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HYDROCELE

PREPARED BY: FERNAND SON DELA CRUZ

DEFINTION

A hydrocele is a scrotal collection of clear fluid ("hydro" = water) in a thin walled sack ("cele" = swelling) that also contains the testicle. Less frequently, due to the common embryological background of male and female gonadal structures, female children or women may also experience a hydrocele. In this case, the sack and connection exist in the labia majora (the outermost and larger of the two labial structures). Because of less potential concern for complications in females with hydroceles, this article will focus predominantly on the male gender. A hydrocele may involve either one side (unilateral) or both sides (bilateral) of the scrotum.

CAUSES

Embryology Between the 28th and 36th week of gestation, the testes, associated blood vessels and nerves migrate from the upper posterior abdominal wall adjacent to the kidneys to the lower abdominal cavity and through a tunnel (inguinal canal) into the scrotum. As each gonad exits the pelvic region through the inguinal canal into the scrotum, it is preceded by a thinly lined "sack" called the process vaginalis. Once the testes and associated structures have entered the scrotum, the trailing end of the process vaginalis generally closes off, completely isolating the contents of the abdominal cavity and obstructing their passage into the inguinal canal or scrotum. Should this closure be incomplete and the communication narrow, free fluid in the abdominal cavity (peritoneal fluid) may seep into and through the process vaginalis and collect in the scrotum forming a hydrocele. If the connection is larger and a portion of the small intestine migrates out of the abdominal cavity into the inguinal canal and/or scrotum, a hernia has developed.

TYPES
A hydrocele is characterized as a nonpainful, soft swelling of the scrotum (one or both sides). The overlying skin is not tender or inflamed. There are two types of hydroceles:

1. COMMUNICATING HYDROCELE

Communicating hydroceles are present at birth and occur as a consequence of the failure of the "tail" end of the process vaginalis to completely close off. Peritoneal fluid (free fluid in the abdominal cavity) is thus free to pass into the scrotum in which the process vaginalis surrounds the testicle. A characteristic feature of communicating hydroceles is their tendency to be relatively small in the morning (having been horizontal during sleep) and increase in size during the day (peritoneal fluid drainage assisted by gravity). Actions which increase intra-abdominal pressure (for example, crying, severe coughing, etc.) will also tend to increase the size of the hydrocele.

Communicating hydrocele: The processus vaginalis is still open, allowing fluid to move between the abdomen and the tunica vaginalis in the scrotum

2. NON-COMMUNICATING HYDROCELE

Non-communicating hydroceles may also be present at birth or develop as a boy matures. In a non-communicating hydrocele the tail end of the process vaginalis has closed appropriately. The fluid surrounding the testicle is created by the lining cells of the process vaginalis and is unable to either drain or be reabsorbed efficiently and thus accumulates. Since this fluid is walled off, the size of the hydrocele is generally stable and does not reflect intra abdominal pressure.

Noncommunicating hydrocele: The processus vaginalis is obliterated so no fluid can move between the abdomen and the scrotum, but the tunica vaginalis contains fluid

Normal: The fluid around the testicles is absorbed. Noncommunicating hydrocele: The fluid stays around the testicles and is not absorbed. Communicating hydrocele: The fluid flows back and forth between the scrotum and the abdomen. Hydrocele of the cord: The fluid is located in the spermatic cord, between the scrotum and the abdomen

DIAGNOSIS

The diagnosis of a hydrocele is generally made clinically. An apt description of a hydrocele surrounding a palpable (something that can be felt) testis would be that of a small water balloon containing a peanut. The differences between communicating and non-communicating hydroceles described above help to support the suspected diagnosis. A bedside test, transillumination, provides confirmation of the condition. Transillumination involves placing a small light source (commonly an otoscope - the medical device used to examine the ear) against the swollen scrotum. The fluid filled nature of the hydrocele side is distinctly different from the non-involved side of the scrotum. In rare cases either ultrasound or X-ray study of the region may be indicated. In unusual cases where a hydrocele may be a secondary phenomenon to pathologic cause (caused by disease), surgical exploration may be necessary to establish the diagnosis.

TREATMENT

In 95% of congenital (present at birth) hydroceles, the natural history is one of gradual and complete resolution by one year of age. For those lasting longer than one year or for those noncommunicating hydroceles that manifest after the first year, surgical repair is indicated since these rarely resolve spontaneously Hydroceles are not usually dangerous and are treated only when they cause pain or embarrassment or when they decrease the blood supply to the penis (rare). Treatment is not usually needed if a hydrocele does not change in size or gets smaller as the body reabsorbs the fluid. Hydroceles in men younger than 65 may go away by themselves. But hydroceles in older men do not usually go away. Fluid can also be removed from a hydrocele with a needle (aspiration). But hydroceles that are aspirated often return, and surgery may then be needed. Aspiration is recommended only for men who are not physically able to have surgery because of the risk of infection and recurrence. If the hydrocele gets larger or causes discomfort, surgery to remove the hydrocele (hydrocelectomy) may be needed.

HYDROCELECTOMY
Hydrocelectomy or hydrocele repair is a procedure that is done to repair scrotum swelling caused by a hydrocele. A hydrocele is a backup of fluid into one or both testicles. This can occur at birth or later in life when a hernia is present. Hydrocelectomy may be performed if: Hydrocele interrupts blood flow to the area Hernia is present Hydrocele is rather large

A-Incision through anterior scrotum, exposing hydrocele sac. Characteristic dark blue shiny appearance of tunica vaginalis (which is sac wall) is due to deep shadow within sac.

B-Hydrocele sac enucleated and removed from scrotum. It is left attached to groin by spermatic cord.
C-Sac opened and excised from testis. D-Skin edges and subcuticular tissues approximated with single mattress sutures of no. 3-0 plain catgut.

OPERATIVE PROCEDURE
(1) An anterolateral incision is made in the skin of the scrotum over the hydrocele mass, using a scalpel with a number 2-0 blade. Bleeding is controlled with Crile hemostats and vessels ligated with number 2-0 plain gut ligatures.

(2) Small retractors may be placed (see figure A), and then the fascial layers are incised to expose the testis and tunica vaginalis. With fine scissors and forceps, the sac is delivered and dissected free (see figureS B and C). The hydrocele may be aspirated. The adherent tunica vaginalis is separated from the internal fascia layers and the sac opened. When the tunica vaginalis has been trimmed as desired, the testis is returned to the scrotal sac. (3) A Penrose drain is placed, and the wound is closed (see figure D) in layers with Atraumatic sutures plain gut number 2-0 on curved cutting needles. The wound is dressed, and a supportive sling dressing or suspensory is usually applied

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