HYDROCELE

HYDROCELE
A hydrocele is a collection of fluid between the parietal and
visceral layers of the tunica vaginalis.
I. Communicating hydroceles
II. Noncommunicating hydroceles

Communicating hydroceles
Failure of the processus vaginalis to close during development
The fluid around the testis is peritoneal fluid

Noncommunicating
hydroceles
No connection to the peritoneum
The fluid comes from the mesothelial lining of the tunica
vaginalis

HYDROCELE
In neonates resolve spontaneously, usually by the first birthday
(1 years old)
In older children and adolescents
noncommunicating hydroceles
idiopathic
secondary
Epididymitis
Orchitis
Testicular torsion
Torsion of the appendix testis or appendix epididymis
Trauma
Tumor. These conditions must be excluded in children and adolescents with
hydrocele.

Clinical presentation
A cystic scrotal mass
Communicating hydroceles : increase in size during the day or
with the Valsalva maneuver
Noncommunicating hydroceles are not reducible and do not
change in size or shape with crying or straining
Examination of patients with hydroceles should include
palpation of the entire testicular surface for findings of
epididymitis, orchitis, testicular torsion, torsion of the appendix
testis or appendix epididymis, trauma, or tumor as the primary
etiology
Doppler ultrasonography may be necessary to exclude these
conditions.

Diagnosis
The diagnosis of hydrocele can be made by physical
examination and transillumination of the scrotum that
demonstrates a cystic fluid collection.
Communicating hydroceles are often reducible;
noncommunicating hydroceles are not.
Doppler ultrasonography may be necessary to evaluate the
testicle and rule out a primary cause.

Management
Surgical repair is indicated for hydroceles in newborns that persist beyond
one year of age, for communicating hydroceles, and for idiopathic
hydroceles that are symptomatic or compromise the skin integrity.
The management of hydrocele in a neonate or child younger than one
year of age usually is supportive. Hydroceles that are present in
newborns, whether communicating or noncommunicating, usually resolve
spontaneously by the first birthday, unless they are accompanied by an
inguinal hernia.
Communicating hydroceles in older patients rarely resolve and pose a risk
for development of incarcerated inguinal hernia. Surgical repair of
communicating hydroceles is usually undertaken on an elective basis.
Idiopathic hydroceles are often asymptomatic. Surgical repair may be
indicated for symptomatic complaints. Reactive hydroceles usually resolve
with treatment of the underlying condition.

UNDESCENDED
TESTES

TERMINOLOGY
Cryptorchidism Cryptorchidism by definition suggests a hidden testis: a testis that is
not within the scrotum and does not descend spontaneously into the scrotum by four
months of age (or corrected age for premature infants). Cryptorchid testes may be absent
or undescended.
Absent testis An absent testis may be due to agenesis or atrophy secondary to
intrauterine vascular compromise (eg, prenatal testicular torsion), also known as the
vanishing testis syndrome or testicular regression syndrome. Boys who have bilaterally
absent testes have anorchia
Undescended testes True undescended testes have stopped short along their normal
path of descent into the scrotum. They may remain in the abdominal cavity or they may
be palpable in the inguinal canal (intracanalicular) or just outside the external ring.
Retractile testes Retractile testes are normal testes that have been pulled into a
suprascrotal position by the cremasteric reflex. These testes can be brought into a
dependent scrotal position and will remain there if the cremasteric reflex is overcome (eg,
by holding the testis in the scrotum for at least one minute)
Ascending testes Ascending testes are noted to be in a scrotal position in early
childhood and then to "ascend" and become undescended (ie, acquired undescended
testes).

Descent of testes
Starts at 8th wk
Reaches deep Inguinal ring by 3rd month
Lies dormant upto 6th month
Traverses Inguinal canal during 7th month
Reaches Superficial ring by 8th month
Reaches bottom of scrotum by 9th month

COMPLICATIONS AND SEQUELAE

OF UNDESCENDED TESTES
Inguinal hernia
Testicular torsion
Testicular trauma
Subfertility
Testicular cancer
intraabdominal > inguinal

Clinical presentation
Absence of testis in scrotum since birth
Hemiscrotum empty, hypoplastic
Testis may or may not be palpable along the path of descent.
70% of UDT are palpable, 30% non palpable.

Investigations
If palpable- no investigations needed
Unilateral impalpable- no investigations needed, but USG is
done by many
Bilateral impalpable- rule out Intersex if genitalia look
abnormal.

MANAGEMENT OF
UNDESCENDED TESTES
Surgical treatment
Hormonal treatment
hCG to stimulate testosterone production and descent

Surgical treatment
Timing of surgery
Palpable testes
Orchiopexy

Nonpalpable testes
Imaging
Exploratory surgery

Associated inguinal hernia

Timing of surgery
Surgical treatment of undescended testes is recommended as
soon as possible after six months of age for congenitally
undescended testes and definitely should be completed before
the child is two years old
In children with testicular ascent later in childhood, surgery
generally should be performed within six months of
identification.