A hydrocele it is an accumulation of fluid in the testicular pouch, between the parietal and visceral tunic. Normally, the testicles have a small amount of fluid between these tunics that gives them sliding mobility when the testicles are palpated. This liquid is produced and absorbed by the cells of the tunica albuginea. When for some reason there is an increase in its production, the liquid gradually increases within the testicular bag, increasing gradually.
Signs of hydrocele
These patients usually do not present local pain. However, when the hydrocele becomes bulky, discomfort may occur when crossing the leg or during intercourse. The diagnosis can be made during physical examination, observing the scrotal distension caused by the accumulation of fluid that leaves the testicular sac tense as the volume of liquid in retention increases. Thus, the amount of liquid can be so exaggerated that it causes aesthetic deformity of the bag.
In the children, the mother can report that the testicular sac increases during the day, being greater in the evening period and that at night disappears (the liquid returns to the abdominal cavity). In the morning the testicular sac is absolutely normal (communicating hydrocele). Thus, these cases occur because communication with the abdominal cavity is taking place and the intracavitary fluid from the abdomen descends into the testicular cavity through a small conduit, called the vaginal peritoneum, through the inguinal region, when the boy stands. Consequently, this anomaly is always associated with indirect inguinal hernia (invagination of loops of the small intestine in the hernial sac) and must be corrected in surgery.
The diagnosis is made by physical examination of the genitalia, with visualization of the enlarged pouch, which may be uni or bilateral.
In the small hydrocele one can palpate the testicle and epididymis perfectly. In a more pronounced hydrocele it is not possible to palpate the testicle to observe its physical characteristics. When performing transillumination with a flashlight the beam of light passes into the hydrocele, which in the solid testicular lesion that increases the scrotum does not happen. The definitive diagnosis is made with ultrasound, which will show the net contents and appearance of the testis and epididymis. Some diseases that affect the testicle and epididymis can be hydrocele, especially those caused by infections. They are usually preceded by local pain. Inflammatory diseases of the organs of the scrotum (epididymitis, testicular torsion, torsion of testicular appendages) may produce reactive hydrocele. These cases deserve diagnostic investigation of the primary lesion, before surgical correction is instituted.
Rare diseases of the testicles, such as testis neoplasm may be associated with hydrocele. For this reason, hydrocele should always be investigated prior to ultrasound surgery to evaluate the integrity of the testis. The visualization of an intratesticular mass should be considered testicular cancer until proven otherwise. Rare cases poorly defined by ultrasonography can be evaluated by magnetic resonance imaging to differentiate inflammation from neoplasia. Therefore, research with specific markers for testicular neoplasia, such as: alpha-fetoprotein, beta-fraction of the hormone gonadotropin and lactic dehydrogenase, should be complemented. This diagnosis is fundamental for planning the surgery that in cancer, the approach must be done inguinally.
The treatment of hydrocele in most cases is surgical. Cases caused by infection of the ascending genital tract, such as epididymitis, should be treated with antibiotics, as hydrocele regression may occur with the treatment of the underlying disease. Benign hydrocele can be approached scrotally, with an incision in the median raphe. Therefore, the one caused by testicular cancer must be approached inguinally, without violation of the scrotum, due to the risk of spreading the neoplasia at a distance by other than the usual pathways, through lymphatic or venous vessels, that is, through the spermatic conduit.
There is no form of prevention, as it is a congenital anomaly in most cases. Cases that occur in young adults, aged 15 to 39 years, in a testicle that is suspected of having a mass must be ruled out the presence of primary testicular neoplasia. Be careful to consider the growth of the pouch as acute chronic epididymitis when associated with hydrocele, instead of testicular neoplasia. This can delay the treatment of one of the fastest growing neoplasms and with great potential to cause metastasis (cancer that goes from its primary place to other organs at a distance) that we know of.