@UrologyQuiz Quiz5 Answer: Primary Hydrocele (Hydrocoele)

Hydrocele is a common cause of scrotal swelling. Hydrocoele occurs when there is abnormal accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis that surround the testicle. In adults and adolescents, hydrocoele is an acquired condition. Its etiology is largely unknown but it is speculated that there is imbalance between fluid production and absorption in the serous membranes of the tunica. (J Family Med Prim Care. 2013 Jan-Mar; 2(1): 109110.
(Fulltext:www.ncbi.nlm.nih.gov/pmc/articles/PMC3894005/#!po=67.3913)

Differential Diagnosis (transillumination in this case a giveaway for a hydrocele) -Primary hydroceles- occur as a result of an imbalance of secretion and absorption of fluid inside the tunica vaginalis or the abdomen. Primary hydroceles may be associated with inguinal hernias -Secondary hydroceles- are caused by trauma, surgery (e.g. vasectomy, varcicocele repair) infection, or neoplastic processes, and yet most hydrocoeles are idiopathic. (Infant hydroceles will be covered another time) - other hernia (Hydrocele key feature- you are able to get above the mass -hernia you cannot) Next step in manahement History- recurrent or first time, infection, recent surgery etc, bother (very important) Clinically most hydroceles are asymptomatic, presenting as painless scrotal swellings. No intervention is necessary unless the hydrocele reaches a critical size that leads to awkwardness or pain in walking. Examination- try to get above mass (confirms scrotal) palpate testicle, transilluminaion, hernia check Investigation- ultrasound NOT often required but if concerned secondary may be necessary (especially if cannot palpate testicle) So treatment options: Observation after reassurance Drainage +/- sclerosant e.g. doxycycline polidocanol (reported success up to almost 80-90%)
www.ncbi.nlm.nih.gov/m/pubmed/23142687/?i=3&from=hydrocoele%20aspiration; www.ncbi.nlm.nih.gov/m/pubmed/24262498/?i=1&from=hydrocoele%20aspiration)

Surgical repair (hydrocelectomy) success in long-term above 90% Comparison: aspiration and sclerotherapy has fewer complications, morbidity and is cheaper but lower success rate and less patient's satisfaction than hydrocelectomy
(www.ncbi.nlm.nih.gov/m/pubmed/19595803/?i=13&from=hydrocoele%20aspiration)

Teaching Points: 1) Primary hydroceles common in adults but always think of possible secondary hydroceles and their underlying aetiology 2) Often NO treatment of hydroceles s required if it is stable and asymptomatic 3) Aspiration is probably more effective (cheaper and easier) than thought but will result in failures and potentially less satisfaction
By @lawrentschuk Editor-in-Chief @UrologyQuiz Assoc. Professor Nathan Lawrentschuk, University of Melbourne AUSTRALIA