Hydrocele

What is Hydrocele?

A hydrocele is an unusual buildup of a watery fluid between the two layers surrounding the testicle. This condition could be there from birth (congenital) or develop over time (acquired).

A congenital hydrocele comes about due to the incomplete sealing of a part of the body involved in testicle development. When a male baby is developing, his testicles form inside his abdomen and move down into the scrotum before he is born. This is guided by a fold in the lining of the abdomen, known as the processus vaginalis. Normally, the processus vaginalis seals off around the time of birth and the lower part remains as a covering over parts of the testicle. If it does not seal off properly, fluid can build up and cause a congenital hydrocele.

There are two main categories of hydroceles: primary and secondary.

1. Primary Hydrocele: This occurs when the processus vaginalis, which helps guide the testicles into the scrotum, seals off around the time of birth or within the first two years of life. However, the bottom part may stay open, and this could potentially cause fluid to build up and form a hydrocele. Depending on where the processus vaginalis seals itself, there are four types of primary hydrocele:
– Congenital Hydrocele: The processus vaginalis remains open, allowing body fluid to move but is too small for bodily contents to squeeze through.

– Infantile Hydrocele: The processus vaginalis gets sealed at the level of a deep abdominal connection (inguinal ring). However, the part below it stays open, allowing fluid to build up.

– Encysted Hydrocele of the Cord: The top and bottom portions of the processus vaginalis get sealed, but the middle part remains open, and fluid accumulates within it.

– Vaginal Hydrocele: The processus vaginalis remains open only around the testicles and as the fluid accumulates, it becomes difficult to feel the testicles.

2. Secondary Hydrocele: This type often arises due to other health issues, such as infections (like filariasis, tuberculosis of the tube that stores and carries sperm, syphilis), injury (trauma, post hernia repair), or cancer. This hydrocele usually remains small, except if caused by filariasis, where it can become quite large.

What Causes Hydrocele?

A hydrocele is a common condition where fluid collects in the scrotum. There are four main ways this can occur:

1. The space inside the scrotum remains connected with the abdomen. This usually happens at birth and is called a “congenital” hydrocele.
2. Too much fluid is produced in the scrotum, which is known as a “secondary” hydrocele.
3. The body isn’t able to drain the fluid effectively.
4. Something interferes with the lymphatic system, which is essential for draining fluid in the body. This often happens due to a parasitic infection called filarial hydrocele.

In children, the main cause of a hydrocele is usually the first case, where the space inside the scrotum is still connected with the abdomen from birth. In adults, the most common cause across the globe is infection by a parasite called Wuchereria bancrofti, which affects 120 million people in over 73 countries. However, in the United States, hydroceles are often caused by medical procedures such as surgeries or trauma to the scrotum.

Risk Factors and Frequency for Hydrocele

At birth, about 80-90% of full-term baby boys have something called a patent processus vaginalis. But by the time they reach two years old, the rate drops to around 25-40%. According to studies done on deceased individuals, this condition remains in about 20% of adults. However, only 6% of these cases become noticeable after the newborn phase. Factors that can increase the risk of this condition are a breech birth, low birth weight, and the use of progestin hormone during pregnancy.

• Around 80-90% of full-term baby boys are born with a patent processus vaginalis.
• By two years old, this number drops to 25-40%.
• Studies indicate that about 20% of adults may still have this condition.
• Only 6% of these cases actually become noticeable after the baby period.
• Risk factors for this condition include a breech birth, low birth weight, and using the hormone progestin during pregnancy.

Signs and Symptoms of Hydrocele

A hydrocele is a condition where there’s a buildup of fluid in a man’s scrotum. This often results in a painless swelling of the scrotum, and it can make it difficult to feel the testicles. One of the key tests for diagnosing a hydrocele is the transillumination, a kind of test where a doctor shines a light through the scrotum to check for fluid. People affected by this condition may notice the swelling in different positions, such as lying down or standing up.

The doctor will usually ask you three key questions during an examination:

• Is it possible to touch the cord above the swelling? If not, this might suggest a hydrocele or a hernia. You can tell these two conditions apart because a hernia will change when you cough and can be pushed back into the abdomen, but a hydrocele usually can’t.
• Does the swelling start from the testis or epididymis, or does it surround these structures? Hydroceles usually surround the testes and epididymis, making them impalpable.
• Does the swelling transilluminate, or allow light to pass through it? This is a common sign of a hydrocele.

Hydroceles are most common in middle-aged and older men, and people living in warm climates are at higher risk. The condition is often painless, which means it can get very large before someone seeks medical help. There’s a type of hydrocele known as a secondary hydrocele, which is usually smaller, unless it’s caused by filariasis, a parasitic disease.

Some hydroceles, known as congenital hydroceles, can seem to come and go because the fluid drains into the abdomen when the person is lying flat. However, applying pressure on the hydrocele does not usually reduce it.

An encysted hydrocele feels like a smooth, oval-shaped lump near the spermatic cord. Sometimes, it can feel like an inguinal hernia, so it’s important for doctors to differentiate between the two. Another rare kind of hydrocele, known as a hydrocele of the canal of Nuck, can develop in females as a cyst anterior to the uterus’ round ligament.

Testing for Hydrocele

Hydrocele, which is a condition where fluid collects around the testicle, can often be diagnosed through medical history and physical examination. However, further tests may be carried out to rule out any other medical or surgical conditions that may be present.

Lab tests

Lab tests may be carried out to rule out other related conditions. For instance:
– In cases of potential inguinal hernia (a condition where a part of the bowel pushes into the groin area), there aren’t any specific lab tests. However, if the hernia is trapped (incarcerated), it may mimic hydrocele. Under these conditions, a condition known as leukocytosis (increased white blood cells) can help to differentiate between the two. Additionally, negative transillumination (a light passed through the area to check for solid growths) and sensing the bowel presence during a physical check-up is indicative of an inguinal hernia.
– If there’s a suspicion of a testicular tumor, tests for serum alpha-fetoprotein and human chorionic gonadotropin (hCG – a hormone) would be considered. These hormones are usually elevated in case of tumors.
– In cases of inflammation of the tube at the back of the testicle (epididymitis) or inflammation of the testicles (orchitis), which can lead to hydroceles, urine tests can be helpful.

Imaging tests

Images of the testicles and surrounding area can help in diagnosing hydrocele. They can also look for other conditions like epididymitis, twisted testicle (testicular torsion), or testicular tumor.

Ultrasonography (a scan using high-frequency sound waves) is recommended when it’s painful or hard to feel the testicle area. An ultrasound scan provides a detailed image of the inner part of the testicles. Hydrocele appears as a clear or dark area around the testes during this examination. Ultrasound scans are also used to determine the size of the hydrocele and to identify conditions like a mass of cysts in the testicles (spermatoceles), testicular tumors, and testicular atrophy (shrinkage). Patients should be examined lying down and standing up since hydrocele might recede into the abdomen based on the patient’s position.

Duplex Ultrasonography provides information on the blood flow to the testicles, which is usually reduced or absent in hydroceles caused by testicular torsion. In hydroceles due to epididymitis, the blood flow to the epididymis would be increased. This type of scan can also detect varicoceles (enlarged veins in the scrotum) by identifying increased blood flow during a Valsalva maneuver (exhaling while mouth and nose are closed).

Plain abdominal radiography or X-ray of the abdomen can be performed in cases of a trapped inguinal hernia to detect the presence of gas in the groin area.

Treatment Options for Hydrocele

Surgery is usually the best way to treat hydrocele, a condition where fluid builds up in the scrotum causing it to swell. This is especially true if the hydrocele starts causing problems or discomfort. For hydroceles present at birth (congenital hydroceles), a surgery called herniotomy is usually performed if they don’t go away on their own. Acquired hydroceles, on the other hand, often go away when the condition that caused them is treated.

There are two popular surgical treatments for hydrocele:

1. Plication: This method works well for hydroceles with thin walls. It has a low risk of complications like blood buildup or infection because it involves less cutting into tissue. In this procedure, called the Lord Plication, the surgeon bunches the layer surrounding the testicle into a ruffle using a series of sutures, helping the sac to form fibrous tissue.

2. Excision and Eversion: This is better for larger hydroceles with thick walls and chyloceles, a type of hydrocele where the fluid is milky. The surgeon removes most of the tunica vaginalis, the sac that surrounds the testes, turns it inside out behind the testes and creates a new pocket for the testes in the scrotum. This is known as the Jaboulay procedure. During the surgery, care is taken not to damage parts like the epididymis, testicular vessels, or the ductus deferens, which connect the testes to the rest of the urinary tract.

Aspiration, another method to treat hydrocele, involves drawing out the fluid with a needle. This technique is used mainly for patients who are not fit enough for surgery. This approach usually gives temporary relief as the fluid often builds up again within a week. There is also a high risk of blood build-up and infection after aspiration. To improve the effectiveness of aspiration, a substance that causes scarring (sclerosant) can be injected into the sac to prevent fluid from building up again. However, the injection can be painful.

Like with any surgery, there can be potential complications such as bleeding, build-up of pus (pyocele), infection, formation of a sinus (an abnormal passage between body parts), and the hydrocele coming back.

What else can Hydrocele be?

The conditions that could be confused with hydrocele, a type of swelling in the scrotum, include:

• Inguinal hernia
• Epididymal cyst
• Spermatocele
• Testicular tumor
• Scrotal edema (swelling due to fluid buildup)
• Varicocele (an enlargement of the veins within the scrotum)

What to expect with Hydrocele

Congenital hydrocele, a type of swelling in a baby boy’s scrotum that’s present at birth, tends to have a great outlook. Most of these hydroceles go away on their own during the first year. If they don’t, a surgery can be done to correct them, which usually has a very high success rate. The likelihood of any damage to the testicle or the hydrocele coming back after the surgery is very low.

As for adult-onset hydrocele, this type of swelling in a man’s scrotum that begins later in life, its prognosis highly depends on what’s causing it. For example, a type called filarial hydrocele, which is caused by infection with a parasite, the outlook depends on how big the hydrocele is and how badly the lymph vessels are blocked.

Possible Complications When Diagnosed with Hydrocele

Complications can arise either from the medical condition itself or the treatment received. Here are some of the potential issues:

• Infection
• Pyocele (a collection of pus)
• Haematocele (a collection of blood)
• Testicle shrinkage
• Infertility (this can occur when swelling cuts off the blood supply to the testicles, halting sperm production)
• Rupture
• Hernia due to hydrocele, although this is not common

Preventing Hydrocele

In infants, a condition known as hydrocele, which is a fluid-filled swelling in the scrotum, typically improves on its own. However, it’s crucial for parents to regularly check for changes and stay vigilant. If this condition continues after the child turns two, it’s advised to seek help from a doctor who specializes in surgery. It’s normal for parents to be worried about this, so it’s vital they receive proper guidance and support.

For adults, hydroceles that are not a symptom of another medical condition can be checked regularly by the patient for changes in size or signs of infection. However, if the hydrocele is caused by an underlying medical problem, it’s essential to see a doctor to prevent potential health risks.

Patients must be informed about possible complications of hydrocele and the available treatment methods. It’s important to understand that even when the condition is managed correctly with medicine or surgery, the hydrocele can still come back.