Urology: Scrotal Fluid Collection (Hydrocele, etc.)

Hydrocele

Definition

  • A Collection of Serous/Peritoneal Fluid in the Scrotum
  • Collects Between in Parietal & Visceral Layers of the Tunica Vaginalis

Types

  • Non-Communicating: Accumulation of Secretions in a Closed Cavity
    • From Secretions of the Mesothelial Lining of the Tunica Vaginalis
    • Most Common in Adults
  • Communicating: Patent Processus Vaginalis, Free Flow of Fluid into Abdominal Cavity
    • Due to Failure of the Processus Vaginalis to Close During Development
    • Most Common in Pediatrics

Causes

  • Idiopathic – Most Common Cause
  • Testicular Torsion
  • Epididymitis
  • Orchitis
  • Torsion of the Appendix Testis
  • Testicular Hematoma
  • Testicular Rupture
  • Reactive from a Testicular Tumor

Presentation

  • Cystic Scrotal Mass
  • Often Asymptomatic
  • Pain
  • Pressure Sensation
  • Skin Irritation

Diagnosis

  • Generally Made by Physical Examination:
    • Transilluminates Well
    • Communicating Hydroceles May Reduce When Lying Supine & Increase with Valsalva
  • Suspect Tumor if Presentation is Acute
  • Consider Scrotal US if Uncertain

Treatment (Adults)

  • Asymptomatic: No Intervention
  • Symptomatic: Hydrocelectomy
    • Surgical Options:
      • Jaboulay Bottleneck Repair: Remove Excess Sac, Evert the Sac Edges & Sew Them Together Behind the Cord
      • Lord Plication: Remove Excess Sac & Plicate/Oversew the Edges
    • May Consider Aspiration with Instillation of a Sclerosing Agent (Tetracycline or Alcohol) – Generally Less Effective

Treatment (Pediatrics)

  • Non-Communicating:
    • Asymptomatic: No Intervention
    • Symptomatic: Hydrocelectomy
  • Communicating:
    • Age 1-2: Observe (Most Spontaneously Resolve by Age 1-2 Years)
    • Age > 2: High Ligation of the Patent Processus Vaginalis
      • Distal Sac is Drained & Left Behind

Hydrocele 1

Hydrocele US 2

Varicocele

Definition

  • Definition: Venous Engorgement Around the Spermatic Cord
  • Due to Tortuous Dilated Pampiniform Plexus

Causes

  • Primary: Idiopathic
  • Secondary: From Venous Obstruction
    • IVC Thrombus
    • Renal Vein Thrombosis
    • Retroperitoneal Tumors
    • Renal Tumors
    • Lymphadenopathy

Presentation

  • Scrotal Swelling – “Bag of Worms” Feeling
  • Often Asymptomatic
  • Pain
  • Pressure Sensation
  • Testicular Atrophy
  • Impaired Fertility
  • Most Common on the Left Side – Left Gonadal Vein is One of the Longest & Drains into the Renal Vein at a Perpendicular Angle

Grading

  • Grade 1: Small & Palpable Only by Valsalva
  • Grade 2: Moderate & Palpable on Standing but Not Visible
  • Grade 3: Large & Visible

Diagnosis

  • Generally Made by Physical Exam
  • Primary Concern is Differentiating Primary & Secondary Causes
  • Consider Imaging (US or CT) if There are Any Signs of Secondary Causes
  • Signs of Secondary Causes
    • Acute Onset
    • Right-Sided Varicocele
    • Persists in the Supine Position

Treatment

  • Most Require No Intervention
  • Indications for Surgical Ligation of the Gonadal Vein Branches:
    • Symptomatic
    • Testicular Atrophy or Abnormal Semen Counts
  • *May Consider Percutaneous Venous Embolization Instead for Select Cases

Varicocele 3

Varicocele US 4

Spermatocele (Epididymal Cyst)

Definitions

  • Epididymal Cyst: Fluid-Filled Cyst at the Head of the Epididymis
    • May Contain Nonviable Sperm
  • Spermatocele: Cyst > 2 cm

Presentation

  • Scrotal Swelling
  • Generally Asymptomatic
  • Chronic Pain
  • Do Not Affect Fertility

Diagnosis

  • Generally Made by Physical Examination:
    • Palpated Mass Separate from the Testis
    • Transilluminates
  • Consider US if Diagnosis is Uncertain

Treatment

  • Asymptomatic: No Intervention
  • Symptomatic: Excision

Spermatocele US 5

References

  1. Morton SU, Prabhu SP, Lidov HGW, Shi J, Anselm I, Brownstein CA, Bainbridge MN, Beggs AH, Vargas SO, Agrawal PB.AIFM1mutation presenting with fatal encephalomyopathy and mitochondrial disease in an infant. Cold Spring Harb Mol Case Stud. 2017 Mar;3(2):a001560. (License: CC BY-NC-4.0)
  2. Dilmen N. Wikimedia Commons. (License: CC BY-SA-3.0)
  3. Gudeloglu A, Parekattil SJ. Update in the evaluation of the azoospermic male. Clinics (Sao Paulo). 2013;68 Suppl 1(Suppl 1):27-34.(License: CC BY-NC-3.0)
  4. Schomynv. Wikimedia Commons. (License: CC BY-SA-3.0)
  5. Wikimedia Commons. (License: Public Domain)