HYDROCELE surgery lecture topic Slides 17.pptx

Lecture slides on Hydrocele. Reference to surgical textbooks, NCBI and youtube

1. HYDROCELE Presenter : Udite Vukicanavanua Student ID: 20180233

2. INTRODUCTION A hydrocele is a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis which directly surrounds the testes and the spermatic cord Range from small soft collections that still permit palpation of scrotal contents, to tense collections of several litres . Hydroceles are common in newborns, the majority of which in neonates resolve spontaneously, usually by the first or second birthday In older children ,adolescents or adults hydroceles may be idiopathic or may occur secondary testicular pathology Most cases are non- painful( pain generally correlated with the size, inflammatory processes)

3. Normal testicular anatomy Hydrocele

4. Anatomic structures that may be involved in scrotal conditions : Testis (testicle): is the male gonad responsible for production of sperm and androgens (primarily testosterone). The normal testis is ovoid, about 3 to 5 cm in length, and firm with smooth surfaces. One testis may be slightly larger than the other, and one testis (usually the left) may hang slightly lower. Tunica vaginalis : is a fascial layer which encapsulates a potential space encompassing the anterior two-thirds of the testis. Different types of fluid may accumulate within the tunica vaginalis ( eg , peritoneal or serous fluid with a hydrocele, blood with a hematocele , pus with a pyocele ). Epididymis: is a tightly coiled tubular structure located on the posterior aspect of the testis running from its superior to inferior poles. Sperm travels from the tubules of the rete testis into the epididymis , which joins the vas deferens distally. The function of the epididymis is to aid in the storage and transport of sperm cells that are produced in the testes, as well as to facilitate sperm maturation.

5. Spermatic cord: consists of the testicular blood vessels, ilioinguinal nerve branches,cremasteric muscle fibers , fat, and the vas deferens. Is connected to the superior pole of the testis and epididymis and traverses cephalad into the retropubic space.

6. HYDROCELE TYPES : 1 . Communicating hydroceles (congenital) : usually develop as a result of failure of the processus vaginalis to close during development thus babies who are born prematurely are high risk. The fluid around the testis and cord is peritoneal fluid. Are often associated with inguinal hernias (complication). - Collection of fluid can occur anywhere along the path of descent of the testis. Embryology Testes — The testes appear on the ventromedial aspect of the urogenital ridge on the posterior abdominal wall during the fifth to sixth week of gestation. By the 10th week, they have descended through the coelomic cavity and can be found close to the groin. The processus vaginalis forms during the third month of gestation from an outward protrusion of the peritoneum that lines the ventral abdominal wall and forms a diverticulum at the internal inguinal ring. Between the seventh and ninth months of gestation, the testes descend through the inguinal canal and into the scrotum, pushing the processus vaginalis ahead and protruding into its cavity. Once this process is complete, the processus vaginalis obliterates spontaneously, usually by age two years .

7. INGUINAL HERNIA TYPES : Indirect inguinal hernia  - Indirect inguinal hernias are the most common type of hernia in both males and females . Are classified as lateral hernias by the European Hernia Society groin hernia classification system .Indirect hernias protrude at the internal inguinal ring ( the site where the spermatic cord in males and the round ligament in females exit the abdomen) .The origin of the hernia sac is located lateral to the inferior epigastric artery Direct inguinal hernia  - protrude medial to the inferior epigastric vessels within Hesselbach's triangle( formed by the inguinal ligament ( Poupart's ligament) inferiorly, the inferior epigastric vessels laterally, and the rectus abdominis muscle medially) 

8. 2. Non-communicating hydroceles ( acquired) : have no connection to the peritoneum; the fluid comes from the mesothelial lining of the tunica vaginalis ( or from fluid remnants after the proximal aspect closes). Are also belived to arise from imbalance of secretion and reabsorption of fluid from the tunica vaginalis ( idiopathic/ primary) or secondary to epididymitis, orchitis , testicular torsion, torsion of the appendix testis or epididymis, trauma, or tumor (reactive hydroceles). These conditions must be excluded . Idiopathic hydrocele is the most common type and arises over a long period of time. Inflammatory conditions of the scrotal contents can produce an acute reactive hydrocele ( treat the underlying condition).

9. Spermatic cord hydrocele   ( congenital) — A hydrocele of the spermatic cord occurs when fluid accumulates along the cord in the inguinal canal or upper scrotum, but is separated from the testes. A cord hydrocele occurs from an abnormal closure of the processus vaginalis where the distal portion closes and midportion remains patent along the cord. -Are typically classified into one of two types: a) Non-communicating (encysted)  – This is the   most common variety and is characterized by fluid pooling along the length of the cord but not communicating with the peritoneal cavity or tunica vaginalis . Since the encysted type does not communicate with the peritoneal cavity, the size does not change with increases in intra-abdominal pressure, such as crying fits or coughing, nor is this type reducible. b) Communicating (funicular)  – Unlike the encysted type, the funicular type communicates freely with the peritoneal cavity at the internal ring. Therefore, the swelling in the inguinal area can enlarge with increased intra-abdominal pressure, and can decrease in size when the patient relaxes. Communicating cord hydroceles can be difficult to distinguish from indirect inguinal hernias on physical examination, and ultrasound is frequently required to establish the diagnosis. Regardless of type, children with spermatic cord hydroceles warrant referral to a surgeon with pediatric and genitourinary expertise. Herniotomy is frequently performed to prevent later development of an indirect inguinal hernia.

10. Encysted non-communicating (B) Funicular communicating

11. CLINICAL PRESENTATION - Patients present with a heavy cystic scrotal mass of one or both testis. -A hydrocele that communicates with the peritoneal cavity may increase in size during the day or with the Valsalva maneuver . In contrast, non- communicating hydroceles are not reducible and do not change in size or shape with crying or straining. -Although rare, large, non-communicating hydroceles may extend through the inguinal ring and into the abdomen creating an abdominal scrotal hydrocele. This condition is suspected when abdominal extension of the hydrocele into the abdominal cavity is present on examination and confirmed by sonogram -In patients with testicular pain and scrotal swelling, the hydrocele may arise from epididymitis, orchitis , testicular torsion, torsion of the appendix testis, testicular rupture, testicular hematoma, or tumor as the primary etiology (reactive hydroceles); Doppler ultrasonography is usually necessary to evaluate these patients further.

12. DIAGNOSTIC EVALUATION : Physical examination : Hydrocele fluid in the scrotal sac generally transilluminates well and demonstrates a cystic fluid collection ( differentiates it from a possible hematocele , hernia, or solid mass). Communicating hydroceles are often reducible; non-communicating hydroceles are not. Imaging modality : Doppler ultrasonography may be necessary to evaluate the testicle and rule out a primary cause or to determine if an abdominoscrotal hydrocele is present. A scrotal ultrasound should be considered if the diagnosis is uncertain since a reactive hydrocele can occur in the presence of a testicular neoplasm or with acute inflammatory scrotal conditions ( orchitis , epididymitis). - blood or urine test may be used to rule out infection.

13. MANAGEMENT: - Most hydroceles do not require intervention. Treatment is only indicated in patients who are symptomatic. For asymptomatic patients with hydroceles, there is no need for routine follow-up. The management of asymptomatic hydroceles in a neonate or child younger than one to two years of age usually is supportive. Hydroceles that are present in newborns , whether communicating or non-communicating, usually resolve spontaneously by the second birthday, unless they are accompanied by an inguinal hernia or are large Surgical repair is indicated for communicating hydroceles that persist beyond one to two years of age and for idiopathic, non-communicating hydroceles that are symptomatic or compromise the skin integrity -Communicating hydroceles in patients older than two years of age rarely resolve and pose a risk for development of incarcerated inguinal hernia. Surgical repair of communicating hydroceles is usually undertaken on an elective basis - Idiopathic non-communicating hydroceles are often asymptomatic. Surgical repair may be indicated for symptomatic complaints and for abdominal scrotal hydroceles -Reactive hydroceles usually resolve with treatment of the underlying condition

14. Scrotal surgery : The most common surgical procedure is excision of the hydrocele sac-- hydrocelectomy (can also perform sac eversion). Recommended for chronic non-communicating hydroceles. Inguinal surgery : incision in the groin or inguinal area, draining the fluid, hernia repair if present and closing off the opening between the scrotum and abdomen. Complications of surgery: injury to testis, urethra, testis/ epididymis, to spermatic cord structures Infections Recurrent hydrocele Bleeding or scrotal hematoma Illioinguinal / genitofemoral nerve injury Wound infection. - Alternative to surgery : Simple aspiration is generally unsuccessful because of the rapid re-accumulation of fluid but may be effective if combined with instillation of a sclerosing agent-- sclerotherapy ( tetracycline , alcohol) into the sac. The potential risks of this approach are a low incidence of reactive orchitis /epididymitis and a higher rate of recurrence, which may then make open surgery more difficult because of the development of adhesions between the hydrocele sac and the scrotal contents. Performed on men who are high risk for complications during surgery.

15. CONCLUSION A hydrocele is a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis which directly surrounds the testes and the spermatic cord. Hydrocele are classified into communicating, non-communicating based on whether or not they communicate with the peritoneum. Pain is generally associated with size and inflammation. Diagnostic evaluation is based on transillumination , on whether the hydrocele is reducible or not, by ultrasonography , blood and urine tests. Management is based on whether or not the hydrocele is symptomatic or persistent , thus surgery may be indicated or simple aspiration with sclerotherapy may be indicated for patients that are high risk for surgical complications.

16. REFERENCE Www-uptodate-com.unifiji.idm.oclc.org. 2022. [online] Available at: <https://www-uptodate-com.unifiji.idm.oclc.org/contents/nonacute-scrotal-conditions-in-adults. Www-uptodate-com.unifiji.idm.oclc.org. 2022. [online] Available at: <https://www-uptodate-com.unifiji.idm.oclc.org/contents/causes-of-painless-scrotal-swelling-in-children-and-adolescents. Www-uptodate-com.unifiji.idm.oclc.org. 2022. [online] Available at: <https://www-uptodate-com.unifiji.idm.oclc.org/contents/inguinal-hernia-in-children .