ManageMent of hydrocele

investigations and

treatMent

s.balaji 16

• Blood-examination : - general investigations like Hb, TLC ,DLC - eosinophilia and microfilaria- filariasis - lymphocytosis and increased ESR- epididymo - orchitis

• Urine examination : - routine : urea ,uric acid ,creatinine -passage of infected urine and presence of E.coli, streptococcus,

staphylococcus-acute epididymitis - tuberculosis bacilli may be seen in urine in tuberculous epididymitis

• Chest X ray : -is an important part of investigation in tuberculous epididymo orchitis to

exclude presence of pulmonary tuberculosis -secondary deposits may be seen un testicular tumors particularly teratomas

• Ultrasonography: - helpful to know the position of the testis, also to know whether

they are normal or not. this investigation is helpful in hydrocele, haematocele, secondary hydrocele, torsion of testis.

• Aspiration : - Milky fluid- spermatocele

- Clear fluid- cyst of epididymis

- In hydrocele an amber colour fluid may be obtained whose specific gravity remains in the range of 1.022 to 1.024 ,it may contain water, inorganic salts, cholesterol, fibrinogen, 6% of albumin

In secondary hydrocele from testicular tumour the fluid will be blood stained.To facilitate better palpation of testis and epididymis fluid should be aspirated out in case of secondary hydrocele

Surgical procedure : Indication for surgery : Vaginal hydrocele Infantile and funicular hydrocele are also treated

surgically in the same manner Contraindication : Secondary hydrocele due to testicular tumors

Position of the patient : supine Anaesthesia : general anaesthesia, surface anaesthesia Preparation of parts : savlon and spirit

procedure of the Surgery :• Incision :Hydrocele is held tense by an assistant and 5-6 cm

incision <depending upon size > is made over the most prominent part of the swelling parallel to the median raphe of the scrotum

• Layers opened :skin, dartos, external spermatic fascia , cremasteric fascia , internal spermatic fascia

• at this stage hydrocele sac is visible and is delivered outside the incision

• Hydrocele fluid is drained by using trocar and cannula• An opening is made in the tunica vaginalis sac and it is enlarged ,all

fluid is drained out. Testis and epididymis are inspected for any pathology

typeS of Surgery :• Depending on the size of the hydrocele and thickness of the wall of the

sac ,two types of surgery can be done ,a)Small tunica vaginaliS Sac (tv) : The sac is opened and the cut edge of sac is plicated to tunica

albuginea .The redundant tunica vaginalis is plicated by interrupted sutures

The sac gets crumpled up and surrounds the testis .This is called lord’s plication. The secretions get absorbed by lymphatics and venous system

B) Sac iS large and thick : Partial excision and eversion of sac is ideal treatment .In this

operation ,after excision of the sac ,cut edge of the sac is everted and sutured behind the testis .this is called jaboulay’s operation

• By eversion of the sac ,the secreting surface of the testis becomes anterior and secretions are absorbed by subcutaneous lymphatics.

Closure : -a corrugated plastic drain is kept in the scrotum and brought out

separately by making a stab incision and is anchored to the scrotal skin by white thread

- Subcutaneous layer by using 2-0 chromic catgut- Skin –interrupted thread(white)/catgut .absorbable sutures

such as catgut or vicryl can also be used- Scrotal support is given to reduce oedema

PostoPerative management • Npo for 6 hours followed by soft diet

• Antibiotics and analgesics• Suture removal after 7-8 days

PostoPerative comPlications :-- haematoma : if large and increasing in size ,wound should be reopened

urgently and bleeders have to be ligated . It may be due to injury of testicular artery ,vein or pampiniform plexus of veins

-- wound infection can result in pyelocele --Injury to the spermatic cordAdvice at discharge : rest for about a week

comPlications of hydrocele :

Haematoma : due to minor trauma Pyelocele :infected haematocele Calcification of the sac wall Rupture of hydrocele sac : traumatic or spontaneous Hernia of the hydrocele sac : in long standing cases when

tension of the fluid within tubica causes herniation through dartos muscle

Differential diagnosis

• acute epididymo orchitis• Tuberculosis epididymo orchitis• Syphilitic orchitis• Subacute epididymo orchitis(filarial)• Lymph varix• Lymph scrotum• Chylocele• Elephantiasis of the scotum• Extravasation of urine

• Torsion of the testis• Tumors of testis - seminoma - teratoma• Cysts - cysts of epididymitis - spermatocele - cysts of an appendage of the testis• Fournier’s gangrene