CASE PRESENTATION

A. PATIENT IDENTITYName : Mr.KAge : 57 years oldSex : MaleAddress : Tegal KarangReligion : Islam

B. ANAMNESIS Main Grievance

Swollen scrotum

Historical of Present Disease6 months prior to admission, patient noted that his scrotum has been swollen.

There isn`t any associated tenderness. There weren’t complains about fever,breathing difficulty,cough,nausea nor vomit.

Historical of Past DiseaseHypertension (-)Diabetes Melitus (-)

Historical of Family DiseaseThere are no other family members who have same disease with the patient.

C. MEDICAL EXAMINATION Present Status

General Condition : moderate Awareness : Compos mentis Blood Pressure : 120/80 Pulse : 88 x/minute Breathing : 21 x/minute Temperature : 36,8 ºC

General StatusHead

Form : Normal, Simetrical Hair : Black Colour, No hair fall Eye : Anemic Conjungtival -/-

Icteric Schlera -/-Light Reflex +/+Isocor pupil

Ear : Normal form, cerumen (-), intact tympani membrane Nose : Normal form, No septum deviation, epitaction -/- Mouth : Normal

Neck Enlargement of lymph nodes (-)

1

Trachea in the middle No mass

Thorax

◦ Lungs - pulmonary Inspection : The chest shape is symmetrical both ofleft and right Palpation : Fremitus tactile and vocal symmetrical right and left,

crepitus (-), tenderness (-), rebound tenderness (-) Percussion : Sound of resonant in both lung fields Auscultation : Sound of vesicular and bronchial the entire lung field,

ronchi -/-, wheezing -/-

◦ Heart Inspection : Ictus cordisis not visible Palpation : Ictus cordispalpable on the left midclavicula ICS line 5 Percussion : Upper limit ICS 3 lineaparasternalissinistra

Right limit ICS 4 lineasternalisdextraLeft limit ICS 5 lineamidclaviculasinistra

Auscultation : Heart sound 1 – 2 pure regular, murmurs (-), gallops (-)

Abdomen Inspection : flat abdomen shape, supple, not visible skin disorders Palpation : tenderness (-), rebound tenderness (-) Percussion : There was a whole field tympanic abdomen Auscultation : Bowel sounds (+) 4x/minute

Extremityo Superior : warm, Edema -/-, CTR < 2”o Inferior : warm, Edema -/-, CTR < 2”

Localized StatusScrotum : soft nontender fullness within the hemiscrotum. Transillumination (+)

D. INVESTIGATIONSLaboratory Examination

2

11/8/2015

Test Result Normal Range

Hematology

Hemoglobin 13,7 g/dl 12- 16 g/dl

Leukocyte 6.830 /uL 5200 – 12400 /uL

Hematocrite 39,6 % 37 – 47 %

Trombocytes 285.000 / uL 150.000-450.000/uL

RadiologyThorax photo : NORMAL

E. DIAGNOSIS OF WORKHydrocele communicans

G. MANAGEMENT PLAN Infusion RL 20 GTT / min Ketorolac 3 x 1 Ceftriaxon 3 x 1

H PrognosisQuo ad vitam: ad bonamQuo ad functionam: ad bonamQuo ad sanationam: ad bonam

LITERATURE REVIEW

3

Background

A hydrocele is a fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord. These fluid collections may represent persistent developmental connections along the spermatic cord or an imbalance of fluid production versus absorption. In rare cases, similar fluid collections can develop along the canal of Nuck[1] in females.

Hydroceles pose little risk of clinical consequence. However, the potential for more than fluid to appear within developmental connections between the abdominal cavity and the scrotum or the association with underlying scrotal pathology requires that hydroceles be evaluated with due prudence. See the image below.

History of the ProcedureThe description of the abdominal cavity parietes to the tunica vaginales is attributed to Galen in 176 AD. However, the clear description of the inguinal anatomy and its relationship to groin hernias and hydroceles was not recorded until the 19th century.

Problem

The presence of fluid within the hemiscrotum has little clinical impact on the testis. However, determining the cause for the increased fluid, specifically any associated clinically significant pathology, remains the primary concern with regard to hydroceles. Once pathology that is more ominous has been excluded, persistence of the hydrocele or associated discomfort may indicate the need for surgical intervention.

Patients who have undergone varicocelectomy may be an important exception in which a hydrocele may be of clinical importance. This procedure, usually performed when dilated vessels around the testes are believed to increase intratesticular temperatures, thereby leading or contributing to male infertility, may damage nearby lymphatic vessels. This, in turn, may cause the formation of postvaricocelectomy hydroceles in approximately 7% of patients, potentiating the insulation of the testicle and leading to persistent problems with sperm production. The use of microscopes during this procedure has significantly decreased the incidence of lymphatic obliteration and, therefore, hydrocele formation.

Epidemiology

Frequency

Patent processus vaginalis are found in 80-90% of term male infants at birth. This frequency rate steadily decreases until age 2 years, when it appears to plateau at approximately 25-40%. Indeed, autopsy series of men have identified a frequency rate of 20% of the processus vaginalis remaining patent until late in life. However, clinically apparent scrotal hydroceles are evident in only 6% of term males beyond the newborn period. Certain conditions, such as breech presentation, gestational progestin use, and low birth weight, have been associated with an increased risk of hydroceles. The incidence of hydroceles in men is less well known.

Etiology

The causes of hydroceles are legion. In children, most hydroceles are of the communicating type, in which patency of the processus vaginalis allows peritoneal fluid to flow into the scrotum, particularly during Valsalva maneuvers.

In the adult population, filariasis, a parasitic infection caused by Wuchereria bancrofti, accounts for most causes of hydroceles worldwide, affecting more than 120 million people in more than 73 countries (see Hydrocele, Filarial). However, this condition is virtually nonexistent in the

4

United States, where iatrogenic causes of hydroceles predominate. Following laparoscopic or transplant surgery in males, inadequate irrigation fluid aspiration may cause hydroceles in patients with a patent processus vaginalis or a small hernia. Careful aspiration of fluid at the end of laparoscopic procedures helps prevent this complication. In noncommunicating hydroceles, for both children and adults, the balance between fluid production within the tunica and the fluid absorption is altered.

A few studies have attempted to show a link between certain molecular derangements and an increased incidence of patent processus vaginales (and therefore hydroceles and indirect hernias). Two such examples include increases in maternal estrogen concentrations during pregnancy and abnormalities in the calcitonin gene-related peptide (CGRP) released by the genitofemoral nerve.[2]

Pathophysiology

The pathophysiology of hydroceles requires an imbalance of scrotal fluid production and absorption. This imbalance can be divided further into exogenous fluid sources or intrinsic fluid production.

Alternatively, hydroceles can be divided into those that represent a persistent communication with the abdominal cavity and those that do not. Fluid excesses are from exogenous sources (the abdomen) in communicating hydroceles, whereas noncommunicating hydroceles develop increased scrotal fluid from abnormal intrinsic scrotal fluid shifts.

Communicating hydroceles

With communicating hydroceles, simple Valsalva maneuvers probably account for the classic variation in size during day-sleep cycles. Nonetheless, with the incidence of patent processus so great, why children with clinically apparent hydroceles are relatively few remains somewhat inexplicable. Chronically increased intra-abdominal pressure (eg, as in chronic lung disease) or increased abdominal fluid production (eg, children with ventriculoperitoneal shunts) probably warrants early surgical intervention.

Noncommunicating hydroceles

Noncommunicating hydroceles may result from increased fluid production or impaired fluid absorption. A sudden onset of scrotal hydrocele in older children has been noted after viral illnesses. In such cases, viral-mediated serositis may account for the net increased fluid production. Posttraumatic hydroceles likely occur secondary to increased serosal fluid production due to underlying inflammation. Although rare in the United States, filarial infestations are a classic cause of the decreased lymphatic fluid absorption resulting in hydroceles.

Presentation

Hydroceles typically manifest as a soft nontender fullness within the hemiscrotum. The testis is generally palpable along the posterior aspect of the fluid collection. When the scrotum is investigated with a focused beam of light, the scrotum transilluminates, revealing a homogenous glow, without internal shadows.

The inability to clearly delineate or palpate the testicular structures; the presence of tenderness, fever, or any gastrointestinal symptoms (eg, vomiting, constipation, diarrhea); or the appearance of internal shadows on transillumination should raise the suggestion of a different diagnosis or some additional underlying pathology. Scrotal ultrasonography is the next logical step.

5

Indications

Indications for intervention in hydroceles include the following:

Inability to distinguish from an inguinal hernia Failure of the hydrocele to resolve spontaneously after an appropriate interval of observation Inability to clearly examine testis Association of hydroceles with suggestive pathology (eg, torsion, tumor) Pain or discomfort Male infertility Patient desire

Relevant Anatomy

The developmental anatomy of the inguinal canal is responsible for the genesis of pediatric communicating hydroceles. As the testis descends from the posterolateral genitourinary ridge at the beginning of the third trimester of fetal gestation, a saclike extension of peritoneum descends in concert with the testis. As descent progresses, the sac envelops the testis and epididymis. The result is a serosal-lined tubular communication between the abdomen and the tunica vaginalis of the scrotum.

The peritoneum-derived serosal communication is the processus vaginalis, and the serosa of the hemiscrotum becomes the tunica vaginalis. At term, or within the first 1-2 years of life, the processus vaginalis of the spermatic cord fuses, obliterating the communication between the abdomen and the scrotum. The processus fuses distally as far as the lower epididymal pole and anteriorly to the upper epididymal pole. Failure of complete fusion may result in communicating hydroceles, indirect inguinal hernias, and the bell-clapper deformity of abnormal testicular fixation in the scrotum.[3]

Contraindications

Seemingly, no true absolute contraindications exist for repair of hydroceles. However, given the minimal clinical consequence of the hydrocele itself, any condition that classifies patients as poor surgical or anesthetic risk may be considered a relative contraindication to surgical repair.

Additionally, while a slight majority of pediatric surgeons across North America would repair any communicating hydrocele (somewhat irrespective of age) if it were clearly communicating, waiting until the child is aged 1-2 years is certainly reasonable. Finally, small atrophic testes, or solitary testes, should be approached with great caution to minimize the risk of anorchia

Medical Therapy

Asymptomatic adults with isolated noncommunicating hydroceles can be observed indefinitely or until they become symptomatic, as complications such as infection or testicular compromise are exceedingly rare. However, if the diagnosis is in question or underlying pathology cannot be excluded, operative exploration is warranted.

Lund et al, in a study of 76 patients with hydrocele testis, found that aspiration and sclerotherapy with polidocanol is an effective treatment with a low recurrence rate. In this prospective, double-blind, randomized study, 36 patients given polidocanol (group 1) were compared with 41 patients given placebo (group 2). Recurrence after the first treatment was seen in 16 (44%) of the polidocanol patients and in 32 (78%) of the placebo patients. Recurrence after re-treatment with polidocanol in both groups was seen in four patients (25%) in group 1 and in 14 patients (44%) in the former placebo group. The overall success rate of treatment in group 1 was 89%.[5]

Surgical Therapy

6

Surgical therapy can be divided into three approaches. The first is an inguinal approach with ligation of the processus vaginalis high within the internal inguinal ring and is the procedure of choice for pediatric hydroceles (typically, communicating). If a testicular tumor is identified on testicular ultrasonography, an inguinal approach with high control/ligation of the cord structures is mandated.

In a study by Saka et al, 69 patients with hydrocele underwent either laparoscopic percutaneous extraperitoneal closure (40 patients) or open repair (29 patients), and the safety and efficacy of the two approaches were compared. There were no significant differences in length of operation, anesthesia, or complications for the two procedures; and no recurrences were observed for either procedure.[6]

In addition, the authors reported on the features of the internal inguinal ring (IIR) found in cases of hydrocele and in cases of inguinal hernia treated during the study period. In the cases of hydrocele, 59.1% of the IIRs were narrow patent processus vaginalis (PPV) with a peritoneal veil; for patients with inguinal hernia, 92% of the IIRs were widely opened PPV.[6]

The second is the scrotal approach with excision or eversion and suturing of the tunica vaginalis and is recommended for chronic noncommunicating hydroceles. This approach should be avoided upon any suspicion for underlying malignancy.

The third, an additional adjunctive, if not definitive, procedure, is scrotal aspiration and sclerotherapy of the hemiscrotum using tetracycline or doxycycline solutions. Recurrence after sclerotherapy is common, as is significant pain and epididymal obstruction, making this treatment a last resort in poor surgical candidates with symptomatic hydroceles and in men in whom fertility is no longer an issue.

Preoperative Details

Preoperative considerations are minimal because outpatient treatment is the routine. Nothing by mouth (NPO) provisions are age- and institution-dependent. Proper provisions for postoperative transportation and observation are arranged prior to surgery.

Intraoperative Details

Intraoperative considerations during inguinal repair include meticulous attention to spermatic cord structures. A "no-touch" approach to the reactive testicular vessels and delicate vasa helps minimize complications. Excessive dissection around the testicular vessels may result in thrombophlebitis of the pampiniform plexus. The distal processus is spatulated widely to provide free drainage of scrotal fluid. The proximal processus is ligated above (deep to) the internal inguinal ring. Failure to identify a patent processus during inguinal exploration should prompt (1) a thorough reexamination of the cord structures and (2) partial or complete excision of the hydrocele or needle aspiration of only the hydrocele prior to closing.

During scrotal approaches, excision of redundant tunica vaginalis (with or without eversion) and suturing of the reflected tunica behind the epididymis results in a postoperative testis that is more easily and more reliably examined. Care must be taken to not injure the vas or epididymis during this procedure. A running hemostatic suture around the line of excision is helpful for assuring hemostasis. Plication of the sac (Lord procedure) is another technique useful for management of large hydroceles. Electrocautery fulguration of the edge of the excised tunica vaginalis promotes scarring and decreases recurrence while decreasing operative time.

Unexpected findings may be dealt with, as appropriate, either for the scrotal approach or by converting to an inguinal approach (eg, testicular tumors). If a testicular tumor is encountered,

7

biopsy with frozen section and orchiectomy with resection of the spermatic cord up to the internal ring is warranted if tumor is confirmed. Placing a drain in the dependent portion of the scrotum is prudent for large hydroceles. A nonsuction drain such as a Penrose can be removed within the first 24-48 hours after surgery. If a drain is not used, expect a large hematoma and significant edema. Often, this enlargement is worse than the original problem, although it almost always transient.

Postoperative Details

Children undergoing inguinal herniorrhaphies for repair of communicating hydroceles generally recuperate with minimal discomfort and exceedingly few restrictions. Tub baths are to be avoided for 5-7 days. The wounds of diaper-aged children are sealed with collodion, Dermabond, or occlusive dressing. No activity restrictions are required, and nonnarcotic analgesics are used minimally.

Patients undergoing scrotal approaches benefit from supportive dressings, such as fluff dressings, in a scrotal support or athletic supporter. Rest and avoidance of vigorous activity help minimize discomfort. Showers may be resumed within 24-48 hours. Occasional doses of synthetic or semisynthetic narcotics may help relieve postoperative discomfort. Adult patients should be counseled that the hydrocele may transiently reaccumulate for a month or so postoperatively owing to edema.

Follow-up

At least one postoperative follow-up visit is recommended. For small infants, chronic recurring hydroceles, or patients with unsuspected intraoperative findings, more protracted follow-up evaluations may be warranted biweekly, monthly, or every 2-3 months to ensure complete recovery and normal testicular size and architecture.

Complications

Complications are largely avoided with meticulous dissection and gentle tissue handling. In addition, extensive dissection should be avoided, as it increases the risk for nerve damage, vascular damage leading to testicular atrophy, and postoperative hematomas.

Injury to spermatic cord structures: The vas or testicular vessels may be injured in 1-3% of inguinal approaches. Some testicular shrinkage has been described in nearly 10% of children undergoing inguinal hernia repair.

Recurrence: Recurrence of the hydrocele after inguinal approaches is most often reactive in nature and usually resolves within several months. Rarely, aspiration or scrotal surgery is warranted.

Bleeding/scrotal hematoma: Either poor intraoperative hemostasis or excessive cord dissection (with inguinal approaches) may result in postoperative bleeding. Hematomas typically resolve over time. If the patient has evidence of ongoing bleeding or is extremely symptomatic, exploration and hematoma evacuation is warranted.

Ilioinguinal/genitofemoral nerve injury: These nerves may be entrapped or divided during inguinal approaches. The injury may be temporary or permanent.

Wound infection: Postoperative wound infections are quite uncommon, particularly in children. Wound infections should be managed with antibiotics and, if necessary, opening the wound.

Outcome and Prognosis

Inguinal repairs of communicating hydroceles are exceedingly successful, with a less than 1% recurrence rate. If a unilateral approach is completed, the small but recognized risk for a

8

metachronous hydrocele or inguinal hernia developing remains, but the rate is likely less than 10%. Likewise, recurrence after tunica excision is also uncommon.

Future and Controversies

Recently, many surgeons have begun to advocate routine diagnostic laparoscopy of the contralateral groin in patients (particularly children) with unilateral hernias. The premise is that unsuspected contralateral hernias are repaired prior to clinical recognition. However, many more patent processus are being ligated than true hernias are being repaired. Whether an increased use of this technique will reduce the incidence of hydroceles in older children or adults remains to be seen. Furthermore, whether utilization of this intraoperative modality is of any utility in inguinal hydrocele repairs is open for debate.

Medical management, or, more importantly, prevention of patent processus vaginalis, has been theorized as possible after full elucidation of the intricate molecular processes that control fetal cell migration, proliferation, and adherence. Although the idea of preventing hydroceles or indirect hernias is interesting, it is far from being applicable in clinical medicine.

REFERENCES1. Manjunatha Y, Beeregowda Y, Bhaskaran A. Hydrocele of the canal of Nuck: imaging

findings. Acta Radiol Short Rep. 2012. 1(3). 2. Clarnette TD, Hutson JM. The genitofemoral nerve may link testicular inguinoscrotal

descent with congenital inguinal hernia. Aust N Z J Surg. 1996 Sep. 66(9):612-7.

9

3. Chang YT, Lee JY, Wang JY, Chiou CS, Chang CC. Hydrocele of the spermatic cord in infants and children: its particular characteristics. Urology. 2010 Jul. 76(1):82-6.

4. Clarke S. Pediatric inguinal hernia and hydrocele: an evidence-based review in the era of minimal access surgery. J Laparoendosc Adv Surg Tech A. 2010 Apr. 20(3):305-9.

5. Lund L, Kloster A, Cao T. The long-term efficacy of hydrocele treatment with aspiration and sclerotherapy with polidocanol compared to placebo: a prospective, double-blind, randomized study. J Urol. 2014 May. 191(5):1347-50.

6. Saka R, Okuyama H, Sasaki T, Nose S, Yoneyama C, Tsukada R. Laparoscopic treatment of pediatric hydrocele and the evaluation of the internal inguinal ring. J Laparoendosc Adv Surg Tech A. 2014 Sep. 24(9):664-8.

10