HYDROCELE

DEFINITION A hydrocele is a fluid-filled sac surrounding a testicle that results in swelling of the scrotum, the loose bag of skin underneath the penis. Up to 10 percent of male infants have a hydrocele at birth, but most hydroceles disappear without treatment within the first year of life. Additionally, adult men can develop a hydrocele due to inflammation or injury within the scrotum. Hydroceles usually aren't painful. Typically not harmful, hydroceles may require no treatment. However, if you have scrotal swelling, see your doctor to rule out other causes, such as testicular cancer or other conditions. Pathophysiology 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. In the majority of cases, the processus vaginalis closes within the first year of life. 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. If 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. 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. An 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.

Causes Hydroceles are common in newborn infants. During normal development, the testicles descend down a tube from the abdomen into the scrotum. Hydroceles result when this tube fails to close. Fluid drains from the abdomen through the open tube. The fluid builds up in the scrotum, where it becomes trapped. This causes the scrotum to become swollen. Hydroceles normally go away a few months after birth, but their appearance may worry new parents. Occasionally, a hydrocele may be associated with an inguinal hernia. Hydroceles may also be caused by inflammation or injury of the testicle or epididymis, or by fluid or blood blockage within the spermatic cord. This type of hydrocele is more common in older men. Symptoms The main symptom is a painless, swollen testicle , which feels like a water balloon. A hydrocele may occur on one or both sides. Diagnosis The diagnosis of a hydrocele is generally made clinically. An apt description of a hydrocele surrounding a palpable (something that can be felt) testis would be that of a small water balloon containing a peanut. The differences between communicating and non-communicating hydroceles described above help to support the suspected diagnosis. A bedside test, transillumination, provides confirmation of the condition. Transillumination involves placing a small light source (commonly an otoscope - the medical device used to examine the ear) against the swollen scrotum. The fluid filled nature of the hydrocele side is distinctly different from the non-involved side of the scrotum. In rare cases either ultrasound or X-ray study of the region may be indicated. In unusual cases where a hydrocele may be a secondary phenomenon to pathologic cause (caused by disease), surgical exploration may be necessary to establish the diagnosis. . Treatment Hydroceles are usually not dangerous, and they are usually only treated when they cause discomfort or embarrassment, or if they are large enough to threaten the testicle's blood supply. One option is to remove the fluid in the scrotum with a needle, a process called aspiration. However, surgery is generally preferred. Aspiration may be the best alternative for people who have certain surgical risks. Sclerosing (thickening or hardening) medications may be injected after aspiration to close off the opening. This helps prevent the future build up of fluid. Hydroceles associated with an inguinal hernia should be repaired surgically as quickly as possible. Hydroceles that do not go away on their own over a period of months should be evaluated for possible surgery. A surgical procedure, called a hydrocelectomy, is often performed to correct a hydrocele.