA T UMOUR MALIGNANCY SECONDARY HYDROCELE

18. COMMON IN COASTAL/TROPICAL REGIONS , ACCOUNTS FOR 80 % OF ALL HYDROCELES IN TROPICAL REGIONS, CAUSED BY Wucheria bancrofti REPEATED ATTACKS OF FILARIAL EPIDIDYMITIS SIZE- LARGE SIZE WITH THICKENED SAC OCCASIONALLY CONTAINS CHOLESTEROL RICH FLUID – CHYLOCELE DUE TO RUPTURED LYPMH VARIX WITH DISCHARGE OF CHYLE IN TO THE HYDROCELE RESEMBLES PRIMARY HYDROCELE MAY BE ASSOCIATED WITH FILARIAL ELEPHANTIASIS. FILARIAL HYDROCELE

19. INFECTION PYOCELE,HEMATOCELE/CLOTT E D HEMATOCELE CALCIFICATION OF SAC ATROPHY OF TESTIS HERNIATION OF HYDROCELE SAC (rare) pure scrotal swelling RUPTURE (rare) INFERTILITY (rare) COMPLICATIONS OF HYDROCELE:

20. SIGNS & SYMPTOMS In the early stages hydroceles are usually asymptomatic. As they enlarge they bulge out and can become a cosmetic problem. Symptoms can develop, as the swelling increases in size, which include: Heaviness, fullness, or dragging sensations due to an enlarged scrotum. There may be mild discomfort radiating along the inguinal area to the mid portion of the back. If pain develops in a Hydrocele it is usually an indication of acute epididymal infection or due to overstretched scrotal skin in huge hydroceles. The size may decrease with recumbency or increase in the upright position. Fever, chills, nausea, or vomiting indicate an infection of a hydrocele.

21. PHYSICAL ASSESSMENT Smooth, cystic mass completely surrounding the testis and not involving the spermatic cord(Possible to get above the swelling) is characteristic of a hydrocele. The consistency of hydroceles can vary with position. Sometimes a hydrocele can become smaller and softer on lying down and become larger and tenser after prolonged standing. Getting above the Swelling When the fluid in the hydrocele is clear, Transillumination is positive. Transillumination may be negative in filarial hydrocele due to prescence of chyle, calcification or in complicated hematocele/pyocele

22. Getting above the swelling positve Transillumination positive Fluctuation positive Non reducible swelling Impulse on coughing negative (positive in congenital hydrocele) Testis cannot be palpated separately. (exception - funicular hydrocele a.k.a encysted hydrocele ) Why is it Hydrocele?

23. IMAGING STUDIES  Uncomplicated hydroceles do not require radiographic studies. Findings from USG can help evaluate for an underlying process, such as a tumour or torsion. Composition of Hydrocele Fluid Color -Straw or amber colored. Composition Water, fibrinogen, inorganic salts, albumin and cholesterol crystals Hydrocele fluid normally won't clot if it is drained into a container but will clot immediately even if it comes into contact with a drop of blood

24. TESTICULAR TUMOUR EPIDIDYMAL CYST SPERMATOCELE EPIDIDYMO-ORCHITIS TESTICULAR CARCINOMA DIFFERENTIAL DIAGNOSIS

25. In Children (congenital hydrocele) , A Non-communicating Hydrocele usually resolves spontaneously by the time the child reaches the age of 1 year. A hydrocele that persists longer than 12 to 18 months is usually a Communicating Hydrocele & requires inguinal Herniotomy ...... In Adults, Treatment depends upon the age of the patient and the degree of discomfort caused by the hydrocele. Surgical excision forms the definitive therapy for hydroceles. When they are small and asymptomatic, hydroceles require no treatment other than reassurance. Indications for surgery – Scrotal discomfort or pain Cosmetic - disfigurement due to the sheer size of the hydrocele. TR E ATMENT

26. Techniques include LORDS PLICATION used for small to medium hydroceles with thin sac. Benefits - reduced risk of hematoma.. Some articles suggest a slight incidence of recurrence of the hydrocele following this procedure. JABOUL A YS OPERATION used for large size hydrocele,after I & D, the sac is everted and sutured behind the testis, associated with a reduced risk of recurrence, may have an increased risk of hematoma. SHARMA & JHAWERS TECHNIQUE after evacuation, the sac with the testis is placed in a neewly creatd pocket between the fascial layers of the scrotum Encysted Hydrocele - Inguinal herniotmy + Incision & drainage of the encysted hydrocele

27. JABOULAY’S PROCEDURE

28. Primary Hydrocele -Operative pics JABOULAY’S PROCEDURE

29. INJURY TO VAS DEFERENS INJURY TO URETHRA INJURY TO TESTIS/EPIDIDYMIS REACTIONARY HAEMORRHAGE - Hematocele INFECTION - Pyocele SINUS FORMATION between layers RECURRENT HYDROCELE COMPLICATIONS OF SURGERY

30. Mind map

31. Classic Clinical case of Hydrocele A 42-year-old male patient presents with right sided scrotal swelling of two years duration . It is a progressively increasing painless swelling . O/E: the right side of the scrotum shows a swelling of 15 x 10 cm size which is confined to the scrotum ( can get above the swelling). The surface of the swelling is smooth and borders are well-defined. There is no local rise of temperature. The swelling is fluctuant and transilluminant . It is not reducible .There is no cough pulse . The right testis is not felt separately . The spermatic cord is felt above the swelling and is tender. The contralateral testis and genitalia are normal. There is no evidence of any mass or lymph nodes in the abdomen

32. Reference Bailey and Love-Short Practice of Surgery Manual on Clinical Surgery -Somen.Das THANK YOU-DOCTOR'S FOR YOUR PRECIOUS TIME