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Simple Hydrocele
Simple (scrotal) hydrocele is an accumulation of fluid
within the tunica vaginalis
Results from persistence of or delayed closure of the
processus vaginalis
Commonly seen at birth, frequently bilateral, may be
quite large. They transilluminate and may seem quite
tense but not painful
Most resolve during the first 2 years of life
Communicating Hydrocele
Persistence of the processus vaginalis which allows
peritoneal fluid to communicate with the scrotum
The classic description is that of a hydrocele that
changes in size
It can be compressible during examination
Transillumination
Important to
help
differentiate
solid from fluidfilled masses
Hydroceles and
spermatoceles
will
transilluminate,
other scrotal
masses
typically WILL
Hydrocele
Treatment
Inguinal approach with ligation of processus vaginalis
high within internal ingunal ring (Pediatric Hydrocele)
Scrotal approach with excision and suturing of tunica
vaginalis (avoided upon any suspicion for underlying
malignancy)
Scrotal aspiration and sclerotherapy
Varicoceles
Dilated and tortous veins of the
pampiniform plexus
Predominant left-sided (90%)
Varicocele grading:
Grade I: palpable only with
valsalva
Grade II: easily palpable
without valsalva
Grade III: large, visible
Grade III: bag of worms
through scrotal skin
History
Typically asymptomatic, cosmetically bag of worms
Increases in size with valsalva or standing position
Physical Exam
Bag of Spaghetti in scrotum palpating cord
ETIOLOGY
Abnormality (incompetence ) valve of internal spermatic
vein
Left spermatic vein joining the left renal vein directly at
a 90 angle
Longer left spermatic vein with increased hydrostatic
pressure
Pressure of superior mesenteric artery on the left renal
vein (Nutcracker phenomenon)
PRESENTATION
Complaints of a scrotal mass
(Bag of worms)
GRADING
GRADE 0
GRADE 1
GRADE 2
GRADE 3
INFERTILITY THEORIES
Stases of blood with testicular hypoxia
Reflux of renal and adrenal metabolites
Increased intra-testicular temperature
TREATMENT
Spermatic venography plus embolisation (not commonly
performed)
Surgery
Open
Palomo (Internal spermatic vein ligation high within internal
inguinal ring)
Ivanisevich
Laparoscopic