Hydrocele

Funicular hydrocele

Communicating hydrocele: (a) Funicular hydrocele, and (b) Congenital hydrocele.

a. Funicular Hydrocele: Processus vaginalis remains patent up to the top where it is shut off from the tunica vaginalis. Diagnostic features: (i) The swelling is inguinal rather than scrotal. (ii) The test is it can be felt separate! (iii) Other features are similar to those of congenital hydrocele.

b. Congenital Hydrocele: In this condition the processus vaginalis remains patent so there is direct communication of the tunica vaginalis with the peritoneal cavity. The communicating orifice at the deep inguinal ring is too small for the development of a hernia.

Herniotomy REF: Fundamentals of Operative Surgery – Vipul Yagnik Page 35, Primary Surgery: Volume One: Non-trauma Chapter 7. Hernias

“Congenital hydrocele will resolve spontaneously within 1 year. Operation is required only when it persists for longer than 1 year”

In congenital hydrocele, the processus vaginalis is patent and connects with the peritoneal cavity. The communication is usually too small to allow herniation of intra-abdominal contents. 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 is often intermittent. Ascites should be considered if the swellings are bilateral.

“Congenital hydroceles are treated by herniotomy if they do not resolve spontaneously” Treatment usually, no treatment of congenital hydrocele is indicated, because this condition typically resolves spontaneously by age 1.

Most surgeons advocate observation in the majority of infants less than 12 months. Others may continue to be observed for longer, as the majority of patent processes vaginalis will close within the first 12-24 months of life

All the other options except lipoma are cystic lesions containing clear fluid and thus will show brilliant transillumination.

Lipoma are not cystic structures but large lipomas are able to show transillumination upto varying extent (though not brilliantly)

Transillumination

• Transillumination involves shining a light through a swelling to detect whether it transmits light brilliantly or not.
• It is a function of the optical density of the component elements of the swelling. Light passes easily through clear fluid but not through solid tissues. If a lump transilluminates then it must contain water, serum, lymph or plasma, or highly refractile fat. Blood and other semi-opaque fluids do not transmit light.
• Thus a cyst containing clear fluid (e.g. hydrocele, cystic hygroma, meningocele) transilluminates brilliantly, one containing opalescent fluid (spermatocele) less so. Fat (lipoma) and subcutaneous tissues also transilluminate to a varying extent.

Hydrocele is the a feature of bancroftian filariasis not brugian.

W.Bancrofti affect the following organs

• Legs
• Breast
• Arms
• Vulva
• Scrotum
• Brugia rarely affects genitals

Hydrocele

Congenital hydrocele results from a persistence of processus vaginalis.

As the testis descends from its retroperitoneal position to beyond the internal ring, it carries with an anteromedial diverticulum of peritoneum (the processus vaginalis).

The process of obliteration of the processus vaginalis begins at 32 weeks gestation and may continue for the first two years of life.

A narrowly patent processus vaginalis which allows the passage of peritoneal fluid results in a communicating hydrocele.

Congenital hydrocele resolve spontaneously upon completion of the process of obliteration of the processus vaginalis.

Occasionally, the fluid collection may persist after closure of the processus vaginalis resulting in a hydrocele of cord (hydrocele of canal of Nuck in females) or non communicating hydrocele.

The treatment of congenital hydrocoele is same as congenital hernia. Herniotomy through an inguinal approach.

Ref: Fundamentals of Surgical Practice edited by Andrew N. Kingsnorth, Aljafri A. Majid, 2006, Page 514; Bedside Clinics In Surgery By M.L. Saha, 2006, Page 468; Fundamentals of Operative Surgery by Vipul Yagnik, 2007, Page 35

A. i.e. It remains in the scrotum 

A hydrocele is an abnormal collection of fluid within some parts of processus vaginalis, usually the tunica. Vaginal Hydrocele is most common & accumulation of fluid is within tunica vaginalis so the swelling remains scrotal. Treatment of Hydrocele is by excision of the sac (Lord’s procedure) and by eversion of the sac (Joboulay’s procedure). Hydrocele of canal of Nuck is similar to encysted hydrocele but occurs in females & cyst lies in relation to the round ligament. Unlike the hydrocele of cord hydrocele of canal of Nuck is always at least partially within the inguinal canal.

Ans. is ‘a’ i.e., Gibbon’s hernia

Gibbon’s hernia is hernia with hydrocele.

Option b: Berger’s hernia is hernia into the pouch of Douglas.

Option c: Beclard’s hernia is a femoral hernia through the opening of the saphenous vein.

Option d: Ogilive’s hernia is hernia through a defect in the conjoint tendon just lateral to where it inserts with the rectus sheath.

Storyline: Edward Gibbon, 1737–1794, the author of “The Decline and Fall of the Roman Empire,” was greatly embarrassed by a large hydrocele. The second time that it was tapped, it became infected, and Gibbon died a few days later. The hydrocele was associated with a large scrotal hernia which had probably been punctured.

Ans. is ‘d’ ie. Herniotomy

• Bailey writes ‑

“Congenital hydrocele are a special form of indirect inguinal hernia and are treated by herniotomy.”

• Congenital hydrocele

In this conditon the processus vaginalis remain patent so there is direct communication of the tunica vaginalis with the peritoneal cavity. The communicating orifice at the deep inguinal ring is too small for the development of hernia.

• It is present since birth*.

In contradication to assumption. congenital hydrocele is not easily reducible* due to narrowness of the deep inguinal ring but when the child lies supine, it disappears.

Ans is ‘b’ i.e. Hydrocele

Ans. is ‘b’ i.e., 10% of cases 

Ans. is ‘a’ i.e., Limited to scrotum 

Ans. is ‘c’ i.e., Herniotomy 

Ans. is ‘a’ i.e., Patent processus vaginalis 

Ans. is ‘c’ i.e., Testes is separate from swelling

Ans. is ‘c’ i.e., Exudation 

Ans. is ‘d’ i.e., Hydrocele

Ans. C: Testicular tumour

The swelling is usually painless. It may reach a prodigious size before the patient presents for treatment. Be wary of an acute hydrocoele in a young man since there may be a testicular tumour.

SECONDARY HYDROCOELE-

Testicular tumours: They can present with a swelling of the scrotum, often diagnosed as hydrocoele. Any young patient with a rapidly growing scrotal swelling could be a testicular neoplasm. Fluid within the sac is haemorrhagic.

A secondary hydrocoele is most frequently associated with acute or chronic epididymo-orchitis. It is also seen with torsion of the testis and with some testicular tumours.

Testicular tumour clinical features

• Irregular testis
• lndurated testis
• Nodular testis
• Nontender enlarged testis
• Young age testicular mass, small hydrocoele
• Heaviness, loss of sensation

Ans. D: Hydrocele

Procedures for acquired hydroceles:

• Lord’s operation is suitable when the sac is reasonably thin walled
• Eversion of the sac with placement of the testis in a pouch prepared by dissection in the fascial planes of the scrotum is an alternative (Jaboulay’s procedure)