HYDROCELEConsultant : dr. Bernard, Sp.U

Reinard (2013-061-102)Selvy Setiawan (2013-061-101)

BACKGROUNDA hydrocele is a collection of serous fluid in between tunica vaginalis parietal and visceral that results from a defect or imbalance of fluid production versus absorbtion. Normally between tunica vaginalis there is only a few drops of fluid.

DEFINITIONFluid-filled sac surrounding a testicle that results in swelling of the scrotum.

ETIOLOGYCommunicating hydrocele is caused by failed closure of the processus vaginalis at the internal ring.Noncommunicating hydrocele results from pathologic closure of the processus vaginalis and trapping of peritoneal fluidHydrocele also can be caused by tuberculosisIn older males, hydrocele develop as a result of inflammation/injury within the scrotum.

CLASIFICATIONCongenital hydroceleResults from a congenital malformation of tunica vaginalis.Acquired hydrocelePrimary (or idiopathic): cause for this is unclear and is produced by defective absorption of fluid in tunica vaginalisSecondary: caused by infection or trauma to testis.

CLASIFICATIONNon-communicating (simple) hydroceleAccumulation of fluid around the testis without communication to the abdominal cavity.Communicating hydrocelePassage of peritoneal fluid to the scrotum through a patent processus vaginalis.Abdominoscrotal hydroceleHydrocele of the cord

EPIDEMIOLOGY>80% of newborn boys5.1 % age of 15 35 tahun33.8 % age of 35 55 tahun Hydrocele is a disease observed only in malesMost hydroceles are congenital at aged 1-2 years.

PATHOPHYSIOLOGYEmbryologically, 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 gestational week with gradual closure through infancy and childhood

HYSTORYMost hydroceles are asymptomatic or subclinicalThe usual presentation is a painless enlarged scrotum, pain may be an indication of an accompanying acute epididymal infection.The patient may report a sensation of heaviness, fullnessPatients occasionally report mild discomfort radiating along the inguinal area to the mid portion of the backThe size may decrease with recumbency or increase in the upright position

PHYSICALHydroceles are located superior and anterior to the testis, in contrast to spermatoceles, which lie superior and posterior to the testis. Hydrocele is bilateral in 7-10% of cases.Hydrocele often is associated with hernia, especially on the right side of the body.Transillumination is common, but it is not diagnostic for hydrocele. Transillumination may be observed with other etiologies of scrotal swelling (eg, hernia). Aspiration --- not recommended

CAUSECommunicating hydrocele is caused by failed closure of the processus vaginalis at the internal ring.Noncommunicating hydrocele results from pathologic closure of the processus vaginalis and trapping of peritoneal fluidAdult-onset hydrocele may be secondary to orchitis or epididimitis. Hydrocele also can be caused by tuberculosis

OTHER CAUSETesticular torsion may cause a reactive hydrocele in 20% of cases. The clinician may be misled by focusing on the hydrocele, which delays the diagnosis of torsion.Tumor, especially germ cell tumors or tumors of the testicular adnexa may cause hydroceleTraumatic (ie, hemorrhagic) hydrocelesAssociated with vp shunt, dialysis, renal transplant, radiation

DIFFERENTIAL DIAGNOSISHernia inguinalisTestiscular torsionOrchitis

LABORATORY STUDIESA CBC with differential may indicate the existence of an inflammatory process.Urinalysis may detect proteinuria or pyuria

IMAGING STUDIESInguinal-scrotal imaging ultrasoundMay be useful to identify abnormalities in the testis, complex cystic masses, tumors, appendages, spermatocele, or associated herniaDoppler ultrasound flow studyThis must be performed emergently if there is suspicion of testicular torsion or of traumatic hemorrhage into a hydrocele or testes

TREATMENTObserve infants with hydrocele for 1-2 years or until definite communication is demonstrated.Spontaneous closure is unlikely in children older than 1 year.In children, hydrocele is treated through inguinal incisions with high ligation of the patent processus vaginalis and excision of the distal sacAll communicating hydroceles should be explored through inguinal incision.

INGUINAL SURGICAL APPROACH Men diagnosed with hydroceles, where there is suspicion for concomitant malignancy, should undergo high-resolution scrotal ultrasound. If malignancy is suspected, an inguinal approach should be used to allow control of the spermatic cord in preparation for radical orchidectomy. If this approach is taken and no malignancy is encountered, the testis can be spared and the hydrocele can be repaired by one of the techniques described below.

SCROTAL SURGICAL APPROACHES When there is no evidence of malignancy on physical examination and high-resolution ultrasound, hydroceles may be approached scrotally through a median raphe or a transverse unilateral incision.In all techniques, the hydrocele is dissected and delivered intact to allow the easiest dissection.

LORDS PROCEDUREThe hydrocele is opened with a small skin incision without further preparation. The hydrocele sac is reduced (plicated) by suture, suitable for medium-sized and thin-walled hydroceles. The advantage of the plication technique is the minimized dissection with a reduced complication rate esp hematome.

JABOULAYS PROCEDUREIncision of the hydrocele sac after complete mobilization of the hydrocele. Partial resection of the hydrocele sac, leaving a margin of 12 cmCare is taken not to injure testicular vessels, epididymis or ductus deferensthe edges are sewn together behind the spermatic cordHydrocele surgery with excision of the hydrocele sas is useful for large or thick-walled hydroceles and multilocular hydroceles.

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