HYDROCELE

Defined as a collection of fluid within the Defined as a collection of fluid within the tunica vaginalis of the testistunica vaginalis of the testis

CASSIFICATION

1. Congenital1. Congenital 2. Primary2. Primary 3. Secondary3. Secondary

1. CONGENITAL

Communicating (“vogbreuk”)Communicating (“vogbreuk”) InfantileInfantile InterstitialInterstitial CordCord

2. PRIMARY HYDROCELE

Idiopathic (aetiology not known)Idiopathic (aetiology not known) Imbalance between the fluid secretion and Imbalance between the fluid secretion and

absorption of the tunica vaginalisabsorption of the tunica vaginalis

3. SECONDARY HYDROCELE

InfectionInfection TraumaTrauma TumorTumor Abnormalities in inguinal lymph nodesAbnormalities in inguinal lymph nodes

DIFFERENTIAL DIAGNOSIS:SCROTAL CYSTIC MASSES Indirect inguinal herniaIndirect inguinal hernia Epididymis cystEpididymis cyst HydroceleHydrocele VaricoceleVaricocele SpermatoceleSpermatocele PiocelePiocele HematoceleHematocele

TREATMENT

CommunicatingCommunicating Tying off the patent processus vaginalisTying off the patent processus vaginalis

PrimaryPrimary HydrocelectomyHydrocelectomy Aspiration + injection of sclerosing agentAspiration + injection of sclerosing agent

SecondarySecondary Treat underlying pathologyTreat underlying pathology

DIFFERENTIATION

HYDROCELEHYDROCELE INGUINALINGUINAL

HERNIAHERNIA

Palpate cord Palpate cord above massabove mass

YESYES NONO

TranslucentTranslucent YESYES NONO

FluctuateFluctuate YESYES NONO

Fluid thrill Fluid thrill YESYES NONO

DIFFERENTIATION

HYDROCELEHYDROCELE INGUINALINGUINAL

HERNIAHERNIA

Testis palpableTestis palpable NONO YESYES

Cough impulseCough impulse NONO YESYES

ReducibleReducible NONO YESYES

Bowl soundsBowl sounds NONO YESYES

FLUID ASPIRATED FROM CYSTIC MASSES SUPRA TESTICULARSUPRA TESTICULAR

CYSTIC MASSCYSTIC MASS

COLOR OF FLUIDCOLOR OF FLUID

Cord hydroceleCord hydrocele Straw color Straw color

SpermatoceleSpermatocele Milky orMilky or

Grey opaque (barley-Grey opaque (barley-water)water)

Epididymis cystEpididymis cyst ClearClear

VARICOCELE

Defined as an abnormal dilatation and Defined as an abnormal dilatation and distension of the veins of the pampiniform distension of the veins of the pampiniform plexusplexus

INCIDENCE

15% in the general population15% in the general population (8% - 23%)(8% - 23%)

16,3% in adolescents16,3% in adolescents (12,4% - 25,8%)(12,4% - 25,8%)

33% in infertile men33% in infertile men (19% - 41%)(19% - 41%)

58% - 93% left sided58% - 93% left sided

ETIOLOGY

Abnormality of the venous valvesAbnormality of the venous valves Left spermatic vain joining the left renal vein Left spermatic vain joining the left renal vein

directly at a 90directly at a 90° angle° angle Longer left spermatic vein with increased Longer left spermatic vein with increased

hydrostatic pressurehydrostatic pressure Pressure of superior mesenteric artery on the Pressure of superior mesenteric artery on the

left renal vein (Nutcracker phenomenon)left renal vein (Nutcracker phenomenon)

PRESENTATION

Complaints of a scrotal massComplaints of a scrotal mass (“Bag of worms”)(“Bag of worms”)

Complaints of scrotal discomfortComplaints of scrotal discomfort Fertility problemsFertility problems Incidental diagnosis with clinical Incidental diagnosis with clinical

examinationexamination Smaller left testisSmaller left testis

CLACCIFICATION

PrimaryPrimary Abnormality of valves in the spermatic Abnormality of valves in the spermatic

veinvein Secondary Secondary

Tumor of the left kidneyTumor of the left kidney Retro-peritoneal massesRetro-peritoneal masses TraumaTrauma

GRADING

GRADE 0GRADE 0 Venous noise on doppler Venous noise on doppler with Valsalva maneuverwith Valsalva maneuver

GRADE 1GRADE 1 Distended veins can be Distended veins can be palpated with Valsalvapalpated with Valsalva

GRADE 2GRADE 2 Distended veins can be Distended veins can be palpated without palpated without ValsalvaValsalva

GRADE 3GRADE 3 Distended veins can be Distended veins can be observedobserved

INFERTILITY THEORIES

Stases of blood with testicular hypoxiaStases of blood with testicular hypoxia Reflux of renal and adrenal metabolitesReflux of renal and adrenal metabolites Increased intra-testicular temperature Increased intra-testicular temperature

INDICATIONS FOR FURTHER MANAGEMENT SymptomaticSymptomatic

** PainPain

** Mass (discomfort)Mass (discomfort) InfertilityInfertility Testicular atrophyTesticular atrophy

TREATMENT

Spermatic venography plus embolisation Spermatic venography plus embolisation with heated contrast/resin/coilswith heated contrast/resin/coils

SurgerySurgery OpenOpen

IvanissevitchIvanissevitchPalomaPaloma

LaparoscopicLaparoscopic