History

Fact Explanation
Swelling in the scrotum Due to abnormal collection of serous fluid within tunica vaginalis. [1]
Pain and discomfort Very rare. If present, is more suggestive of a secondary cause such as a tumour or epididymo-orchitis. [2]
References
  1. BAILEY & LOVE. Short practice of surgery. 26th ed. London: CRC press Taylor & Francis Group, 2013 pg 1382
  2. BROWSE, Normen L. Browse's introduction to the symptoms and signs of surgical disease. 4th ed. London: Hodder Arnold, 2005. pg 347

Examination

Fact Explanation
Uniformly enlarged scrotum with impalpable testis Swelling is due to abnormal collection of serous fluid within the tunica vaginalis. The testis is impalpable as it is surrounded by fluid. An impalpable testis is the cardinal physical sign that distinguishes hydrocele from an epididymal cyst. [1] But in an encysted hydrocele of the cord the testis and the cord can be palpated separately.[3]
Fluctuant Hydrocele fluctuates as it contains fluid. If large enough a fluid thrill may be elicited. [1]
Transilluminant Because it contains yellow clear fluid. However, chronic hydroceles tends to transilluminate less due to calcification of sac. [1]
Distinct from superficial inguinal ring Therefore can "get above the mass" on palpation. This helps to differentiate hydrocele from inguinal hernia. [2] But a congenital hydrocele can extend in to the superficial inguinal ring.[3]
Composition Can be lax or tense according to the pressure of the contained fluid.[1]
References
  1. BROWSE, Normen L. Browse's introduction to the symptoms and signs of surgical disease. 4th ed. London: Hodder Arnold, 2005. pg 347
  2. RAMACHANDRAN, Manoj. POOLE, Adam. Clinical cases and OSCEs in surgery.1st ed. London: Churchill Livingstone, 2008 pg 130-132
  3. PALMER L. S.. Hernias and Hydroceles. Pediatrics in Review [online] December, 34(10):457-464 [viewed 09 March 2014] Available from: doi:10.1542/pir.34-10-457

Differential Diagnoses

Fact Explanation
Epididymal cyst This represents cystic degeneration of the epididymis. The lump is brilliantly transilluminable and separately palpable from the testis. [1]
Indirect Inguino scrotal hernia Inguinal hernia can present as a scrotal lump. Although most of them are asymptomatic, some can present with groin pain or a dragging sensation. Pain may worsen with Valsalva manoeuvre. [2] On examination, an inguinal hernia can be differentiated from a hydrocele by being unable to "get above the lump". [1]
Hematocele Can occur due to acute hemorrhage into tunica vaginalis following testicular trauma. May also result from vessel damage during needle drainage of a hydrocele. This will be associated with pain, tenderness and reduced transillumination. [1]
Testicular carcinoma Testicular carcinoma may present as a painless testicular lump. It is one of the most common cancers in young men with an average patient age of 32 years. Hydrocele may accompany testicular carcinoma. On examination detection of supraclavicular and para-aortic masses are highly suggestive of testicular carcinoma. [3]
Spermatocele Spermatoceles are cystic dilatations of the efferent ductules of the epididymis which contain sperms. Most spermatoceles are painless and < 1 cm in diameter. A spermatocele often lies on the posterolateral aspect of the testis.[4]
References
  1. BAILEY & LOVE. Short practice of surgery. 26th ed. London: CRC press Taylor & Francis Group, 2013. pg 1382
  2. LeBLANC,Kim Edward. , LeBLANC, Leanne L. , LeBLANC, Karl A. Inguinal Hernias: Diagnosis and Management. American Family Physician. 2013,87(12), 844-848. [viewed 06/03/2014] available from http://www.aafp.org/afp/2013/0615/p844.html
  3. JENNIFER JUNNILA, PATRICK LASSEN. Testicular Masses. American Family Physician.1998,57(4), 685-692. [viewed 06/03/2014] available from http://www.aafp.org/afp/1998/0215/p685.html
  4. YEH H.C., WANG C.J., LIU C.C., WU W.J., CHOU Y.H., HUANG C.H. Giant Spermatocele Mimicking Hydrocele: A Case Report. Kaohsiung Journal of Medical Sciences.2007, 23 (7), 366-369 [viewed 06/03/2014] available from http://www.kjms-online.com

Investigations - for Diagnosis

Fact Explanation
Ultrasound examination of the scrotum To confirm the hydrocele.[1] To differentiate between intratesticular lesions such as a testicular carcinoma from extratesticular lesions. [2] For prenatal diagnosis of congenital hydrocele. [3]
Tumour markers - AFP, beta hCG and LDH levels To exclude testicular carcinoma[4]
Diagnostic aspiration SHOULD BE AVOIDED, as it may lead to implantation of malignant cells along the needle tract. [5]
References
  1. BAILEY & LOVE. Short practice of surgery. 26th ed. London: CRC press Taylor & Francis Group, 2013 pg 1382
  2. D’ANDREA, A., COPPOLINO, F., CESARANO, E.,RUSSO, A., CAPPABIANCA, S., GENOVESE, E.A., FONIO, P., MACARINI, L. US in the assessment of acute scrotum. Crit Ultrasound Journal. 2013, 5 [viewed on 06/03/14] available from www.ncbi.nlm.nih.gov/pmc/articles/PMC3711727/
  3. MASSARO,G. , SGLAVO,G. , CAVALLARO,A. , PASTORE,G. , NAPPI,C. , Di CARLO,C. . Ultrasound Prenatal Diagnosis of Inguinal Scrotal Hernia and Contralateral Hydrocele. Case Reports in Obstetrics and Gynecology, 2013 [viewed on 06/03/2014] available via http://www.hindawi.com/journals/criog/2013/764579/
  4. JENNIFER JUNNILA, PATRICK LASSEN. Testicular Masses. American Family Physician.1998,57(4),685-692. [viewed 06/03/2014] available from http://www.aafp.org/afp/1998/0215/p685.html
  5. RUCHITA TYAGI, PRANAB DEY. Needle tract seeding: An avoidable complication. Diagnostic Clinicopathology. 2014 [viewed on 07/03/2014] available from http://www.onlinelibrary.wiley.com/doi/10.1002/dc.23137/full

Investigations - Fitness for Management

Fact Explanation
ECG Usually required in anyone over the age of 65 or in patients with a history of cardiovascular, pulmonary or anesthetic complications in order to assess their cardiorespiratory reserve. [1]
Full blood count To assess the hemoglobin count, as an indicator for fitness for surgery. [1]
Urea and electrolytes Usually required in anyone over the age of 65 or in those taking regular diuretics. [1]
References
  1. BAILEY & LOVE. Short practice of surgery. 26th ed. London: CRC press Taylor & Francis Group, 2013 pg 231

Investigations - Followup

Fact Explanation
Ultrasound examination of the scrotum To detect formation of hematocele following needle aspiration or to detect recurrent hydrocele. [1]
References
  1. BAILEY & LOVE. Short practice of surgery. 26th ed. London: CRC press Taylor & Francis Group, 2013 pg1382

Management - General Measures

Fact Explanation
Assess and optimize co-morbid conditions To reduce surgical and anesthetic complications. [1]
References
  1. BAILEY & LOVE. Short practice of surgery. 26th ed. London: CRC press Taylor & Francis Group, 2013 pg.1382

Management - Specific Treatments

Fact Explanation
Watchful waiting A small hydrocele may require no treatment other than reassurance. [1]
Cannula drainage This will relieve the symptoms, but tends to re-accumulate. Thus it is suitable for patients who are unfit for scrotal surgery. [2]
Aspiration followed by sclerotherapy Sclerosants such as phenol, tetracycline or sodium tetradecylsulfate are injected following aspiration. Useful in treating recurrent hydroceles. [3]
Surgical Management - Lord's operation Suitable when the sac is reasonably thin walled.[2]
Surgical Management - Jaboulay's procedure Evertion of the sac with placement of the testis in a pouch prepared by dissection in the fascial planes of the scrotum. [2]
References
  1. RAMACHANDRAN, Manoj. POOLE, Adam. Clinical cases and OSCEs in surgery.1st ed. London: Churchill Livingstone, 2008 pg 130-132
  2. BAILEY & LOVE. Short practice of surgery. 26th ed. London: CRC press Taylor & Francis Group, 2013 pg 1382
  3. PARKS, K. , LEUNG, L. Recurrent hydrocoele. Journal of Family Medicine and Primary Care- Official Publication of Family Physicians of India. 2013, 2 (1), 109-110 [viewed on 06/03/2014] available from http://www.jfmpc.com