hydrocele ppt final.pptx

hydrocele

1. WELCOME 1

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3. An Approach to the Management of Hydrocele Presented by Dr Shivakumara Aladakatti BAMS 2 nd year PG Scholar Dept of PG Studies in Shalya Tantra JSS Ayurveda Medical College, Mysore-570028 Guided by Dr Siddesh Aradhyamath MS, Ph.D Professor and Head Dept of PG Studies in Shalya Tantra JSS Ayurveda Medical College, Mysore-570028 3

4. Contents Introduction Anatomy of Scrotum and testes Definition of Hydrocele Types of Hydrocele Vaginal Hydrocele Composition of Hydrocele fluid Clinical Features Local Examinations Differential Diagnosis Complications of Hydrocele Congenital Hydrocele Funicular Hydrocele Infantile Hydrocele Encysted Hydrocele Bilocular Hydrocele Secondary Hydrocele Investigations for Hydrocele Surgical treatment Ayurvedic view of Hydrocele 4

5. Introduction Abnormal collection of serous fluid between the visceral and parietal layers of the tunica vaginalis is termed as Hydrocele. It is the commonest reason for painless scrotal swelling. Affects about 1% of men, mostly above forty years of age, and 4.7% neonates It is common in newborn males. Most hydroceles in newborns are harmless and will resolve on their own by 12 months of age. The causes of hydroceles that develop in children are different from those in adults. 5

6. Introduction Hydrocele was described as early as the 15th century by Ambroise Pare. Age — Primary hydrocele is common in middle-aged people. It is not uncommon in children. Geographical distribution.— Hydrocele is more common in Tropical countries . And in North I ndia 6

7. Anatomy of scrotum The scrotum (Latin bag) is a cutaneous bag containing the right and left testes, the epididymes and the lower parts of the spermatic cords. 7

8. Blood supply Nerve supply 8

9. TESTIS The Testis is the male gonad. It is homologous with the ovary of the female. It is suspended in the scrotum by the spermatic cord. It lies obliquely, so that its upper pole is tilted forwards and laterally. The left testis is slightly lower than the right. Shape and Size The testis is oval in shape, and is compressed from side-to-side. It is 3.75 cm long, 2.5 cm broad from before backwards, and 1.8 cm thick from side-to-side. An adult testis weighs about 10 to 15 g. 9

10. Blood supply Lymphatics 10

11. Nerve supply The testis is supplied by sympathetic nerves arising from segment T10 of the spinal cord. They pass through the renal and aortic plexuses. 11

12. Definition of Hydrocele A hydrocele is an abnormal collection of serous fluid in the tunica vaginalis of the testis or within some part of the processus vaginalis. 12

13. TYPES Congenital Hydrocele Acquired Hydrocele 1. Primary or idiopathic hydrocele The cause of which is unknown i.e. there is no associated disease in the testis or the epididymis. 2. Secondary hydrocele when hydrocele is secondary to a disease in the testis and/or in the epididymis. A secondary hydrocele is usually small. 13

14. Conti… PRIMARY OR IDIOPATHIC HYDROCELE (i) Vaginal hydrocele — the commonest. (ii) Encysted hydrocele of the cord. (iii) Infantile hydrocele. (iv) Congenital hydrocele, (v) Funicular hydrocele. Three very rare varieties are — (vi) Hydrocele of the canal of Nuck. (vii) Hydrocele of the hemial sac. (viii) Hydrocele en bisac. 14

15. Composition of the hydrocele fluid The hydrocele fluid is amber coloured. Its specific gravity varies between 1.022 to 1.024 It contains water, inorganic salts, 6% of albumin and some fibrinogen. In old standing cases variable amount of cholesterol and tyrosine crystals. 15

16. PRIMARY OR IDIOPATHIC HYDROCELE VAGINAL HYDROCELE — This is by far the commonest variety of hydrocele. In this condition there is abnormal accumulation of serous fluid within the tunica vaginalis. Aetiology — Though there is no associated disease of the testis or the epididymis, yet there must be some reason why abnormal accumulation of serous fluid takes place in some individuals and not in all. The possible reasons are Defective absorption of hydrocele fluid by the tunica vaginalis due to Damage to the endothelial wall by low grade infection is the most probable explanation. Excessive production of fluid within tunica vaginalis Interference with drainage of fluid by the lymphatic vessels of the cord. There may be some connection with the peritoneal cavity as in the congenital variety 16

17. SIGNS AND SYMPTOMS In majority of cases the only complaint is — swelling of the scrotum. Occasionally patient does not seek Advise till the sac has attained enormous size. Normally testes are not palpable unless there is an infection and Filarial hydrocele. Fluctuant Initially transilluminant Discomfort to the patient Inflammatory signs if the secondary infection. Can get above the swelling 17

18. LOCAL EXAMINATIONS (i) Position Though hydrocele is often unilateral, it may be bilateral as well. (ii) On inspection one side or both the sides of the scrotum are enlarged with a notch at the middle of the affected side of the scrotum. (iii) It is a purely scrotal swelling and one can get above the swelling. 18

19. Fluctuation test It is positive, as it is a cystic swelling. The cyst is often tense in primary hydrocele. 19

20. Trans illumination Test It is always positive as the hydrocele fluid is clear. 20

21. (vi) On percussion it is always dull. (vii) Reducibility.— Vaginal hydrocele cannot be reduced. (viii) Palpation of the testis.— Though occasionally testis may be palpable posterior to the vaginal hydrocele, but the testis cannot be felt separately as the fluid of hydrocele surrounds the body of the testis. In case of secondary hydrocele when it is lax the testis may be palpable through the fluid. 21

22. Differential Diagnosis 1. Complete descended hernia. 2. Haematocele. 3. Pyocele Varicocele 22

23. 5. Filariasis of the scrotum. 6. Cysts in relation to the epididymis 7. Encysted hydrocele of the cord. 8. Tumours of the testis 23

24. DIFFERENTIAL DIAGNOSIS Fournier’s Gangrene Spermatocele 24 24

25. Complications of a hydrocele Infection. Atrophy of the testis. Rupture — may be traumatic. Haematocele — may result from trauma, Herniation of the hydrocele sac — occurs in only long standing cases. The sac herniates through the dartos muscle due to tension of the fluid. Calcification of the sac — sometimes occurs in longstanding cases. Infertility 25

26. CONGENITAL HYDROCELE In this condition the processus vaginalis remains patent so there is direct communication of the tunica vaginalis with the peritoneal cavity . 26

27. FUNICULAR HYDROCELE In this condition the processus vaginalis remains patent upto the top of the testis where it is shut off from the tunica vaginalis DIAGNOSTIC FEATURES.— The swelling is inguinal rather than scrotal. (ii) The testis can be felt separately. (iii) Other features are similar to those of congenital hydrocele 27

28. INFANTILE HYDROCELE Here tunica and processus vaginalis (hydrocele) are distended up to deep inguinal ring, but sac has no connection with the general peritoneal cavity. 28

29. ENCYSTED HYDROCELE OF THE CORD When the central portion of the processus vaginalis remains patent, but its upper and lower parts are obliterated, in such condition Fluid accumulates in the patent portion of the processus vaginalis and presents a swelling in relation to the spermatic cord. Such swelling is a localized oval cystic swelling situated in the scrotal region, inguinoscrotal region or in the inguinal region. 29

30. Hydrocele-en- bisac or Bilocular hydrocele Hydrocele has got two intercommunicating sacs, one above and one below the neck of the scrotum. Upper one lies superficial or in the inguinal canal. 30

31. Hydrocele of the Canal of the Nuck It occurs in females, in relation to the round ligament, always in the inguinal canal. HYDROCELE OF THE HERNIAL SAC It is due to adhesions of the content of hernial sac. Fluid secreted collects in the sac and forms hydrocele of the hernial sac. 31

32. SECONDARY HYDROCELE Causes Infection: Filariasis Tuberculosis of epididymis - 30% cases have secondary hydrocele Syphilis Injury: Trauma, postherniorrhaphy hydrocele Tumour: Malignancy Secondary hydrocele rarely attains large size. It is usually small, lax and testis is usually palpable Exception is, secondary hydrocele due to filariasis. It can be very large. 32

33. Investigations Hb%,TC,DC,ESR,BT,CT Urea and Creatinine HIV and HBsAg USG of scrotum CT scrotum Fluid Analysis 33

34. Conservative line of management Antibiotics Analgesics and Anti-inflammatory if pain is there Tapping should be done Sclerotherapy 34

35. Tapping This operation, though not a radical treatment, is often indicated in case of old patients. A wheal of local anesthetic solution is raised in an area of the scrotal skin that is free of visible vessels. Incision is made on this place of the scrotal wall till the tunica vaginalis is reached A fine trocar and a cannula are then thrust into the sac through the scrotal incision The fluid is evacuated slowly to avoid shock. Once all the fluid has been evacuated, the cannula is withdrawn and the wound in the scrotal wall is sealed. 35

36. Surgeries for hydrocele • Subtotal excision of the sac • Jaboulay’s operation • Evacuation and eversion • Lord’s plication 36

37. Indications for surgery Medical disqualification due to untreated Hydrocele Interference with work Interference with sexual function Interference with Micturition due to the penis getting buried in the scrotal sac Negative impact on patient’s family Dragging pain Liability to trauma in view of nature of patient’s work or mode of transportation such as excessive cycling. 37

38. Pre-Operative NBM 6 hours prior to the surgery Consent taken from the patient Inj TT 0.5ml stat dose Inj Xylocaine test dose blood urine routine investigations USG Abdomen and Pelvis Chest x-ray (PA) view if necessary Physician fitness for surgery Part preparation 38

39. procedure Under G/A or spinal or L/A after painting and draping vertical incision of about 6-8 cm in length is made over the scrotum, anteriorly 1 cm lateral to the median raphe Skin, dartos, external spermatic fascia, internal spermatic fascia are incised Bluish hydrocele sac is identified, i.e. parietal layer of the tunica vaginalis of testis. Fluid is evacuated using trocar and cannula. Sac is opened. Drain all the collected fluid, Eversion of sac and suturing done After that put a drain and close the wound 39

40. Subtotal excision of sac If the sac is thick, in large hydrocele and chylocele, subtotal excision of the sac is done ( tunica vaginalis is reflected on to the cord structures and epididymis posteriorly ,) Jaboulay’s operation Often the sac is excised partially and then eversion is done, which is called as Jaboulay’s operation . Lord’s procedure of excision of sac This operation is mainly indicated for big size hydrocele. The steps of operation up to opening of the tunica vaginalis are same as those of the previous operation. The tunica vaginalis is now sutured with 10 to 12 catgut sutures from the out edge of the tunica to the reflection of the tunica from the testis and the epididymis. When these sutures are tied, the whole tunica is bunched at the edge of the testis. 40

41. Post-operative NBM 6 hours after procedure start with sips of water and followed by liquid diet Restricted head movements Proper wound care management Post op antibiotics to prevent infection Drain should be removed after 48 hours. 41

42. Complications of surgery • Reactionary hemorrhage • Infection • Pyocele • Sinus formation • Recurrent hydrocele 42

43. Ayurveda 43

44. MutravrddHi मुत्रसधरणशीलस्य मुत्रव्रुद्धिर्भवति, सा गच्छतोऽम्बूपूर्णा द्रुतिरिव क्षुभ्यति मुत्रक्रुच्छ्रवेदनाम् व्रुषणयोः श्वयथुं कोशयोश्चापादयति, तां मुत्रवॄद्धिं विध्यात् ( su ni 12/6) Mutrajavruddi occurs in those people who suppress the urge of Urination habitually, in coarse of time, the scrotum develops movements like a bag full of water, Dysuria, pain in the testicles and swelling of the scrotum. This should be understand as mutrajavrddi . 44

45. Chikitsa मूत्रजां स्वेदयित्वा तु वस्त्रपत्तेन वेष्टयेत् ॥१८॥ सेवन्याः पार्श्वतोऽधस्ताद्विध्येद् व्रिहिमुखेन तु ॥ अथात्र द्विमुखां नाडीं दत्वा विस्रावयेद्भिषक् ॥१९॥ मूत्रं नाडिंमथोध्रुत्य स्थगिकाबन्धमाचरेत् ॥ शुद्धायां रोपणं दद्याद् ( su chi 19) Scrotal enlargement caused by urine should be fomented and bandaged. Then it should be punctured with trocar at the lower part on side of the raphe and fluid should be drained out by surgeon after introducing cannula with double Opening.Then the cannula should be removed and stump bandage applied. After the wound is cleansed. Healing measures should be employed. 45

46. मूत्रजं स्वेदितं स्निग्धैर्वस्त्रपत्तेन वेष्ठितं । विध्येदधस्तात्सेवन्याः स्रवयेच्च यथोदरम् ॥३९॥ व्रणं च स्थगिकाबद्धं रोपयेत् ( AH chi 13\39) Mutraja vrddhi should be given Fomentation. Wrapped with cloth soaked in oil. Punctured below near the R aphea . Fluid drained out by using vrihimukha shastra . Applied with Sthagika Bandha and wound should be Treated. 46

47. Formulations Lashunadi kashayam Lashuna Erandadi kashayam Haritakyadi Kashayam Varanadi Ghritam Lashunadhya Ghritam 47

48. Pathya Vyayama Maintain hygiene Vegetables and fruits Wearing good and Suitable inner wears Apathya Guru, snigdha and sheeta Ahara Kaphakara Ahara- vihara Excessive exercise and cycling Not maintaining Hygiene 48

49. Discussion Hydrocele is an easily treatable surgical disease and no acute conditions are noted A hydrocele is often diagnosed with an ultrasound of the scrotum and testicles. The sonogram will typically demonstrate a thin-walled, anechoic fluid collection on the anterolateral aspect of the testicle. Hydrocele can be taken as a elective case for surgery 49

50. Discussion People are afraid of the organ involved in this disease and they think that it is very serious but it is normal for surgeons Scrotal swelling can be seen in all age group and in tropical regions more.in children it will be congenital and resolve by it’s own up to 1 year of Age. In middle aged people it is primary or idiopathic , but in old age people one should confirm with Testicular cancer . In our classics mutra vrddhi explained under vrddhi roga.The earliest method of treating this is tapping, Sthagika Bandha and Gophana Bandha, which even holds good in modern days also. One should not neglect this condition without taking proper treatment then it leads to complications . 50

51. conclusion Hydrocele is not a cumbersome disease It is more in North Indian people and who are riding bicycles more in South India its occurrence is less. It is common in newborn males. Most hydroceles in newborns are harmless and will resolve on their own by 12 months of age It can be treated by surgical methods more satisfactorily than conservative line. 51

52. references Prof. Sriram Bhat M SRB’s Manual of Surgery. New Delhi,Jaypee publications,5 th Edition, 2017. page no 1017. Somen das, A concise text book of Surgery, Kolkata, 6 th Edition,2010. page no 1180. Bailey & Love, ed ; Norman S Williams et al ; Short Practice of Surgery. London: Taylor & Francis Group, 27 th edition, 2018. B D Chaurasia’s Human Anatomy volume 2, 5 th Edition, CBS Publishers and Distributors, 2020. page no 260 Acharya YT, et al ; Susruta Samhita with Nibandha Sangraha and Nyayachandrika commentary. Varanasi: Chaukhambha Surbharati Prakashan , 2012 edition. Nidana sthana , Chapter 12 , Shloka no 6 52

53. references Acharya YT, et al ; Susruta Samhita with Nibandha Sangraha and Nyayachandrika commentary. Varanasi: Chaukhambha Surbharati Prakashan , 2012 edition. Chikitsa Sthana , Chapter 19 , Shloka no 18-19. Dr. P.V. Tewari Caraka Samhita English Translation of text with Ayurveda Dipika commentary of cakrapani datta , Varanasi: Chaukhambha Vishvabharati . Student Edition, 2020. Chikitsa Sthana , Chapter 12 , Shloka no 94-95. Prof. K. R. Srikantha Murthy Vaghata’s Astanga Hridayam , English Translation, Varanasi,Chowkamba Krishnadas Academy 2004. chikitsa Sthana 13 chapter, shloka no 39. 9. An Elsevier journal of Infertility seconadary to an infected hydrocele; A case report, by Moayid Fallatah , Alfaisal University, Riyadh, Saudi Arabia. 8 November 2019. 53

54. 54 Thank You All…

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57. मुत्रेण पूर्णं म्रुदु मेदसा चेत् स्निग्धं च विध्यात् कठिनं च शोथम् ॥ ९४ ॥ विरेचनाभ्यङ्गनिरुहलेपाः पक्वेषु चैव व्रणवच्चिकित्सा। स्यन्मूत्रमेदःकफ़जं विपाट्य विशोध्य सीव्येद् व्रणवच्च पक्वम् ॥ ९५ ॥ ( cha chi 12\94) The scrotum filled with urine is soft, while if it is filled with medas the swelling will be unctuous and hard. these should be treated with Virechana Abhyanga Niruha basti Lepa The scrotal swelling caused by mutra , medas and kapha should be incised, after cleansing the morbidity it shoud be sutured. 57

58. DIAGNOSTIC FEATURES (i) Congenital hydrocele is present since birth. (ii) When the patient lies horizontal, the hydrocele disappears as the fluid in the tunica vaginalis drains into the abdominal cavity. In the erect posture hydrocele appears again. (iii) In contradistinction to assumption, congenital hydrocele is not easily reducible due to narrowness of the deep inguinal ring. 58

59. INFANTILE HYDROCELE DIAGNOSTIC FEATURES.— Not necessarily it is seen in infants, it is often seen in adults. (ii) It gives rise to an inguinoscrotal swelling, very much similar to the inguinal hernia. It is not reducible and there is no impulse on coughing. (iii) It is a cystic swelling. (iv) Fluctuation test is positive. (v) Transillumination test is positive. (vi) It does not disappear when the patient lies down. 59

60. DIAGNOSTIC FEATURES encysted Oval cystic swelling in relation to the spermatic cord. (ii) Such cystic swelling is seen in the inguinal, inguino -scrotal or scrotal region depending on which part of the processus vaginalis is patent. (iii) The testis can be felt separate from the swelling. (iv) In the swelling fluctuation test and transillumination test are positive. 60

61. Conti.. (v) As the upper part of the processus vaginalis is obliterated — the swelling is not reducible and cough impulse is absent. (vi) Traction test.— This important test is pathognomonic of this condition. When gentle traction is exerted on the testis the swelling moves downwards and becomes less mobile. 61

62. Filarial Hydrocele and Chylocele • Occurs commonly in coastal region, and in and around the equator. • Usually occurs after repeated attacks of filarial epididymitis. • Hydrocele is usually of large size and the sac is thickened. • Fluid contains fat, rich in cholesterol, and is derived from ruptured lymph varix into the tunica. • It is often difficult to differentiate from primary hydrocele. 62

63. Drainage Unnecessary drainage is not at all advised. Drainage is only indicated (i) When the hydrocele is a big one. (ii) When the surgeon is not sure about haemostasis . (iii) In case of haematocele . (iv) In case of filariasis . (v) In case of infected sac. Drainage is provided with a corrugated rubber sheet which is fixed to the skin with nylon or silk. The drainage must be removed within 48 hours or earlier if the soakage is much less 63