Hydrocoele

An abnormal collection of serous fluid in a part of the processus vaginalis, usually the tunica vaginalis

• Hydrocoele fluid is made up of albumin and fibrinogen

Pathophysiology

1. Excessive production of fluid within the sac (secondary)
2. Defective absorption of fluid (most primary hydrocoeles)
3. Interference with lymphatic drainage of scrotal structures
4. Connection with the peritoneal cavity via a patent processus vaginalis (congenital)

Aetiology

• Acquired
  • Primary (vaginal)
    • Most common in middle and later life, and in hot countries
    • Usually painless - can reach a very large size
  • Secondary to epididymal or testicular disease
    • Most commonly acute or chronic epididymo-orchitis
    • Also seen with torsion or malignancy
    • Secondary hydrocoeles are usually lax and of moderate size, with a palpable underlying testicle
    • Don't puncture the hydrocoele if malignancy is suspected - fear of seeding
    • Should subside when the primary lesion resolves
  • Secondary to infection
    • Filarial hydrocoele - Wucheria bancrofti - tropical countries
      • Occasionally contains liquid fat, caused by rupture of lymphatic varix, causing chylocoele
      • Treatment by excision of sac
  • Idiopathic
• Congenital
• Haematocoele
  • Most commonly caused by needle aspiration of a hydrocoele
    • Diagnose with reduced transillumination of the sac and pain/tenderness along with consistent history
    • Can be a/w tumours or trauma too

Presentation

• History
  • Intermittent hydrocoele - this is usually seen in the context of a child with patent processus vaginalis, draining when they lie down
  • Acuity - beware acute hydrocoele in young man
• Examination
  • Transillumination?
  • Possible to 'get above the swelling'?
    • If not, may represent an inguinal hernia
  • Is it primarily testicular or epididymal, or is it enclosing both (hydrocoele)?
  • Hydrocoele usually surrounds testis such that it becomes impossible to palpate them separately
  • Encysted hydrocoeles of the cord - swelling moves downward and becomes less mobile if testis is pulled gently downward. Can be mistaken for an inguinal hernia.
  • Hydrocoele of canal of Nuck can occur in women - analogous to cord hydrocoele in men

Investigation

• Clinical diagnosis, but an ultrasound may be necessary to look at testis, especially if it's non-palpable due to a tense hydrocoele
• Acute hydrocoele, especially in a young man - need to exclude cancer

Treatment

• Indications for surgery
  • Congenital hydrocoeles not resolving spontaneously - herniotomy
  • Symptomatic acquired hydrocoele
• Aspiration
  • Usually reaccumulates within a week
  • May be ok for men unsuited to surgery, although you can operate with local anaesthetic anyway
  • Can result in bleeding -> haematocoele
• Sclerosant e.g. tetracycline
  • Painful but effective
• Operations
  • Lord's operation - plication - minimal dissection and low risk of haematoma
  • Jaboulay's procedure - eversion
    • I think midline raphe cut
    • Dissect to tunica vaginalis and entirely dissect it free (get above sac)
    • Open tunica vaginalis with midline cut from top to bottom
    • Evert sac and suture behind testis
    • Return to scrotum, so testis is now directly inside scrotum
  • Excision - often causes a large scrotal haematoma - not recommended