Hydrocele

Pembimbing : dr. Bernard, Sp.U

Marlene Elita (2012.061.117)
Fiona Valentina (2012.061.119)
Ryan Wijaya Kusuma (2013.061.004)

Background
A hydrocele is a collection of serous fluid in
between tunica vaginalis parietal and visceral
that results from a defect or irritation in the
tunica vaginalis of the scrotum.
Hydroceles also may arise in the spermatic
cord or the canal of Nuck
Pathophysiology
Embryologically, the processus vaginalis is a
diverticulum of the peritoneal cavity. It
descends with the testes into the scrotum via
the inguinal canal around the 28th gestational
week with gradual closure through infancy
and childhood

Clasification
In a communicating (congenital) hydrocele, a
patent processus vaginalis permits flow of
peritoneal fluid into the scrotum. Associated
with Indirect inguinal hernias
In a noncommunicating hydrocele, a patent
processus vaginalis is present, but no
communication with the peritoneal cavity (
Adult vs Infant
Adult hydroceles are usually late-onset
(secondary). Late-onset hydroceles may
present acutely from local injury, infections,
and radiotherapy; they may present
chronically from gradual fluid accumulation.
Hydrocele can adversely affect fertility
Infant hydroceles are ussually caused by a
patent processus vaginalis
Epidemiology
More than 80% of newborn boys have a patent
processus vaginalis, but most close spontaneously
within 18 months of age.
The incidence of hydrocele is rising with the
increasing survival rate of premature infants, VP
shunts, and dialysis
Hydrocele is a disease observed only in males
Most hydroceles are congenital at aged 1-2 years.
Chronic or secondary hydroceles usually occur in
men older than 40 years.
Hystory
Most hydroceles are asymptomatic or subclinical
The usual presentation is a painless enlarged scrotum,
pain may be an indication of an accompanying acute
epididymal infection.
The patient may report a sensation of heaviness,
fullness
Patients occasionally report mild discomfort radiating
along the inguinal area to the mid portion of the back
The size may decrease with recumbency or increase in
the upright position
Physical
Hydroceles are located superior and anterior to the
testis, in contrast to spermatoceles, which lie
superior and posterior to the testis.
Hydrocele is bilateral in 7-10% of cases.
Hydrocele often is associated with hernia, especially
on the right side of the body.
Transillumination is common, but it is not diagnostic
for hydrocele. Transillumination may be observed
with other etiologies of scrotal swelling (eg, hernia).
Aspiration --- not recommended
Cause
Communicating hydrocele is caused by failed
closure of the processus vaginalis at the
internal ring.
Noncommunicating hydrocele results from
pathologic closure of the processus vaginalis
and trapping of peritoneal fluid
Adult-onset hydrocele may be secondary to
orchitis or epididimitis. Hydrocele also can be
caused by tuberculosis
Other cause
Testicular torsion may cause a reactive
hydrocele in 20% of cases. The clinician may
be misled by focusing on the hydrocele,
which delays the diagnosis of torsion.
Tumor, especially germ cell tumors or tumors
of the testicular adnexa may cause hydrocele
Traumatic (ie, hemorrhagic) hydroceles
Associated with vp shunt, dialysis, renal
transplant, radiation
differential diagnosis
Hernia inguinalis
Testiscular torsion
Orchitis
laboratory studies
A CBC with differential may indicate the
existence of an inflammatory process.
Urinalysis may detect proteinuria or pyuria

imaging studies
Inguinal-scrotal imaging ultrasound
May be useful to identify abnormalities in the
testis, complex cystic masses, tumors,
appendages, spermatocele, or associated hernia
Doppler ultrasound flow study
This must be performed emergently if there is
suspicion of testicular torsion or of traumatic
hemorrhage into a hydrocele or testes
Treatment
Observe infants with hydrocele for 1-2 years
or until definite communication is
demonstrated.
Spontaneous closure is unlikely in children
older than 1 year.
In children, hydrocele is treated through
inguinal incisions with high ligation of the
patent processus vaginalis and excision of the
distal sac
Inguinal Surgical Approach
Men diagnosed with hydroceles, where there is
suspicion for concomitant malignancy, should undergo
high-resolution scrotal ultrasound.
If malignancy is suspected, an inguinal approach should
be used to allow control of the spermatic cord in
preparation for radical orchiectomy.
If this approach is taken and no malignancy is
encountered, the testis can be spared and the hydrocele
can be repaired by one of the techniques described
below.

Scrotal Surgical Approaches
When there is no evidence of malignancy on
physical examination and high-resolution
ultrasound, hydroceles may be approached
scrotally through a median raphe or a
transverse unilateral incision.
In all techniques, the hydrocele is dissected
and delivered intact to allow the easiest
dissection.
Lords procedure
The hydrocele is opened with a small skin
incision without further preparation.
The hydrocele sac is reduced (plicated) by
suture, suitable for medium-sized and thin-
walled hydroceles.
The advantage of the plication technique is
the minimized dissection with a reduced
complication rate esp hematome.
Jaboulays procedure
Incision of the hydrocele sac after complete mobilization
of the hydrocele.
Partial resection of the hydrocele sac, leaving a margin
of 12 cm
Care is taken not to injure testicular vessels, epididymis
or ductus deferens
the edges are sewn together behind the spermatic cord
Hydrocele surgery with excision of the hydrocele sas is
useful for large or thick-walled hydroceles and
multilocular hydroceles.