Hydrocele Varicocele

HYDROCELEDefined as a collection of fluid within the tunica vaginalis of the testis

CASSIFICATION1. Congenital2. Primary3. Secondary

1. CONGENITALCommunicating (vogbreuk)InfantileInterstitialCord

2. PRIMARY HYDROCELEIdiopathic (aetiology not known)Imbalance between the fluid secretion and absorption of the tunica vaginalis

3. SECONDARY HYDROCELEInfectionTraumaTumorAbnormalities in inguinal lymph nodes

DIFFERENTIAL DIAGNOSIS:SCROTAL CYSTIC MASSESIndirect inguinal herniaEpididymis cystHydroceleVaricoceleSpermatocelePioceleHematocele

TREATMENTCommunicatingTying off the patent processus vaginalisPrimaryHydrocelectomyAspiration + injection of sclerosing agentSecondaryTreat underlying pathology

DIFFERENTIATION

HYDROCELEINGUINALHERNIAPalpate cord above massYESNOTranslucentYESNOFluctuateYESNOFluid thrill YESNO

DIFFERENTIATION

HYDROCELEINGUINALHERNIATestis palpableNOYESCough impulseNOYESReducibleNOYESBowl soundsNOYES

FLUID ASPIRATED FROM CYSTIC MASSES

SUPRA TESTICULARCYSTIC MASSCOLOR OF FLUIDCord hydroceleStraw color SpermatoceleMilky orGrey opaque (barley-water)Epididymis cystClear

VARICOCELEDefined as an abnormal dilatation and distension of the veins of the pampiniform plexus

INCIDENCE15% in the general population(8% - 23%)16,3% in adolescents(12,4% - 25,8%)33% in infertile men(19% - 41%)58% - 93% left sided

ETIOLOGYAbnormality of the venous valvesLeft spermatic vain joining the left renal vein directly at a 90 angleLonger left spermatic vein with increased hydrostatic pressurePressure of superior mesenteric artery on the left renal vein (Nutcracker phenomenon)

PRESENTATIONComplaints of a scrotal mass(Bag of worms)Complaints of scrotal discomfortFertility problemsIncidental diagnosis with clinical examinationSmaller left testis

CLACCIFICATIONPrimaryAbnormality of valves in the spermatic veinSecondary Tumor of the left kidneyRetro-peritoneal massesTrauma

GRADING

GRADE 0Venous noise on doppler with Valsalva maneuverGRADE 1Distended veins can be palpated with ValsalvaGRADE 2Distended veins can be palpated without ValsalvaGRADE 3Distended veins can be observed

INFERTILITY THEORIESStases of blood with testicular hypoxiaReflux of renal and adrenal metabolitesIncreased intra-testicular temperature

INDICATIONS FOR FURTHER MANAGEMENTSymptomatic*Pain*Mass (discomfort)InfertilityTesticular atrophy

TREATMENTSpermatic venography plus embolisation with heated contrast/resin/coilsSurgeryOpenIvanissevitchPalomaLaparoscopic