HYDROCELE

Consultant : dr. Bernard, Sp.U

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

BACKGROUND
A 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.

DEFINITION

Fluid-filled sac surrounding a testicle that

results in swelling of the scrotum.

ETIOLOGY

Communicating 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 fluid
Hydrocele also can be caused by tuberculosis
In older males, hydrocele develop as a result of
inflammation/injury within the scrotum.

CLASIFICATION
Congenital hydrocele
Results from a congenital malformation of tunica
vaginalis.
Acquired hydrocele

Primary

(or idiopathic): cause for this is unclear and

is produced by defective absorption of fluid in tunica
vaginalis
Secondary: caused by infection or trauma to testis.

CLASIFICATION
Non-communicating (simple) hydrocele
Accumulation of fluid around the testis without
communication to the abdominal cavity.
Communicating hydrocele
Passage of peritoneal fluid to the scrotum through
a patent processus vaginalis.
Abdominoscrotal hydrocele
Hydrocele of the cord

EPIDEMIOLOGY

>80% of newborn boys

5.1 % age of 15 35 tahun
33.8 % age of 35 55 tahun
Hydrocele is a disease observed only in males
Most hydroceles are congenital at aged 1-2
years.

PATHOPHYSIOLOGY

Embryologically, 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

HYSTORY

Most hydroceles are asymptomatic or

subclinical
The 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, fullness
Patients occasionally report mild discomfort
radiating along the inguinal area to the mid
portion of the back
The size may decrease with recumbency or
increase in the upright position

PHYSICAL

Hydroceles 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

CAUSE

Communicating 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 fluid
Adult-onset hydrocele may be secondary to
orchitis or epididimitis. Hydrocele also can be
caused by tuberculosis

OTHER CAUSE

Testicular 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 hydrocele
Traumatic (ie, hemorrhagic) hydroceles
Associated with vp shunt, dialysis, renal
transplant, radiation

DIFFERENTIAL DIAGNOSIS
Hernia inguinalis
Testiscular torsion
Orchitis

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

IMAGING STUDIES

Inguinal-scrotal imaging ultrasound

May

be useful to identify abnormalities in the testis,

complex cystic masses, tumors, appendages,
spermatocele, or associated hernia

Doppler ultrasound flow study

This

must be performed emergently if there is

suspicion of testicular torsion or of traumatic
hemorrhage into a hydrocele or testes

TREATMENT
Observe 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 sac
All 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 PROCEDURE
The 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 PROCEDURE

Incision of the hydrocele sac after complete

mobilization of the hydrocele.
Partial resection of the hydrocele sac,
leaving a margin of 12 cm
Care is taken not to injure testicular vessels,
epididymis or ductus deferens
the edges are sewn together behind the
spermatic cord
Hydrocele surgery with excision of the
hydrocele sas is useful for large or thickwalled
hydroceles
and
multilocular
hydroceles.