SCROTAL HYDROCOELE

Scrotal hydrocoele is an abnormal accumulation of fluid in the tunica vaginalis sac (Figure 9.41). The swelling that results is often enormous and usually uncomfortable. In adults, the hydrocoele fluid is located entirely within the scrotum; the surgical treatment is straightforward and can be performed by a non specialist.

Diagnosis

Palpation will confirm that the swelling is scrotal; it will be soft or tense, fluctuant and may mask the testis and epididymis. Lymphoedema of the scrotum is characterized by thickened skin.

Treatment

Aspiration is not recommended, as the relief is only temporary and repeated aspirations risk infection. Injection of sclerosants is not recommended, as it is painful and, although inflammation is reduced, it does not effect a cure.
Surgery is the most effective treatment.

Of the various alternative operations, eversion of the tunica vaginalis is the simplest, although recurrences are still possible.

Wash the scrotal skin and treat any lesions, for example wounds made by traditional healers, with saline dressings. The presence of skin lesions is not a contraindication to surgical treatment, so long as there are healthy granulations with little or no infection.

Technique

1	Perform the procedure with local infiltrate, spinal or general anaesthesia. Prepare the skin widely with antiseptic. Place a sterile towel under the scrotum (Figure 9.42); elevating the scrotum with tissue forceps will facilitate this. Stand on the side of the lesion.
Figure 9.42
2	Press on the hydrocele to render it tense, make an oblique incision over the hydrocele in a skin crease (Figure 9.43) or in the midline, which is less haemorrhagic. Continue incising through the layers of the scrotal wall down to the tunica vaginalis. This is normally recognized by a lattice of fine blood vessels in a thin, translucent membrane unless the membrane has been thickened by previous infection or trauma. Ligate all vessels encountered with 2/0 absorbable suture (Figure 9.44).
Figure 9.43
Figure 9.44
3	By means of blunt dissection with scissors, find a plane of cleavage between the sac and the fibrous coverings. With gauze and scissors, continue separation to the termination of the spermatic cord where it is attached to the hydrocele (Figures 9.45, 9.46). If the sac is inadvertently opened, catch the edges of the opening with forceps and introduce a finger into the sac to stretch it and the overlying tissues as an aid in dissection. Puncture the sac and collect the fluid in a dish (Figure 9.47). Catch the edge of the hole with forceps and, after making sure that the epididymis is not adherent to its posterior surface, slit the sac vertically with scissors (Figure 9.48).
Figure 9.45
Figure 9.46
Figure 9.47
4	Evert the testis and the epididymis through the hole and inspect them for tuberculosis, schistosomiasis and cancer. If cancer is present, do not return the testicle to the scrotum. Clamp and divide the cord structures and remove the testis. Biopsy the testicle, then refer the patient if tuberculosis or schistosomiasis is suspected. Reunite the edges of the everted sac behind the cord and epididymis with a few interrupted stitches of 2/0 absorbable suture (Figure 9.49). Maintain careful haemostasis throughout; it is important to stop even the slightest bleeding to minimize the risk of haematoma formation. Insert a latex drain, bringing it out inferiorly through a counter incision, and fix it to the skin with a stitch (Figure 9.50, 9.51).
Figure 9.49
Figure 9.50
Figure 9.51
5	Replace the testis and the cord. Close the dartos muscle with interrupted 2/0 absorbable suture and the skin with interrupted 2/0 non-absorbable suture (Figure 9.52, 9.53). Apply a compression dressing of gauze and then a T-bandage.
Figure 9.52
Figure 9.53

Aftercare

Support the scrotum in an elevated position. Remove the drain after 24–48 hours.

Complications

Possible complications include haematoma formation, infection and recurrence. If haematoma develops despite every care having been taken to stop bleeding during surgery, remove a few stitches from the wound, open the edges with a pair of large artery forceps and express the clots from the wound. This procedure may need to be repeated over several days. Antibiotics do not always prevent infection; if it does occur, give appropriate antibiotic therapy and drain the wound. Even with treatment, however, an infection may take up to 2 months to clear.