INTRODUCTION:
Unusual fluid accumulation between the tunica vaginalis parietal and visceral layers is known as a hydrocele ruptured hydrocele is an uncommon disorder in conventional clinical practice; how ever it is a very common occurrence that produces scrotal lump and pain in males1. Its root terms are hydro’s, which means water, and kele, which indicates bulk in Greek. Despite the distinct aetiologies, surgery can be required for both. Both disorders need to be considered in a differential diagnosis of scrotal tumours 2. The testis migrates down the posterior wall towards the deep inguinal ring, most likely under the influence of the hormone mullerian duct inhibitory factor. It is formed from primordial germ cells and coelomic epithelium in a longitudinal collapse high on the posterior abdominal wall at an altitude parallel to the developing kidney3.
Premedication, which can be administered intramuscularly with morphine or orally with diazepam, is required for surgical procedures involving general or local anesthesia. Hydrocele is predictable to have an effect on 1percent of adult men and more than 80precent of newborn boys have a patent processus vaginalis, but most close unexpectedly within 18 months of age or hydrocele congenital in 12 months of age4. 26.79 million Cases of hydrocele have been reported globally, with 48% of those cases occurring in India. 94% of the wives of hydrocele patients report being unhappy with their sexual lives 5.
Structure of hydrocele:
Fig no.1 Hydrocele
ANATOMY OF THE SCROTUM:
The scrotum, a thin external skin sac with two compartments, is part of the male reproductive system. Inside each compartment are the glands responsible for producing sperm and one or both of the testes, which are the sperm storage organs. Among humans and some other land-dwelling mammal species, the scrotum is a unique anatomical characteristic. Situated right in front of the anus and behind the penis, it is continuous with the lower abdomen's skin. Sharp muscular tissue (dartos fascia) encircles the scrotal wall, which is a thin layer of skin. There are many sebaceous (oil-producing) and sweat glands, as well as some hair, on the skin, which has more pigment than the surrounding areas. The raphe, a median ridge, serves as an external marker for the separation of the scrotal cavity into two sections6.
The scrotum is divided into two sections by the septum, a muscular wall that is connected to the internal raphe. The testes are kept safe and at a temperature that is a few degrees below body temperature by the scrotum. Consequently, the scrotum is external to the body wall; in addition, it contracts when exposed to cold, effort, or sexual desire, and it expands and relaxes when heated. It retains heat when contracted and allows air to circulate to produce cooling when it is relaxed, making it smooth and extended. For sperm to proliferate and become viable, the scrotum's relatively cold Temperature is believed to be crucial. Age causes a weakening and relaxing of the scrotal muscular tone.
Testes are kept cold by the complex blood system around them in animals like stallions, rats, and boars whose scrotum is constantly pressed up against the body. Temporary sterility results from the scrotum's inability to chill the testes, which can happen in cats with high fevers or during the sweltering summer7.
Fig no2: Anatomy of Scrotum
EPIDEMIOLOGY:
1. SEX: In comparison to girls, boys have hernias six times more frequently. In contrast to men, women experience bowel imprisonment more frequently. Women are more likely than men to become imprisoned in their ovaries or fallopian tubes. Consequently, compared to men, women experience a decreased overall incidence of bowel strangulation8.
2. AGE: As people mature, PPV incidence declines. In neonates, PPVs range from 80% to 94% Compared to babies born on time, premature infants weighing less than 1500g have a 20-fold increased risk of hernias.
One percent of adult males are thought to have hydrocele. While the majority of males who are born have a patent processus vaginalis, most of them close on their own by the time they are 18 months old9.
PATHOPHYSIOLOGY: Neonatal newborns frequently have hydroceles. As the testicles grow normally, they pass from the abdomen into the scrotum through a tube. If this tube does not seal, hydroceles occur. Through the exposed tube, fluid escapes the abdomen. The accumulated fluid becomes stuck in the scrotum. Scrotal enlargement results from this. Though their appearance may scare new parents, hydroceles usually disappear a few months after birth. On rare occasions, an inguinal hernia and hydrocele may coexist. Other possible causes of hydroceles include fluid or blood blockage in the spermatic cord, as well as inflammation or damage to the testicle or epididymis. It is more typical for older men to have this kind of hydrocele10.
Scrotal fluid production and absorption must be out of balance for it to occur. Exogenous fluid sources and intrinsic fluid generation are more categories into which this imbalance can be separated. Hydroceles can be classified into two groups based on whether they exhibit continuous connection with the abdominal cavity or not. For communicative hydroceles, fluid excesses originate from external sources, while aberrant internal shifts in the scrotal fluid cause excessive fluid in non-communicating hydroceles. Excessive production of fluid within the sac is secondary hydrocele11.
ETIOLOGY:
Congenital hydroceles form the testis's tunica vaginalis cavity and the processus vaginalis, which descends from the testis to the parietal peritoneum. Normally, the vaginal canal remains obliterated until the fourth month of life. The most common cause of congenital hydroceles is a failure to close the vaginal canal, also known as communicating hydroceles. Acquired hydroceles: the tunica vaginalis cavity maintains a balance between fluid production and outflow. This equilibrium is upset by the following conditions: inflammation, tumors, trauma to the testicles, twisting of the testis or testicular appendages, and inadequate lymphatic drainage (after varicoceles or inguinal hernia surgery)12.
There are 4 important mechanisms where the hydrocele can develop:
1. A surplus of fluid output.
2. Inadequate fluid absorption.
3. Establishment of contact with the peritoneal cavity via a patent vaginalis.
4. Interference, similar to filarial hydroceles, with the lymphatic drainage of scrotal tissues 13.
TYPES
OF HYDROCELE:
Non-communicating Hydrocele: In this hydrocele patients, the sac surrounding the testicle in the scrotum are not connected to the abdominal cavity. Newborns are frequently discovered to have this sort of hydrocele, which usually resolves or goes away with time. As long as the swelling is reducing, it can be safely observed, however it might take up to a year for this to happen."Adult-type" hydrocele is the name given to this type of hydrocele in older individuals. If swelling develops in the scrotum in an older kid or adolescent, consultation with a doctor is essential. These can be caused by various issues, including infection, torsion (twisting of the testicles), or a tumor. It is possible for a non-communicating hydrocele to exist from birth. Without any medical intervention, it usually disappears on its own about a year. A smooth, painless lump or swelling, or a changing scrotum size, can be symptoms. Long-term issues are uncommon after it resolves or is treated. If the child is under a year old, the surgeon will likely advise monitoring the hydrocele. If the hydrocele does not improve after a year old, surgery will be required to correct it. Non-communicating hydroceles typically dissolve within the first year of life 14.
Fig no.3Non-communicating
Communicating hydrocele:
The testicles, or pouch that contains your testes, swell when you have a hydrocele, a sac filled with fluid surrounding your testicle. Communicative hydrocele is one type of hydrocele. A communicative hydrocele is one that has a communication opening into your abdominal cavity. A vast, empty area in your body, the abdominal cavity houses your stomach, small and large intestines, kidney, bladder, liver, and other essential organs in addition to abdominal fluid. The enlargement is brought on by the connection, which permits stomach fluid to enter your scrotum. A hydrocele that communicates is a more dangerous condition than one that does not. A hydrocele that is not communicating typically stays the same size or grows extremely slowly. The size of a communicative hydrocele can vary during the day. It could grow to be quite big and uncomfortable. Usually, a physical examination by a healthcare professional can identify a communicative hydrocele. In order to view any fluid surrounding a testicle, they could beam a light through your or your child's scrotal cavity. Should the scrotum feel firm to the touch or appear extremely enlarged, a healthcare physician may occasionally request an ultrasound. Testing for alternative potential causes of swelling, such as testicular cancer, can also be done painlessly with an ultrasound 15.
Fig.no4.Communicating
Case report of hydrocele:
An extensive left-sided scrotal edema that lasted three years was reported by a 52-year-old man to us. Without any accompanying pain, the swelling increased steadily. The scrotum had never before experienced trauma. Three children were born into his wonderful marriage. His typical sexual activities were hindered for almost the last two years by the huge scrotal enlargement with the penis almost buried. His regular everyday activities were also impeded by it. Nothing noteworthy was found during the general physical examination. There were no hernia orifices broken, and the abdomen was basically normal. As seen in figure 1, he had a large scrotal enlargement on the left side. A portion of the phallus was buried in the scrotal enlargement, and the penile skin was stretched. Anxious yet erratic swelling occurred. You could not feel the ipsilateral testis 6. Passing the transillumination and swelling tests proved to be beneficial. The patient's laboratory tests revealed that she had no microfilaria and that her absolute eosinophil count was normal. There was a large hydrocele of the left side tunica vaginalistestis, as seen by inguinoscrotal ultrasound. A local anesthetic was used during his hydrocelectomy. A straw-colored liquid that poured from the tunica vaginalisweighed around 1.5 liters. It looked like that side's testes were flattened. The recovery followingsurgery went smoothly. Following a half-year follow-up, the patient is doing well and has a higher quality of life 16.
Fig: Age-distribution of instances of reported abdominscrotal hydrocele by decade.
PROGNOSIS:
Congential hydrocele has a great prognosis. By the conclusion of the first year of life, the majority of congential cases come to an end. Surgery can easily treat persistent congenital hydrocele. In one study, operative repair (OR) and laparoscopic percutaneous extra peritoneal closure (LPEC) were compared for hydroceles safety and effectiveness. It was discovered that LPEC was a secure and efficient method of treating hydrocele. Forty of the 69 patients received LPEC, while 29 received OR. The duration of the procedure, the level of anesthesia, and the complications did not differ significantly. In neither group were there any recurrences noted. In a Danish trial including 77 males, 36 of whom received polidocanol at the beginning and 41 of whom received a placebo, it was demonstrated that polidocanol was an effective treatment for hydrocele testis.
Depending on the extent of the hydrocele testis (less than 100ml, between 100 and 200ml, and greater than 200 ml), patients were treated with 1, 3, or 4ml of polidocanol upon aspiration17. In the polidocanol group, 89% of patients received treatment successfully overall. Following the initial course of treatment, Recurrence occurred in 16 44% of the treated individuals and 32 78% of the placebo group. Both groups received polidocanol when there was a recurrence. Recurrence after polidocanol retreatment occurred in four out of fourteen patients, or 25%; in the preceding placebo group, recurrence after retreatment. One session of doxycycline-based sclerotherapy combined with hydrocele aspiration showed to be helpful in curing 84% of uncomplicated nonseptated hydroceles. The authors of the study concluded that the success rate of this procedure is similar to that of hydrocelectomy. Aspiration of hydroceles and doxycycline sclerotherapy were used in this study on 29 patients (mean age, 52.8 years) with 32 nonseptated hydroceles. Using a single aspiration and sclerotherapy technique, 27 84% of the hydroceles were successfully fixed. Three of the patients who had unsuccessful results from a second procedure and needed hydrocelectomy, one desired an immediate surgical correction, and one had hydrocele satisfactorily cured with a second aspiration and sclerotherapy treatment 18.
Symptoms of hydrocele:
1. Themajor symptom of hydrocele is swelling on both sides of scrotum that may feel like a water balloon.
2. Swelling those changes in size during the day.
3. Discomfort, soreness, redness.
4. Pain
5. Feeling of weightiness.
6. Injury or inflammation within the scrotum.
7. Infection, including a sexually transmitted infection.
8. Unbalanced fluid production and absorption from the tunica vaginalis.
9. The most common symptom is swollen scrotum.
10. Skinulceration19.
Causes of hydrocele:
A. Babies: Prior to birth, a hydrocele may occur. In a developing kid, the testicles usually descend into the scrotum from the stomach area. Testicles are surrounded by fluid thanks to a sac that arrives with each one. Usually, the fluid is absorbed when each sac shuts. Occasionally, after the sac closes, the fluid remains. Non-communicating hydrocele is the term used for this. Around age one or two, the fluid is often absorbed. Occasionally, the sac remains open. A communicative hydrocele is what is meant by this. Fluid may return to the stomach region or the sac may dilate. Inguinal hernias are frequently associated with hydroceles that communicate.
B. Older people: An injury may result in the formation of a hydrocele. Alternatively it may develop as a result of an internal scrotal swelling known as inflammation. An infection within the testicle or in the little, coiled tube located at the rear of each testicle may be the source of inflammation 20.
TREATMENT:
Since hydroceles usually go away on their own with time, most babies and infants with the condition won't need any therapy. Periodically checking the scrotum, parents and caregivers should call a doctor if the swelling gets particularly large or if the baby is in pain. The best course of action for those with really large and unpleasant hydroceles may be surgery to remove them. The hydrocele can also be drained by means of needle aspiration (Trusted Source). To extract the fluid during this treatment, a physician pokes a lengthy needle into the sac. After that, they might use sclerotherapy injecting chemicals into the hydrocele to prevent it from filling up with fluid. Adults who are at risk of surgical complications should benefit most from this treatment21.
SURGICAL INDICATION:
1. Anesthetic and surgical supplies:
2. Anesthesia is often administered either locally or generally. While pre-medication (oral diazepam or intramuscular morphine) is required, local anesthesia can be used during the treatment. Using 7–10ml of 1% lidocaine, local infiltration is administered. After 5-7ml of intradermal infiltration at the site of incision, local anesthesia is finished. Eight Allis forceps are needed for the Lord procedure, in addition to standard surgical equipment. Bipolar forceps have the potential to aid in coagulation and reduce "electrical trauma" within the testis. The anesthesia and surgical instrumentsMost often, anesthesia is either general or loco regional. Local anesthesia, which needs to be paired with the procedure, is an option with pre-medication (oral diazepam or Intramuscular (morphine). There is a localized spermatic cord where it emerges from the outside inguinal ring; it is pressed up against the pubic bone. A 1% lidocaine infiltration is used. (7–10ml) What local anesthesia is finished with 5–7ml of intracutaneous near the incision site infiltrate. Conventional surgical instruments are needed, and the Lord procedure requires eight Allis forceps. Bipolar forceps could be useful for coagulation and reduce "electrical trauma" to the testicles.
Fig no.5.
3. MEDICAL METHODS: To treat hydrocele, several surgical methods are employed. Men only shave their penis and scrotum and antiseptic was used to thoroughly clean the region. Either a midline scrotal approach or between blood vessels that are in motion. For bilateral, midline is a better choice, transverse is more secure for local hydrocele and anesthetic.
Fig no.6.
4. generally, all procedures include making a tiny incision in the skin and extracting the testis completely. If lumbar blocks are used as local anesthetic, at this time, the pain (colic) could a result of traction on the experienced vessels.
Fig no.7.
5. The Andrews Procedure: This procedure is most commonly referred to as the "bottle" operation. A 2-3 centimeter incision made in the hydrocele, or tunica vaginalis, the region around the testicle, is used to transfer the sperm. That process could be lastly, secure the trimmed edges around either departing from the everted sac or the chord structures exposed. The next step is to complete the two-layer closing.
Fig no.8.
6. The Jaboulary or Winkle man Method: The majority of the sac is then removed following the delivery of the testis through a tunica incision. Leaving a tiny scratch on the edges of the testicle.
Fig no.9.
Once the remnant has been everted, hemorrhage could be quickly managed with a running suture encircling the cord with the free edges closed frameworks. To avoid endangering the blood flow to the testicles, an approximate measure of the margins is loosened around the cord. This technique is also used to remove the parietal tunica vaginalis in close proximity to the testicle and epididymis. To aid with homeostasis, electroshock therapy can be administered to the margin. The standard bilayer closure that is used to scrotum seal 22.
Fig no.10.
DIAGNOSIS:
A pediatrician or adult physician can make the diagnosis of hydrocele. Together with a physical examination, they will inquire about your symptoms. A physical examination may involve the physician pressing on your groin area or having you cough to monitor any changes in swelling. To get a better idea of any abdominal fluid present, they could flash a light through your scrotum. With just a physical examination, a physician can diagnose the majority of hydroceles. The physician might request imaging tests to corroborate their diagnosis, such as:
a) Subcutaneous ultrasound: The soft tissues in your pelvis, including your testicles, can be seen on an ultrasound by using high-frequency sound waves. If a patient is diagnosed with hydrocele, this is the most frequently ordered imaging test.
b) CAT scan (computerized tomography): An X-ray called a CT scan creates three-dimensional images of your testicles by taking cross-sectional photos of your body, or slices. Compared to a traditional X-ray, a CT scan is more accurate 23.
CLINICAL INDICATION:
Progression of painless scrotal lump is a common symptom of acquired hydroceles. Hydrocele always transilluminates when examined under a light source during the physical examination. Infection with them can cause pain (pyocele) 24.
RISK FACTOR:
1. Trauma
2. Surgery
3. Ehlers-Danlos syndrome
4. Premature and low-birth-weight infants.
5. Peritoneal dialysis.
6. Lymphatic obstruction.
7. Ventriculoperitoneal shunt.
8. Indirect inguinal hernia.
9. Increases intra abdominal pressure.
PREVENTION:
Hydrocele has no control over your baby's development of hydrocele. Keeping your scrotum and testicles safe from harm is the best defense against a hydrocele in older kids, teens, and adults. A hydrocele, or fluid-filled sac encircling your testicle, can be surgically removed or repaired with hydrocelectomy. Less than an hour is typically needed to finish the process.
Fiber-rich foods like fruits and vegetables can help with hydrocele, as can drink lots of water or other wholesome fluids to stay hydrated. In a regular diet, fresh fruits such as oranges, peaches, apples, grapes, and pineapples are crucial. However, the most significant fruit is the strawberry, which has antioxidant properties. Red, orange strawberries have a high antioxidant content and aid in the body's detoxification.
Foods high in processed carbohydrates, such as those with added sugar and salt, and foods stored in artificial and chemical preservatives should be avoided when suffering from hydrocele. Junk food should be avoided because it has little fiber, vitamin, and mineral content, such as pizza and burgers25.
CONCLUSION:
In the tunica vaginalis, between the parietal and visceral layers, there is an uneven accumulation of liquid. Men experience scrotal lump and agony from this extremely common condition, which can lead to rupture of A unique situation in everyday clinical practice is hydrocele. There are fewer than ten incidents reported in contemporary journalism. A significant proportion of hydrocele patients (94%) report being unhappy with their sexual lives. There are 26.79 million occurrences of hydrocele worldwide, with 48% of cases occurring in India. For 29 patients (mean age, 52.8years) with 32 nonseptated hydroceles, the study included aspiration of the hydroceles and doxycycline sclerotherapy as treatment More than 30 billion men and boys are affected by the hydroceles. Overall cost ranges of laser surgery of hydrocele between 25,000 to 1,35,000/-.
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Received on 22.12.2023 Modified on 14.03.2024
Accepted on 26.04.2024 ©A&V Publications All right reserved
Res. J. Pharmacology and Pharmacodynamics. 2024;16(2):107-113.
DOI: 10.52711/2321-5836.2024.00019