Hydrocele
& its Case
-by
Pooja Yadav
Yashansh Jindal
Definition
● A hydrocele is an abnormal collection of serous
fluid in a part of the processus vaginalis, usually
the tunica vaginalis around the testis and
occasionally along the spermatic cord.
● Acquired hydroceles are primary or idiopathic, or
secondary to epididymal or testicular disease.
Incidence
● Hydroceles affect an estimated 1% of adult men.
● More than 80% of newborn boys have a patent
processus vaginalis, but most close spontaneously
within 18 months of age.
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 week of
gestation with gradual closure through infancy
and childhood.
Types
1. Communicating (congenital) hydrocele:
a patent processus vaginalis permits flow of
peritoneal fluid into the scrotum (tunica vaginalis);
associated with indirect inguinal hernias.
2. Non-communicating (vaginal) hydrocele:
● The processus vaginalis is closed with no
communication with the peritoneal cavity.
● Instead, fluid accumulation can be due to excessive
production and/or defective absorption by the tunica
vaginalis, primarily because of disruption to the
lymphatic drainage of scrotal structures.
3. Infantile hydrocele & Hydrocele of the cord:
● Distal end of the processus vaginalis closes, but
mid-portion remains patent.
● Infantile Hydrocele (c): The proximal end will be
open and communicating with the tunica vaginalis.
● Hydrocele of Cord (d): The proximal end will be
closed.
● Non-communicating primary hydroceles are the
most common type of hydrocele globally.
● Secondary hydroceles usually occur in men >40
years and may present acutely from local injury
(including torsion), infection, neoplasm or radio-
therapy.
Clinical Features
● A primary hydrocele is seen most commonly in
middle and later life.
● Swelling is usually painless, therefore it may reach
a significant size before the patient presents for
treatment.
● In congenital hydrocele, pressure on the hydrocele
does not always empty it but the hydrocele fluid may
drain into the peritoneal cavity when the child is lying
down; thus, the hydrocele may be intermittent.
● Ascites should be checked for if the swellings are
bilateral.
● A hydrocele of the cord is a smooth oval swelling
that lies above the testis near the spermatic cord,
which can be mistaken for an inguinal hernia.
Treatment
● Congenital hydroceles are treated by ligation of
the patent processus vaginalis (herniotomy) if
they do not resolve spontaneously.
● Small hydroceles do not need treatment. If they
are size-able and bothersome for the patient,
then surgical treatment is indicated.
● There are three main surgical techniques for
hydroceles:
1. Plication
2. Eversion
3. Aspiration
1. Plication: Lord's operation is suitable when the
sac is reasonably thin walled .There is minimal
dissection and reduced risk of haematoma.
2. Eversion: The sac is opened and everted behind
the testis, with placement of the testis in a pouch
prepared by dissection in the fascial planes of the
scrotum (Jaboulay's procedure).
Plication Eversion
3. Aspiration: Aspiration is simple but the fluid always
reaccumulates within a week or so.
It may be suitable for men who are unfit for scrotal
surgery.
Case Presentation –
Hydrocele
Demographics
• Name: Mr. Rameshbhai Patel
• Age/Sex: 46/M
• Occupation: Farmer
• Address: Rajkot
• Marital status: Married, 2 children
Chief Complaint
● Swelling in right side of scrotum
● Duration: 11 months
History of Present Illness (1/2)
● Gradual onset, slowly progressive swelling
● Painless, occasional dragging sensation
● Does not reduce on lying down, no cough impulse
● No fever, trauma, urinary complaints, constipation.
History of Present Illness (2/2)
● No urethral discharge or genital ulcers
● No systemic symptoms (fever, weight loss, night sweats)
● No childhood history of scrotal swelling (hydrocele/hernia)
● Highlight: Swelling confined to scrotum, not affected by
posture/strain
Past, Family & Personal History
● Past history: No HTN/DM/TB/surgeries
● Family history: Nil significant
● Personal: Smoker (2 bidis/day), vegetarian diet, no other
addiction
Points for Examination
● Patient was well oriented to time, place and person before
beginning examination.
● Examination was done under adequate light with
adequate exposure.
● Local examination was done in both, standing and supine
position.
General & Systemic Examination
● Vitals: Pulse 82/min and regular, RR 18/min, Afebrile
● General: No pallor, icterus, edema, lymphadenopathy,
cyanosis, clubbing
● Systemic:
Hernial Orifices- Normal, no cough impulse
Abdomen- Soft, non tender, no organomegaly
Local Examination- Inspection
● Right hemiscrotal swelling, ovoid, around 8 × 6 cm
● Overlying skin normal, no redness or ulceration
● Scrotal rugosity are reduced
● Confined to scrotum, no extension to inguinal region
Local Examination- Palpation
● Fluctuant, cystic, non-tender with normal temperature
● Testis not separately palpable, normal spermatic cord
palpable
● No cough impulse, not reducible
● Positive transillumination
Transillumination
positive
Provisional Diagnosis
● Right vaginal hydrocele (non-communicating)
● Differentials (can be ruled out by USG)-
Indirect inguinal hernia
Epididymal cyst
Spermatocele
Testicular tumour
Management
● Definitive- Right Hydrocelectomy (Lord’s plication)
● Follow up-
Scrotal support, avoid heavy lifting/straining
Key Learning Points
● Classical Presentation: Painless, progressive, scrotal
swelling which is non-reducible with no cough impulse and
shows positive transillumination
● USG can be used to rule out other testicular pathologies
● Surgery: treatment of choice in adults
Scrotal Swelling –
Examination Video
