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Hydrocele-Varicocele

Anatomy of Scrotal Contents


Tunica vaginalis
surrounds the
anterior 2/3rd of the
testicle and creates
a potential space
for hydroceles and
hematoceles

Anatomic Scrotal Mass: Hydrocele


Hydrocele
Fluid within tunica vaginalis and spermatic cord
Called communicating hydrocoele if processus
vaginalis is patent
Etiology
Failure of patent processus vaginalis to close
Failure of peritoneal fluid to be re-absorbed
History
Typically painless mass
Physical Exam
Transilluminates
Cannot palpate testicle
Consider ultrasound due to possibility of
neoplasm causing Hydrocele

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

Hydrocele of the cord


Segmental closure of the processus, which leaves
a loculated hydrocele of the cord
Presents as a painless mass which is mobile and
transilluminates

Anatomic Scrotal Mass

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

Anatomical Scrotal Mass: Varicocele

Anatomical Scrotal Mass: Varicocele


Varicocele
Varicosities of pampiniform plexus
90% on left side; seen in 15% of male population
Associated with male factor infertility but most men
with varicoceles can expect normal fertility

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)

Complaints of scrotal discomfort


Fertility problems
Smaller left testis

GRADING
GRADE 0

Venous noise on doppler


with Valsalva maneuver

GRADE 1

Distended veins can be


palpated with Valsalva

GRADE 2

Distended veins can be


palpated without Valsalva

GRADE 3

Distended veins can be


observed

INFERTILITY THEORIES
Stases of blood with testicular hypoxia
Reflux of renal and adrenal metabolites
Increased intra-testicular temperature

INDICATIONS FOR FURTHER


MANAGEMENT
Symptomatic
* Pain
* Mass (discomfort)
Infertility
Testicular atrophy (Volume <20 ml, length <4 cm)

TREATMENT
Spermatic venography plus embolisation (not commonly
performed)
Surgery
Open
Palomo (Internal spermatic vein ligation high within internal
inguinal ring)
Ivanisevich
Laparoscopic

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