INFORMATION FOR CANDIDATE:

Your next patient in general practice is a 44 year old

Alf Ginger who has experienced discomfort from the
heaviness of a swollen right scrotum over the last 6
months. He first noticed a painless small swelling in
the right side of his scrotum but did not think much
about it. However, over the last 3 months it has
gradually increased in size and causes him a feeling
of heaviness and his wife became quite alarmed
because she is worried about cancer.
YOUR TASK IS TO:
Take a brief history
Examine the patient
Arrange appropriate investigations
Discuss the diagnosis and management with the
patient

HOPC: Your next patient in general practice is a 44 year old Alf Ginger who has
experienced discomfort from the heaviness of a swollen right scrotum over the last 6
months. He first noticed a painless small swelling in the right side of his scrotum but did
not think much about it. However, over the last 3 months it has gradually increased in size
and causes him a feeling of heaviness, fullness and dragging and his wife became quite
alarmed because she is worried about cancer.
PHx. + FHx.: unremarkable
SHx: married roof tiler, 2 children (18 + 20 y), non smoker, social drinker, NKA, no
medication.
EXAMINATION: well looking man with normal vital signs.
The right scrotum appears swollen, non tender, testicle not identifiable, transillumination
positive!!!! No inguinal enlarged lymphglands.
INVESTIGATIONS:
Blood and urine tests to exclude infection
U/S to confirm hydrocele
DIAGNOSIS: HYDROCELE
Hydrocele can be primary or secondary:
1. PRIMARY: represents a collection of fluid within the tunica vaginalis which
obscures the palpation of the underlying testis and is readily transilluminable. It is
treated initially by aspiration, if recurrent, subtotal excision of the parietal tunica is
performed.
2. SECONDARY hydrocele is usually a response to underlying pathology in the
testis or epididymis, so that treatment is directed to the underlying pathology.
A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of
the tunica vaginalis, the investing layer that directly surrounds the testis and spermatic
cord. It is the same layer that forms the peritoneal lining of the abdomen. Hydroceles are
believed to arise from an imbalance of secretion and reabsorption of fluid from the tunica
vaginalis and are usually not dangerous and dont affect the fertility!
Hydroceles range in size from small, soft collections that still allow palpation of the
scrotal contents to massive, tense collections of several liters that make examination
impossible. Symptoms of pain and disability generally increase with the size of the mass.
Hydrocele fluid in the scrotal sac transilluminates well, which differentiates the process
from a possible haematocele, hernia, or solid mass. A scrotal ultrasound should be
considered if the diagnosis is in question since a reactive hydrocele can occur in the
presence of a testicular neoplasm or with acute inflammatory scrotal conditions.
Idiopathic hydroceles usually arise over a long period of time and are most common.
Other causes can be inflammatory conditions of the scrotal contents (epididymitis,
torsion, appendiceal torsion), infections, including sexually transmitted diseases, scrotal
injury and radiation. They can produce an acute reactive hydrocele, which often resolves
with treatment of the underlying condition.
Idiopathic hydroceles are often asymptomatic, despite considerable scrotal enlargement.
Thus, treatment is necessary only for symptomatic complaints or for the rare situation of
compromised scrotal skin integrity from chronic irritation, pressure, etc.

The most common treatment is surgical excision of the hydrocele sac. Simple aspiration is
generally unsuccessful due to rapid reaccumulation of fluid. On the other hand,
percutaneous aspiration of the hydrocele fluid may be successful if combined with
instillation of a sclerosing agent into the sac. The potential risks of the latter approach are
a low incidence of reactive orchitis/epididymitis and a higher rate of recurrence, which
may then make open surgery more difficult because of the development of inflammatory
adhesions between the hydrocele sac and the scrotal contents.
Hydroceles discovered in infancy are usually "communicating," since they are associated
with a patent processus vaginalis, which allows flow of peritoneal fluid into the scrotal
sac. They usually disappear in the recumbent position and are often associated with
herniation of abdominal contents (indirect hernia) through the processus vaginalis.
Surgical repair is advised in these cases.
It is important to rule out other possible causes for swellings, such as a tumor. Sometimes
a hydrocele is associated with an inguinal hernia, in which a weak point in the abdominal
wall allows a loop of intestine to extend into the scrotum and which may require
treatment.

The testicle is vertical and its anterior portion is surrounded by the tunica vaginalis.

A hydrocele is a fluid accumulation between the parietal and visceral layers of the tunica
vaginalis. The hydrocele depicted above is noncommunicating (there is no connection
between the hydrocele and the peritoneum; the fluid comes from the mesothelial lining of
the tunica vaginalis ).

Scrotal lumps
The scrotum contains the testes and distal parts of the spermatic cords, covered by layers of
fascia and the dartos muscle. The testes are invested with tunica vaginalis derived from the
peritoneal cavity during their descent.
Disorders of the scrotum may be acute or chronic and bilateral or unilateral. Lumps may be cystic,
solid or otherwise such as a varicocele, oedema and hernia. Solid lumps include a testicular
tumour, epididymo-orchitis, and torsion of the testes. Cystic lumps include hydroceles, epididymal
cysts and spermatoceles, and resolving extravasation. A comparison of scrotal lumps appears in
Figure 93.6 and Table 93.3 . Lumps in the scrotum usually develop from deeper structures,
particularly the testes and their coverings, rather than scrotal skin. 1 Refer to Figure 93.6 for a
comparison of scrotal lumps.
The cardinal sign of a true scrotal mass is that it is possible to get above it.
The patient usually presents with pain or a lump.

Fig. 93.6 Basic comparison of scrotal lumps

Table 93.3 Features of scrotal lumps

Possible clinical
setting

Hydrocele

Any age
Primary or
secondary
tumour
infection
torsion

Cyst of epididymis
*Epididymal cysts and Asymptomatic or
spermatoceles clinically dragging sensation
similar

Chronic epididymoorchitis

Position

Confined to
scrotum
Anterior:
surrounds testis
except posteriorly

Palpation

Transillumination

Smooth, pearYes
shaped
Lax or tense
Testis impalpable,
non-tender

Behind and above Smooth and

Yes
testis
tense
Multilocular
swelling
Testis easily
palpable
Appears separate
from testis
Behind and above
No
testis
Firm swelling

Table 93.3 Features of scrotal lumps

Possible clinical
setting

Position

Non-specific
Tuberculosis
Chlamydia
(Occasional
associated small
hydrocele)

Varicocele

Carcinoma

Palpation

Transillumination

Hard and craggy

Normal testis

Usually left-sided
Soft, like bunch of
Dragging discomfort Along line of
No
worms or grapes
spermatic cord
Collapses when
Above testis
patient supine
and testis
elevated
Testis often
smaller

Young men 20-40

Painless lump
Loss of testicular
sensation

In body of testis
Usually felt
anteriorly
May be hydrocele

Enlarged firm
testis
Feels heavy if
large
Normal
epididymis
(palpable)

No

MANAGEMENT:
Surgical excision (hydrocelectomy). Removal of a hydrocele may be performed on an
outpatient basis using general or spinal anesthesia. The surgeon may make an incision in
the scrotum or lower abdomen to remove the hydrocele. If a hydrocele is discovered
during surgery to repair an inguinal hernia, your doctor may remove it even if it's causing
you no discomfort.
A hydrocelectomy may require you to have a drainage tube and wear a bulky dressing
over the site of the incision for a few days after surgery. Also, you may be advised to wear

a scrotal support for a time after surgery. Ice packs applied to the scrotal area during the
first 24 hours after surgery may help reduce swelling. Surgical risks include blood clots,
infection or injury to the scrotum.

Needle aspiration. Another option is to remove the fluid in the scrotum with a needle.
This treatment isn't widely used because it's common for the fluid to return. The injection
of a thickening or hardening (sclerosing) drug after the aspiration may help prevent the
fluid from reaccumulating. Aspiration and injection may be an option for men who have
risk factors that make surgery more dangerous. Risks of this procedure include infection
and scrotal pain.
Sometimes, a hydrocele may recur after treatment.