Abnormal collection of fluid within the tunica vaginalis, surrounding the testis.
Pathophysiology:
- Communicating
- Failure of closure of the processus vaginalis during first year of life
- Non-communicating
- Fluid secretion by the tunica vaginalis exceeding fluid reabsorption
Clinically – cannot get above, transilluminates, generally painless. Ultrasound worthwhile especially if cannot palpable testis reliably.
Causes:
- Inflammatory
- Post trauma
- Infective
- Malignancy
- Previous surgery (i.e. varicocele repair) / disruption of lymphatics
Management:
- Conservative – recommended for patient who have little bother
- Percutaneous drainage – 80 % or more recurrence
- Injection of sclerosant
- Various agents described – doxycycline, alcohols, polidocanol, betadine
- Drainage of hydrocele with cannula, then injection of sclerosant
- Reported 75 % success rates
- Recurrent hydroceles may be thick and loculated
- Surgical
- Jaboulay or Lord procedure
- Orchidectomy can be considered in the very very large hydrocele
Principle of hydrocele surgery is mobilisation of the hydrocele sac followed by plication or inversion, with or without excision.
Lord procedure may be preferred in smaller hydroceles with thin walls – supposed less haematoma risk. Interrupted 1 cm plication sutures circumferentially around tunica. “Spanish collar”.
Jaboulay preferred for thick walled or larger hydroceles. Excision of excess tunica with eversion of the sac and closure behind the testis.
Meticulous haemostasis. Closure in 2 layers. Drain for very large hydroceles with risks of haematoma. Small but not zero risks of testis vascular injury, atrophy and vas injury.