05 surg gastro hydrocele

8/16/2019 05 Surg Gastro Hydrocele

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INFORMATION FOR CANDIDATE:

Your next patient in general practice is a 44 year old

Alf Ginger who has experienced discomfort from the

heaviness of a swollen right scrotum over the last 6months. He first noticed a painless small swelling in

the right side of his scrotum but did not think much

about it. However over the last ! months it has

gradually increased in si"e and causes him a feeling

of heaviness and his wife became #uite alarmed

because she is worried about cancer.

YOUR TASK IS TO:

• $ake a brief history

• %xamine the patient

• Arrange appropriate investigations

•&iscuss the diagnosis and management with the patient



HOPC: Your next patient in general practice is a 44 year old Alf Ginger who has

experienced discomfort from the heaviness of a swollen right scrotum over the last 6

months. He first noticed a painless small swelling in the right side of his scrotum but did

not think much about it. However over the last ! months it has gradually increased in si"e

and causes him a feeling of heaviness fullness and dragging and his wife became #uite

alarmed because she is worried about cancer.

PHx. + FHx.: unremarkable

SHx: married roof tiler ' children ()* + ', y- non smoker social drinker /A no

medication.

EXAMINATION: well looking man with normal vital signs.

$he right scrotum appears swollen non tender testicle not identifiable transillumination

positive0000 o inguinal enlarged lymphglands.

INVESTIGATIONS:

• 1lood and urine tests to exclude infection

• 23 to confirm hydrocele

DIAGNOSIS: HYDROCELE

Hydrocele can be primary or secondary5

). 789A7Y5 represents a collection of fluid within the tunica vaginalis which

obscures the palpation of the underlying testis and is readily transilluminable. 8t is

treated initially by aspiration if recurrent subtotal excision of the parietal tunica is

performed.

'. %:;&A7Y hydrocele is usually a response to underlying pathology in thetestis or epididymis so that treatment is directed to the underlying pathology.

A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of

the tunica vaginalis the investing layer that directly surrounds the testis and spermatic

cord. 8t is the same layer that forms the peritoneal lining of the abdomen. Hydroceles are

believed to arise from an imbalance of secretion and reabsorption of fluid from the tunica

vaginalis and are usually not dangerous and don<t affect the fertility0

Hydroceles range in si"e from small soft collections that still allow palpation of the

scrotal contents to massive tense collections of several liters that make examination

impossible. ymptoms of pain and disability generally increase with the si"e of the mass.

Hydrocele fluid in the scrotal sac transilluminates well which differentiates the process

from a possible haematocele hernia or solid mass. A scrotal ultrasound should beconsidered if the diagnosis is in #uestion since a reactive hydrocele can occur in the

presence of a testicular neoplasm or with acute inflammatory scrotal conditions.

8diopathic hydroceles usually arise over a long period of time and are most common.

;ther causes can be inflammatory conditions of the scrotal contents (epididymitis

torsion appendiceal torsion- infections including sexually transmitted diseases scrotal

in=ury and radiation. $hey can produce an acute reactive hydrocele which often resolves

with treatment of the underlying condition.

8diopathic hydroceles are often asymptomatic despite considerable scrotal enlargement.

$hus treatment is necessary only for symptomatic complaints or for the rare situation of

compromised scrotal skin integrity from chronic irritation pressure etc.



$he most common treatment is surgical excision of the hydrocele sac. imple aspiration is

generally unsuccessful due to rapid reaccumulation of fluid. ;n the other hand

percutaneous aspiration of the hydrocele fluid may be successful if combined with

instillation of a sclerosing agent into the sac. $he potential risks of the latter approach are

a low incidence of reactive orchitis3epididymitis and a higher rate of recurrence which

may then make open surgery more difficult because of the development of inflammatoryadhesions between the hydrocele sac and the scrotal contents.

Hydroceles discovered in infancy are usually >communicating> since they are associated

with a patent processus vaginalis which allows flow of peritoneal fluid into the scrotal

sac. $hey usually disappear in the recumbent position and are often associated with

herniation of abdominal contents (indirect hernia- through the processus vaginalis.

urgical repair is advised in these cases.

8t is important to rule out other possible causes for swellings such as a tumor. ometimes

a hydrocele is associated with an inguinal hernia in which a weak point in the abdominal

wall allows a loop of intestine to extend into the scrotum and which may re#uire

treatment.

The testicle is vertical and its anterior portion is surrounded by the tunica vaginalis.



A hydrocele is a fluid accumulation between the parietal and visceral layers of the tunica

vaginalis. $he hydrocele depicted above is noncommunicating (there is no connection

between the hydrocele and the peritoneum? the fluid comes from the mesothelial lining of

the tunica vaginalis -.

Scrotal lumpsThe scrotum contains the testes and distal parts of the spermatic cords, covered by layers offascia and the dartos muscle. The testes are invested with tunica vaginalis derived from theperitoneal cavity during their descent.Disorders of the scrotum may be acute or chronic and bilateral or unilateral. Lumps may be cystic,solid or otherwise such as a varicocele, oedema and hernia. Solid lumps include a testiculartumour, epididymo-orchitis, and torsion of the testes. Cystic lumps include hydroceles, epididymalcysts and spermatoceles, and resolving extravasation. comparison of scrotal lumps appears in

!igure "#.$ and Table "#.# . Lumps in the scrotum usually develop from deeper structures,particularly the testes and their coverings, rather than scrotal s%in. & 'efer to !igure "#.$ for acomparison of scrotal lumps.The cardinal sign of a true scrotal mass is that it is possible to get above it.The patient usually presents with pain or a lump.



Fig. 93.6 Basic comparison of scrotal lumps

Table 93.3 Features of scrotal lumps

Possible clinical

setting Position Palpation

Trans-

illumination

Hydrocel e ny age(rimary orsecondary) tumour) infection) torsion

Confined toscrotum nterior*surrounds testisexcept posteriorly

Smooth, pear-shapedLax or tenseTestis impalpable,non-tender

+es

Cyst of epididymis pididymal cysts andspermatoceles clinicallysimilar

symptomatic ordragging sensation

ehind and abovetestis

Smooth andtense/ultilocularswellingTestis easilypalpable ppears separate

from testis

+es

Chronic epididymo- orchitis

ehind and abovetestis !irm swelling

0o



Table 93.3 Features of scrotal lumps

Possible clinicalsetting

Position PalpationTrans-

illumination

0on-specificTuberculosisChlamydia12ccasionalassociated smallhydrocele3

4ard and craggy0ormal testis

Varicocele Dragging discomfort5sually left-sided long line ofspermatic cord bove testis

Soft, li%e bunch of worms or grapesCollapses whenpatient supineand testiselevatedTestis often

smaller

0o

Carcinoma +oung men 67-87(ainless lumpLoss of testicularsensation

9n body of testis5sually feltanteriorly/ay be hydrocele

nlarged firmtestis!eels heavy iflarge0ormalepididymis

1palpable3

0o

MANAGEMENT:

Surgic! "xci#i$% &'()r$c"!"c*$(,. 7emoval of a hydrocele may be performed on an

outpatient basis using general or spinal anesthesia. $he surgeon may make an incision in

the scrotum or lower abdomen to remove the hydrocele. 8f a hydrocele is discovered

during surgery to repair an inguinal hernia your doctor may remove it even if it@s causing

you no discomfort.

A hydrocelectomy may re#uire you to have a drainage tube and wear a bulky dressingover the site of the incision for a few days after surgery. Also you may be advised to wear



a scrotal support for a time after surgery. 8ce packs applied to the scrotal area during the

first '4 hours after surgery may help reduce swelling. urgical risks include blood clots

infection or in=ury to the scrotum.

N"")!" #-ir*i$%. Another option is to remove the fluid in the scrotum with a needle.

$his treatment isn@t widely used because it@s common for the fluid to return. $he in=ection

of a thickening or hardening (sclerosing- drug after the aspiration may help prevent the

fluid from reaccumulating. Aspiration and in=ection may be an option for men who have

risk factors that make surgery more dangerous. 7isks of this procedure include infection

and scrotal pain.

ometimes a hydrocele may recur after treatment.

05 surg gastro hydrocele

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