Scrotal Swelling(Hydrocele)

and Masses

DR.AMAR RATHOD M.S.(Mumbai)

Scrotal Swelling and Masses

1. Hydrocele

2. Hernia

3.Varicocele

5.Spermatocele

4.Testicular Masses

Evaluation of the Scrotum

• Layers of scrotum-skin, Subcut tissue,dartos muscle,Ext,Cremasteric Fascia ,Int spermatic fascia, & tunica vaginalis.

• Normal testes measure 4.5 x 2.5 cm and are rubbery in consistency

• Epididymis lies posteriolateral to the testis and varies in its degree of testicular attachment

• Masses arising from within the testes are usually malignant; those from epididymis and spermatic cord structures usually benign

Anatomy Review

Anatomy Review

Hydrocele

“Hydro" - meaning water and “Cele" - meaning out pouching

• Abnormal collection of serous fluid in between the two layers of tunica vaginalis or within some part of processus vaginalis.

Aetiology

• Primary- unknown cause

• Secondary-due to disease in the testis

Aetiology

Primary- unknown cause• Vaginal hydrocele• Encysted hydrocele• Infentile hydrocele• Funicular hydrocele• Hydrocele of canal of Nuck• Hydrocele of hernial sac• Hydrocele of bisac

Secondary-due to disease in the testis• Acute epididymo-orchitis

• Syphilitic infection• Chronic epididymo-orchitis• Malignant disease• Trauma• Lymphatic Disease

• Post herniorrhapy

Causes Normally there is balance between produced fluid and its reverse

absorption.

• Defective absorption of fluid• Excessive production of fluid• Interference with Drainage of fluid by

lymphatic vessels of cord• Connection to peritoneal cavity

(congenital)

Composition of fluid

• Amber Coloured

• Sp. Gravity 1.022-1.024

• Water

• Inorganic salt

• 6% albumin

• Fibrinogen

• Cholesterol

Clinical Feature

• Common in middle Age

• Common in tropical courtiers

• SYMPTOMES:

swelling of the scrotal region

Clinical Test

1.Fluctuation

2.Transillumination

3.Palpation of the testis(Reaching above the swelling)

4.Reducibility

• BLOOD EXAMINATION

- Eosinofilia And Microfaileriasis Seen In Faileriasis - Lymphocytosis And ESR seen In Acute Epididymo-orchities

• URINE EXAMINATION

-Tuberculose Epididymo-orchities

• SCROTAL ULTRASOUND. -To confirm diagnosis -Identification position of testis -To know testis are normal or not

• MRI.

INVESTIGATION

D.D.

• Inguinal Hernia• Haematocele• Pyocele• Chylocele• Faileriasis of scrotum• Cyst• Tumours of the testis• Lipoma of cord

Complication

• Infection and Pyocele formation

• Atrophy of the Testis

• Rupture due to Trauma/ Spontaneous

• Haematocele

• Hernia of the hydrocele of the Sac through the Dortous muscle in long standing case

• Calcification of sac.

Management• Conservative Watchful waiting

• Surgery (L.A./Spinal/G.A.)

• Indication• Inconvenience while walking• Infection / trauma• Excoriation of skin by urine• Infertility (Testicular Atrophy)• Cosmetic• Difficulties in intercourse• Herniation of Hydricele sac• Medical fitness for jobs

Contra indications

• Local infection of skin• Poor general condition

1.Jaboulays method of eversion of Sac- mostly practiced now a days for small & medium size.

2.Lords procedure- Big size Hydrocele

3.Excision of sac - Haematocele -infected Sac4.Subtotal excision - Big size Hydrocele -circular incision,middle of Scrotum5.Tapping- Not a radical surgical treatment To be Avoided as for as possible

6.Andrew”s method- Eversion of sac with Excision

7.Sharma Jhawars subdartos pouch

IN INFENT HYDROCELE SHOULD BE LEFT ALONE AS THEY MAY DISAPPEAR SPONTANEOUSLY

If persist – Surgery incision-inguino-Scrotal upper end of Sac ligated

Complication of surgery

• Haemorrhage• Damage to cord,Testis,Epididymis,Pampiniform plexus• Torsion of testis• Haematoma• Haemoscrotum• Pyoscrotum• Infection• Stitch abscess• Urinary retention• Necrosis• Recurrence• Epididymo-orchitis

Congenital Hydrocele

• Processus vaginalis remain patent

• Communicating orifice at the deep inguinal ring is too small for the development of hernia.

• Diagnosis-present since birth

Pt lies-disappears

in erect posture appear again

• This condition may be associated with Tuberculous peritonitis

Funicular hydrocele

• Processus vaginalis patent up to top of testis, where it is shut off from the tunica vaginalis

• Diagnosis-

swelling in inguinal region rather than scrotal

• Testis can be felt

• Swelling reduced when lies down.

Infantile Hydrocele • This condition is just opposite to funicular hydrocele-

vaginalis is shut off from the peritoneal cavity at the deep inguinal ring.

• Diagnosis- seen in infants & adult

Inguino scrotal swelling similar to inguinal hernia

• Not reducible /cough impels –ve

• Cystic swelling

Encysted Hydrocele• Central portion of processus vaginalis remain

patent- upper and lower end oblitrated.• Oval cystic • swelling(scrotal/inguinal/inguino-scrotal)

• Diagnosis- cystic swelling in relation to spermatic cord• Testis felt separate.• Traction test-

• Hydrocele of Bisac-

hydrocele having two intercommunicating sac.

One above & one below, upper sac connected with

processus vaginalis

• Hydrocele of Hernial Sac

• Hydrocele of canal of Nuck

Ayurvedic Aspect• Introduction-

Vriddhi is being discussed in Sushrut-Samhita Nidan sthan chapter 12 & Chikitsa sthan chapter 19

*Vaataj = Tortion of testes / Strangulated Hernia* Pittaj = Abscess / Pyocele* Kaphaj = ? Tumor of testes e.g.Seminoma * Raktaj = Haematocele* Medaj = Filarial swelling / Lypoma* Mutraj = Hydrocele* Aantraj = Inguinal hernia

• Defination-

• maU~sya maU~sadRSatrlasya vaRiw: maU~vaRiw È

• Samprapti:

• AMQa: p`kuiptao Anyatmaao ih daoYa: flakaosavaaihnaIriBap`pVQamanaI; flakaoYayaao: vaRiwMjanayait , taM vaRiwima%yaacaxato Èsau.ina.12

Poorvha Roop

•baistkiTmauYkmaoZoYau vaodnaa maa$tinaga`h: , flakaoSaSaaofcEaoit È

sau.ina.12

Rupa: PRODROMAL FEATURES

• maU~saMQaarNaSaIlasya maU~vaRiwBa-vait saagacCtao|mbaupUNaa-M dRitirva xauByait , maU~kRcC/vaodnaaM vaRYaNayaao: EvayaqauM kaoSayaaoEcaapadyait Èsau.ina.12

• Scrotum develop movement like Bag of water,dysuria,pain in testicels and swelling of scrotum.

Chikitsa

• Fomentation

• Lepa with Latakaranj patra

• Wrap with cloth and then puncture made by the side of raphae below the most prominent part of the swelling with help of BRIHIMUKHA SHASTRA

• Drainage tube

• Sthagika bandha

THANK YOU

Testicular Masses

• Testicular masses are usually malignant and must be fully evaluated

• If any doubt whether a mass is within or outside the testicle, scrotal US and urologic consultation should be obtained

• Tumors of testis are usually painless, firm, solid lesions within the substance of the testis. These lesions do not transilluminate

Testicular Masses

• Any mass, any pt, any time felt to be in the testicle MUST be addressed with direct contact with a urologist. Do not simply place a consult and hope for the best…to do so would be malpractice

Testicular Pt Ed

• Benefit of monthly TSE is now questioned…however…

Etc…

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Questions?

THANK YOU

TYPES

• Congenital

1. Vaginal Hydrocele

2. Infentile Hydrocele

3. Congenital Hydrocele

4. Hydrocele of cord

• Acquired

1. PrimaryHydrocele

2. seconderyHydrocele