Classifying Hydroceles of the Pelvis and Groin: An Overview of Etiology, Secondary Complications, Evaluation, and Management

Use of a vessel-sealing device compared with Jaboulay's technique for adult hydrocelectomy surgery: a retrospective cohort study

Hydrocele is a common benign scrotal condition affecting adult men. The gold standard of treatment includes hydrocelectomy, with the use of Winkelman's/Jaboulay's technique or Lord's procedure. The vessel-sealing device (VSD) is a blood vessel-sealing system, known to enhance patient's postoperative outcomes in multiple different surgeries. The aim of this study was to compare the procedural and postoperative outcomes of a novel hydrocelectomy method using a VSD to the conventional hydrocelectomy using the Jaboulay's technique. We performed A retrospective review for all adult cases who underwent surgical hydrocelectomy at Hillel Yaffe Medical Center between 2011 and 2022. Study cases were grouped into one of two groups, patients undergoing conventional hydrocelectomy, or patients undergoing hydrocelectomy with the use of a VSD. Patients operated using other techniques were excluded. Data collected included demographic data and operative and postoperative parameters. Among 102 patients, 47 underwent Jaboulay's technique and 55 underwent hydrocelectomy using a VSD. We observed significantly shorter duration of hospitalization (1.18 vs 1.53, P = 0.038) and shorter surgery time (31.87 vs 37.4, P = 0.003) when using the VSD during a hydrocelectomy compared to conventional surgical hydrocelectomy. Both techniques indicated low complication rates and no recurrent hydrocele was observed in either group. We report our experience with a novel surgical technique that includes hydrocelectomy with the use of VSD. Our findings demonstrated shorter surgery time and length of hospitalizations, which may indicate improved patient's postoperative outcomes with the use of the VSD for hydrocelectomy.

Sclerotherapy in the Treatment of Hydroceles: A Comprehensive Review of the Efficacy, Types of Sclerosants, and Comparative Outcomes Against Hydrocelectomy

While hydrocelectomy is the gold-standard for treating hydroceles, it poses an increased risk to patients and a greater burden to the healthcare system. Sclerotherapy is an alternative treatment for hydroceles that involves injecting a sclerosant into the hydrocele under ultrasound guidance. This literature review aimed to assess the types of sclerosants used and how sclerotherapy compares to hydrocelectomy. A literature search was conducted of MEDLINE and EMBASE using the terms "sclerotherapy" and "hydrocelectomy," which yielded 1058 studies, of which 29 met the inclusion criteria. Only studies published after 2000 were included to ensure the most recent information was reviewed. The results showed hydrocele sclerotherapy is done using a variety of sclerosants. The most used agents are polidocanol, phenol, and STS. Of these, phenol had the highest clinical success rate of 96.5%. There was evidence for the use of atypical agents, such as tetracycline antibiotics, which yielded cure rates up to 93%, and alcohol, which was found to be especially useful for treating multiseptated hydroceles. The results comparing sclerotherapy to hydrocelectomy indicated hydrocelectomy to be a more effective method in completely curing hydroceles. However, this came at the cost of more complications. Additionally, sclerotherapy was found to be more advantageous for secondary outcomes, such as healthcare costs and burden to patients. In conclusion, this review shows that while hydrocelectomy is more effective, sclerotherapy is a valuable alternative for treating hydroceles. Due to the lack of standardization among studies, a definitive conclusion cannot be made regarding which sclerosant is best to use.

A Review of Classification, Diagnosis, and Management of Hydrocele

This article summarizes and updates a number of issues related to hydrocele including anatomy, embryology, classification, etiology, clinical manifestations, imaging findings, and management. Hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers arising from the mesothelial lining of the tunica vaginalis that surrounds the testis and spermatic cord directly. Hydroceles result from an imbalance of secretion and reabsorption of fluid from the tunica vaginalis. Hydroceles can be divided into two types as primary and secondary. The diagnosis should be based on medical history, clinical manifestations, and imaging studies. Understanding the causes and types of hydroceles is useful for accurately diagnosing and treatment strategy. Hydroceles can be managed by conservative treatment, fluid aspiration, or hydrocelectomy.

Testicular mesothelioma disguised as hydrocele: a case report

BACKGROUND

Testicular tumors have many different manifestations. The majority of these cases are presented as an incidental finding during hydrocelectomy. Malignant mesotheliomas are uncommon tumours that can arise from the coelomic epithelium of the pleura, peritoneum, pericardium, and tunica vaginalis.

CASE PRESENTATION

We present a 51-year-old South Asian (Indian) male patient with a rare case of mesothelioma, presenting with right hydrocele, to whom a right hydrocelectomy was performed. Any history of trauma or asbestos exposure was not present. Histopathological and immunohistochemistry reports revealed a malignant mesothelioma of tunica vaginalis. There was no invasion of the tumour to the epididymis and spermatic cord. Imaging studies showed no signs of metastasis. 1 month later, a high inguinal orchidectomy was performed. The patient underwent adjuvant chemotherapy thereafter and is still on follow-up.

CONCLUSION

Although hydrocele is common, detailed evaluation is mandatory to rule out certain rare tumours-testicular and paratesticular variants.

Malignant Epithelioid Mesothelioma of the Tunica Vaginalis Testis Presenting as Hydrocele in a Kidney Transplant Recipient

Mesotheliomas of the tunica vaginalis testis are rare malignant tumors that can present as a scrotal mass or hydrocele. These tumors are typically aggressive with high rates of recurrence and metastasis. Suspected risk factors for malignant mesothelioma include asbestos exposure, chronic inflammation, trauma, and persistent hydrocele. We report the case of a malignant epithelioid mesothelioma of the tunica vaginalis testis that presented as a finding at hydrocelectomy and was ultimately treated with radical inguinal orchiectomy. This patient was on chronic immunosuppression therapy with tacrolimus and mycophenolate mofetil secondary to a kidney transplant but had none of the common risk factors for mesothelioma formation. To our knowledge, this is the first case describing a possible connection between chronic immunosuppression and mesothelioma of the tunica vaginalis. However, future studies are needed to investigate this association and discern whether this could have played a role in our patient or if his mesothelioma formation was coincidental.

Practice Variation in the Management of Adult Hydroceles: A Multinational Survey

Background

Although hydrocele is one of the most common urologic pathologies, it is seldom studied, and the major urologic associations have no guidelines for the management of adult hydroceles.

Objective

To characterize international practice variation in the treatment of adult hydroceles.

Design setting and participants

An international survey was conducted addressing the management of hydroceles among urologists in Belgium, Denmark, Finland, Iceland, Japan, and the Netherlands from September to December 2020. We invited a random sample of 170 urologists from each country (except Iceland).

Outcome measurements and statistical analysis

Urologists' treatment options, factors relevant for decision-making, expected patient satisfaction, and outcomes after aspiration versus surgery were assessed.

Results and limitations

Of the 864 urologists contacted, 437 (51%) participated. Of the respondents, 202 (53%) performed both hydrocelectomies and aspiration, 147 (39%) performed hydrocelectomies only, and 30 (8%) performed aspiration only. In Belgium (83%), the Netherlands (75%), and Denmark (55%), urologists primarily performed hydrocelectomies only, whereas in Finland (84%), Japan (61%), and Iceland (91%), urologists performed both hydrocelectomies and aspiration. Urologists favored hydrocelectomy for large hydroceles (78.8% vs 37.5% for small), younger patients (66.0% for patients <50 yr vs 41.2% for ≥70 yr), patients with few or no comorbidities (62.3% vs 23.1% with multiple comorbidities), and patients without antithrombotic agents (53.5% vs 36.5% with antithrombotic agents). Most urologists considered patient satisfaction to be highest after hydrocelectomy (53.8% vs 9.9% after aspiration) despite believing that hydrocelectomy is more likely to cause complications (hematoma 77.8% vs 8.8% after aspiration). Estimates varied between countries.

Conclusions

We found a large variation in the treatment of adult hydroceles within and between countries. Optimization of hydrocele management globally will require future studies.

Patient summary

Our international survey shows that treatment of adult hydrocele varies considerably within and between countries.

Gross Hydrocele With Completely Buried Penis: A Case Report

A gross hydrocele is caused by fluid accumulation within a layer wrapped around the testicle, called the tunica vaginalis, derived from the peritoneum. A 65-year-old male complained of a non-tender, fluctuant bulge in his right scrotum despite having a fully buried penis, a large hydrocele, and urinary retention. After ultrasonography, the diagnosis was confirmed, and the patient underwent a successful surgical procedure that included a hydrocelectomy and tunica vaginalis excision. The patient reported few postoperative complications and a notable improvement in his quality of life. Surgery is a successful approach for treating gross hydrocele, with minimal morbidity and excellent cosmetic outcomes.

Hydrocele Masking Testicular Tumour With Extensive Nodal Disease: A Case Report and Literature Review

Hydrocele is one of the most common causes of scrotal swellings. Fluid accumulation within the tunica vaginalis, a remnant of the peritoneum covering the testicle, leads to scrotal swelling. It is known to be a benign condition with no subsequent complications apart from increasing in size causing discomfort. Some patients could cope with the swelling effect and continue their life with no desire for further management while others are not fit for surgical intervention and would be treated conservatively with the same concept. However, once the testicle becomes swollen by the surrounding fluid, it would be difficult to examine the testicle itself even by an expert physician. We present here a 46-year-old patient who has been diagnosed with right hydrocele for a long time. The patient noticed general weakness and loss of weight. Initial investigations showed iron deficiency anemia and imaging showed retroperitoneal lymphadenopathy. Eventually, testicular ultrasonography showed a right testicular tumour that was masked by a hydrocele, resulting in delayed presentation of metastatic testicular cancer.

Pathology of African Swine Fever in Reproductive Organs of Mature Breeding Boars

African swine fever (ASF) is a severe, globally important disease in domestic and wild pigs. The testing of alternative transmission routes has proven that the ASF virus (ASFV) can be efficiently transmitted to sows via semen from infected boars through artificial insemination. Boars intramuscularly inoculated with the ASFV strain “Estonia 2014” showed grossly and microscopically visible changes in the testis, epididymis, prostate, and vesicular gland. The gross lesions included hemorrhages on the scrotum, testicular membranes, and parenchyma; edema; hydroceles; and proliferations of the tunica vaginalis. Histopathologically, vasculitis and perivasculitis was detected in the testis and epididymis. Subacutely infected animals further revealed a degeneration of the testicular and epididymal tubules, pointing to the destruction of the blood–testis and blood–epididymis barriers upon disease progression. This was confirmed by evidence of semen round cells and sperm abnormalities at later time points after the infection. The histopathology was associated with the presence of viral DNA and the infectious virus, and in a limited amount with viral antigens. In most scenarios, the impact of these changes on the reproductive performance and long-term persistence of the virus is probably negligible due to the culling of the animals. However, under backyard conditions and in wild boar populations, infected males will remain in the population and the long-term fate should be further evaluated.

The Development of Normal Fetal External Genitalia Throughout Gestation

In this review, we describe normal development of fetal genitalia throughout gestation as well as the identification of normal male and female genitalia on ultrasound. We use abnormal and ambiguous genitalia as illustrative tools to assist with the identification of normal genitalia and recognition of some of the most common abnormalities in external genitalia development.

Spontaneous, atraumatic hydrocele rupture: A case report

There is little information in the literature on the management and prognosis of ruptured hydroceles. We present a case report of spontaneous, atraumatic left hydrocele rupture in a 64-year-old male. His hydrocele was initially diagnosed as non-complex and appeared to have ruptured spontaneously three years after initial onset. On follow-up in clinic, mild re-accumulation of fluid was observed, and no pain was reported by the patient. Post-rupture fluid re-accumulation was minimal in our patient but there is potential for significant fluid re-accumulation based on other reports of ruptured hydroceles.

The Cyst of the Canal of Nuck: Anatomy, Diagnostic and Treatment of a Very Rare Diagnosis-A Case Report of an Adult Woman and Narrative Review of the Literature

The cyst of the canal of Nuck is an extremely rare female hydrocele, usually occurring in children, but also in adult women. It is caused by pathology of the canal of Nuck, which is the female equivalent to the male processus vaginalis. Due to its rarity and the lack of awareness among physicians, the cyst of the canal of Nuck is a seldom-encountered entity in clinical practice and is commonly misdiagnosed. We report on a case of cyst of the canal of Nuck in a 42-year-old woman, who presented with a painful swelling at her right groin. In addition, we conducted a review of the current available literature. This review gives an overview of the anatomy, pathology, diagnostics, and treatment of the cyst of the canal of Nuck. The aim of this review is not only to give a survey, but also to raise awareness of the cyst of the canal of Nuck and serve as a reference for medical professionals.

A Rare Case of Bilateral Abdominoscrotal Hydrocoele in a 10-Month-Old Infant Managed Laparoscopically

Abdominoscrotal hydrocoeles (ASH) are an increasingly rare form of hydrocoeles. They can present in any age group; however, they are more commonly reported in the paediatric population. Although not yet confirmed, the aetiology of ASH has been under scrutiny for the past two centuries, and scarcity of reported cases hinders this process. Clinical examination is oftentimes sufficient to make the diagnosis; however, confirmatory ultrasonography is recommended. Although old reports favoured a more conservative approach with watchful waiting, the risk of serious secondary complications is high, and surgical intervention is hence considered standard of care. Different approaches have been described, each with their own benefits, with minimally invasive surgery becoming more prevalent as of late. A case of a 10-month-old boy with bilateral ASH treated with a laparoscopic technique is presented.

The role of scrotal ultrasonography from infancy to puberty

Background

Scrotal ultrasonography is an essential diagnostic tool in daily clinical practice. The availability of new‐generation ultrasound machines characterized by clearly improved image quality, low health cost, and higher patient safety, represents only some characteristics of ultrasound investigation. The usefulness of scrotal ultrasonography is particularly evident in the period of life from infancy to puberty, during which males undergo important morphofunctional changes, and several pathological conditions may occur.

Objectives

This pictorial review primarily aimed to investigate the aspects of ultrasonography related to the normal physiological development of the gonads from mini‐puberty to pubertal onset. This study also aimed to provide an update on the use of ultrasonography in main andrological pathologies that may occur during this period. The conditions that are discussed in depth are: cryptorchidism, inguinoscrotal hernias, and hydrocele in the neonatal phase; acute scrotum, epididymo‐orchitis, and testicular cancers in childhood; and hypogonadism, varicoceles, testicular microlithiasis, and oncohematological pathology in puberty.

Discussion

We provided an ultrasound slant for all the above‐mentioned pathologies while purposely avoiding excessive deepening of the pathogenetic, clinical, and therapeutic aspects. Studying the ultrasound aspects of the gonads also facilitates differential diagnosis between various conditions and represents a good aid in evaluating therapeutic success (e.g., in hypogonadism or postsurgical evaluation of varicoceles and cryptorchidism).

Conclusion

Scrotal ultrasonography is now globally recognized as the necessary completion of clinical–laboratory overview in gonads evaluation. This diagnostic procedure is even more indispensable in the infancy–childhood–puberty period for the evaluation of normal gonadal development as well as diagnosis of other possible diseases.

Laparoscopic vs. Open Repair Surgery for the Treatment of Communicating Hydrocele in Children: A Retrospective Study From a Single Center

Purpose: This study evaluated the outcomes of laparoscopic repair (LR) and open repair (OR) surgery for communicating hydrocele in children.

Patients and Methods: We collected the clinical data and follow-up data of all boys (<14 years) who underwent communicating hydrocele surgery in the pediatric surgery department at Yijishan Hospital of Wannan Medical College from January 2017 to December 2018 and retrospectively analyzed the data.

Results: In this study, 155 patients were retrospectively enrolled, including 90 patients in the OR group and 65 patients in the LR group. There were significant differences in operation time and the recurrence of hydrocele between the two groups. The persistence of scrotal swelling in the LR group was significantly lower than that in the OR group. There was no significant difference in postoperative hospitalization time or incision infection rate between the two groups.

Conclusion: In conclusion, this study shows that laparoscopic treatment of children with communicating hydrocele has the advantages of a hidden incision, a shortened operation time, and a reduced postoperative recurrence rate and can be used as the preferred surgical method. However, laparoscopic treatment should be selected according to the specific condition of each child and cannot completely replace traditional open surgery.

Dietary supplements in the management of varicocele-induced infertility: A review of potential mechanisms

Varicocele is a main cause of lower production of spermatozoon and infertility with multiple pathophysiological mechanisms. In the past decades, the use of dietary supplements has significantly increased due to both the modern lifestyle and the food shortages of the industrialised countries. The purpose of this review paper is to collect scientific evidences from basic and clinical studies which support the use of dietary supplements to define the clinical framework for patients with varicocele. In the present review, we used keywords such as dietary supplements, varicocele, male infertility, oxidative stress, DNA fragmentation, sperm parameters to find the proper articles. The standard search biomedical engines were used for seeking the papers. The use of dietary supplements such as minerals, vitamins and antioxidants has an essential role in the prevention and treatment of varicocele by increasing the levels of antioxidant enzymes (e.g. peroxidase, superoxide dismutase and catalase) and decreasing the levels of inflammatory markers (e.g. tumour necrosis factor-α, interleukin-6 and interleukin-1) in testis. According to the results, the dietary supplements may alleviate the spermatogenesis in varicocele patients through different mechanisms such as suppression of stress oxidative and inflammation in testicular tissue.

Cyst of the Canal of Nuck in adult females: A case report and systematic review

Defects in the Canal of Nuck are rare abnormalities of the female genitalia, which are typically detected and repaired in young age. In the present report, a case of a Nuck cyst in a 40-year old female patient is described. Additionally, the current literature concerning cases of women with hydrocele of Nuck canal was systematically reviewed. A total of 16 case reports of 16 patients with Nuck hydrocele (mean age of 35.18 years), have been reported to date. A right inguinal mass was noted in 13 patients (81.3%) whereas in 3 patients a left-sided mass was noted. The surgical approach was open in 13 cases and laparoscopic in 3 cases. Two cases underwent hydrocelectomy and inguinal ring ligation, whereas in 7 cases a simple cystectomy was performed. In 2 cases the round ligament was excised along with the hydrocele. In one of these 2, ligamentum rotundum necrosis and presence of a haemorrhagic cyst of the canal of Nuck were identified. Hernia repair and hydrocelectomy was performed in 5 cases. A cyst of the Canal of Nuck is relatively rare, but should be considered during the diagnosis of inguinal masses in female patients.

Persistence of the processus vaginalis and its related disorders

The processus vaginalis is a blind-ended evagination of the abdominal wall that develops during fetal life and typically undergoes obliteration in early life. Persistence of the processus vaginalis is associated with a number of pathologies including congenital indirect inguinal hernias, communicating hydroceles, funicular and encysted hydroceles, canal of Nuck cysts, and acquired undescended testis. Whilst all are detectable sonographically, there is little educational material relevant to the field of ultrasound with much of the literature directed at surgical and primary care physicians. Furthermore, within the literature there is a lack of consensus on several areas including the anatomy and embryology of the processus vaginalis and the mechanisms behind its obliteration. As such the objective of this paper is to distil the information regarding the persistent processus vaginalis as it is relevant to ultrasound and in doing so address the literature gap for sonographers and sonologists. The anatomy and embryology of the persistent processus vaginalis will be discussed including causative mechanisms for anomalies with their sonographic appearance highlighted.

Infertility secondary to an infected hydrocele: A case report

Hydroceles are one of the most common causes of scrotal swelling affecting around 1% of the adult population. While hydroceles are usually asymptomatic, some hydroceles can lead to infertility. We will present a case of a 34-year-old man who was referred to our center as a case of primary infertility (sever oligospermia 1.1 million/ml) for 4 years and was found to have bilateral hydroceles (infected right hydrocele). At 18 months post bilateral hydrocelectomy, the patient's total sperm count improved to 43 Million/ml. Therefore, we highly recommend considering hydrocele as an etiology in any patient with idiopathic infertility.

Amyand hernia: scrotal pyocele, associated with perforated vermiform appendix and complicated by testicular ischemia in neonate

The presence of vermiform appendix in an inguinal hernia sac is known as Amyand’s hernia. This research paper examines the case of a 28-day-old Syrian male presented with a history of an infected right-sided hydrocele from the age of 14 days. Upon admission, ultrasonography was reported as a right testicular torsion. Accordingly, emergency surgical exploration was performed, and by exposing the spermatic cord fascia, 7 mL of pus was drained, revealing the cecum and perforated appendix lying beside the right testis, which showed evidence of ischemia and bluish discoloration.

Modulation of the inflammatory response after sclerotherapy for hydrocoele/spermatocoele

OBJECTIVE

To investigate the modulation of the inflammatory response after sclerotherapy for hydrocoele/spermatocoele.

PATIENTS AND METHODS

All patients with hydrocoele or spermatocoele presenting at the Department of Urology, University Hospital, Linköping, Sweden, from 2006 to 2012, were included in this prospective observational study of sclerotherapy for hydrocoele/spermatocoele using polidocanol as a sclerosing agent and adjuvant antibiotic and anti-inflammatory medication (AAAM) for modulation of the inflammatory response. Patients were clinically evaluated within 24-48 h after a complication or adverse event possibly related to sclerotherapy. Evaluation of cure was scheduled after 3 months and re-treatment, if necessary was carried out in the same manner as the first treatment. Groups of patients were compared using the chi-squared test and logistic regression analysis.

RESULTS

From a total of 191 patients, AAAM was given to 126, of whom 5% had subclinical epididymitis/swelling (SES) compared to 26% of the patients without AAAM (P < 0.001). No other complication was observed. The rate of cure for the whole group of patients was 93% after one or two treatments and significantly higher in the group with AAAM than in the group without AAAM (96% vs 88%, P = 0.03).

CONCLUSIONS

Modulation of the inflammatory response after sclerotherapy resulted in a lower incidence of SES and an increased cure rate.

A challenging abdomino-scrotal hydrocele-successful resolution with the help of interventional radiology guided sclerosis

Abdomino-scrotal hydrocele is a rare condition that presents in male infants. There is no consensus in the literature over treatment. We present the case of a 4-year-old boy with what was thought to be a straight forward congenital hydrocele that persisted despite ligation of a patent processus vaginalis and a Jaboulay procedure. A subsequent Magnetic Resonance Imaging scan identified a large intra-abdominal component connecting to the scrotum. Laparoscopic excision of the intra-abdominal component was performed successfully, but the hydrocele persisted. The hydrocele resolved without complication following two episodes of image intensifier guided sclerotherapy carried out by the interventional radiology team.