A hydrocele is a collection of watery fluid around the testicle.

This is a common problem in newborn males and usually goes away within the first year of life. When the testicle drops into the scrotum (about the eighth month of pregnancy), a sac (the processus vaginalis) from the abdominal cavity travels along with the testicle. Fluid can then flow to the scrotum to surround the testicle. This sac usually closes and the fluid is absorbed. When the sac closes and the fluid remains, this is called a noncommunicating hydrocele. This means that the scrotal sac can be compressed and the fluid will not flow back into the abdomen. This type of hydrocele is often found in newborns and the fluid will usually be absorbed with time. If the scrotal sac is compressed and the fluid slowly goes back up into the abdomen or if the hydrocele changes size, this is called a communicating hydrocele. This type of hydrocele usually appears smaller in the morning when the child wakes up and larger in the evening after activity. A communicating hydrocele shows that the sac or processus vaginalis is still open.

Alternatively, hydroceles can be divided into those that represent a persistent communication with the abdominal cavity and those that do not. Fluid excesses are from exogenous sources (the abdomen) in communicating hydroceles, whereas noncommunicating hydroceles develop increased scrotal fluid from abnormal intrinsic scrotal fluid shifts.

Communicating hydroceles
With communicating hydroceles, simple Valsalva probably accounts for the classic variation in size during day-sleep cycles. Nonetheless, with the incidence of patent processus so great, why children with clinically apparent hydroceles are relatively few remains somewhat inexplicable. Chronically increased intra-abdominal pressure (eg, as in chronic lung disease) or increased abdominal fluid production (eg, children with ventriculoperitoneal shunts) probably warrants early surgical intervention.

Noncommunicating hydroceles
In noncommunicating hydroceles, the pathophysiology may occur as a result of increased fluid production or as a consequence of impaired absorption. A sudden onset of scrotal hydrocele in older children has been noted after viral illnesses. In such cases, viral-mediated serositis may account for the net increased fluid production. Posttraumatic hydroceles likely occur secondary to increased serosal fluid production due to underlying inflammation. Although rare in the United States, filarial infestations are a classic cause of the decreased lymphatic fluid absorption resulting in hydroceles.

During fetal development, an extension of the peritoneum migrates distally through the inguinal canal with the gubernaculum in the first trimester. Normally, this thin membrane that extends through the inguinal canal and descends into the scrotum (processus vaginalis) is obliterated proximally at the internal inguinal ring, and the distal portion forms the tunica vaginalis. [3] [6]

Normal anatomyCreated by the BMJ GroupIn the majority of cases, the processus

vaginalis closes within the first year of life. [5] [6] [7] [8]If it is not obliterated at the internal ring, it is referred to as a patent processus vaginalis, and the tunica vaginalis communicates with the peritoneum, so that peritoneal fluid flows freely between both structures and a communicating hydrocele forms.

Communicating hydroceleCreated by the BMJ GroupIf the communication is large enough,

intra-abdominal structures, such as intestine, omentum, bladder, or genital contents, may be found in the inguinal canal, and this complication is known as an indirect inguinal hernia. [2] [3] While the processus vaginalis forms in both sexes in the first trimester, it does not enlarge in females. Hydrocele of the canal of Nuck is rare and results from the failure of the processus vaginalis to close, which causes fluid to accumulate within the inguinal canal. A non-communicating or simple hydrocele occurs in cases where the processus vaginalis is obliterated and secretion exceeds absorption of fluid from the tunica vaginalis.

Noncommunicating hydroceleCreated by the BMJ GroupAn abdominoscrotal

hydrocele is a simple hydrocele that enlarges through the inguinal canal resulting in an abdominal component. A hydrocele of the spermatic cord is the result of segmental closure of the processus vaginalis. It is loculated and usually does not communicate with the peritoneal cavity. [2]

Common causes: o In infants, usually due to the following: Incomplete closure of the processus vaginalis from the peritoneum

Residual peritoneal fluid that has yet to be reabsorbed after processus closure (a patent processus vaginalis accompanies the testis during normal descent and normally fuses spontaneously after the testis reaches the scrotum; incomplete obliteration of the patent processus vaginalis can result in simple hydrocele, hydrocele of the cord, communicating hydrocele through a narrow patent processus vaginalis, or a widely patent processus with complete inguinal hernia) In older boys and men may be idiopathic but usually due to abnormal absorption or secretion secondary to another pathologic process such as: Trauma Ischemia Infection (sexually transmitted or other) Testicular tumor Increased intra-abdominal pressure Rare causes:

o o o o o

Infants may sometimes present with hydrocele secondary to intrascrotal or intra-abdominal pathology Infant girls may have a hydrocele of the canal of Nuck or meconium hydrocele of the labia Filariasis may produce hydrocele in infected boys and men Hydrocele may be seen following ipsilateral renal transplantation Serious causes:

Hydrocele may be secondary to testicular torsion or incarcerated/strangulated hernia Hydrocele may be secondary to testicular cancer Risk factors Premature and low-birth-weight infants Indirect inguinal hernia Primary testicular/intrascrotal pathology Trauma Surgery Increased intra-abdominal pressure Lymphatic obstruction Ventriculoperitoneal shunt Peritoneal dialysis Ehlers-Danlos syndrome Bladder exstrophy

Screening

Summary approach
Screening for hydrocele in the general population is not indicated, as early detection will not significantly change outcome or management in the majority of cases Infants with congenital communicating hydrocele (ie, with associated indirect inguinal hernia) may benefit from exploration of the contralateral side to assess need for bilateral hernia sac ligation, but this is controversial and usually reserved for infants at high risk such as premature infants and those with increased abdominal pressure

Screening modalities
Surgical exploration
If contralateral patent processus vaginalis is found, can electively repair at the same time Controversial, as it exposes patient to longer surgical time and increases risks of surgical complications

Predisposing factors-modifiable Scrotal Injury Infection (STI)

Precipitating-non-modifiable AGE GENDER

Abnormal absorption or secretion of residual peritoneal fluid Retention of fluid inside the scrotum Scrotal swelling Reduced blood flow in the testes