Recurrent hydrocoele.

Hydrocele is a common cause of scrotal swelling in general practice and is caused by a patent space in the tunica vaginalis. Treatment is often conservative unless the hydrocele grows to a critical size that leads to discomfort or difficulty in walking, in which case drainage is necessary. Depending on the communication of the tunica vaginalis with the peritoneal cavity and other coexistent morbidities, hydrocoele may recur despite repeated drainage posing a problem to management in general practice. We hereby presented a 72-year male with a huge hydrocoele that recurred despite repeated drainage and hernia sac repair, arousing thoughts on this subject and discussions as to the most appropriate management.

Introduction

Hydrocoele occurs when there is abnormal accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis that surround the testicle. In adults and adolescents, hydrocoele is an acquired condition. Its etiology is largely unknown but it is speculated that there is imbalance between fluid production and absorption in the serous membranes of the tunica. Clinically most hydrocoeles are asymptomatic, presenting as painless scrotal swellings. No intervention is necessary unless the hydrocoele reaches a critical size that leads to awkwardness or pain in walking, in which case drainage can be done in general practice settings. Most often than not, the problem will be settled. Thus said, hydrocoeles can be recurrent despite recurrent drainage, where pathological conditions like hypoproteinemia, filarial infections, or pelvic cavity malignancies have to be excluded. If the cause of recurrent hydrocoele remains idiopathic, surgical procedures like sclerotherapy or hydrocoelectomy can be considered as definitive treatment.

Case Report

GP is a 72-year old man with massive recurrent hydrocoele of his right scrotum. The first episode occurred 4 years ago which he did not notice until the scrotal swelling made walking difficult. He presented to his family doctor who aspirated 480 cc of straw-color fluid. However the problem recurred 5 more times over the next 48 months despite needle aspiration. Repeated ultrasound and magnetic resonance imaging of his pelvis and abdomen had not revealed any specific pathology or obstructive mass that could explain this recurrent lesion. Moreover, bacterial culture, malignant cytology and acid fast bacilli staining had been performed on three of the six previous aspirates, which were all negative. The smallest amount of fluid drained was 400 cc and the largest amount was from the most recent visit (640 cc) [Figure 1]. Patient suffered from multiple comorbidities including hypertension, dyslipidemia, atrial fibrillation, congestive heart failure, generalized epilepsy, and benign prostatic hypertrophy. Past medical history included repaired aortic artery dissection, pneumothorax, transient ischemic attacks, thromboembolism and subarachnoid hemorrhage. Patient is a 60 pack-year smoker with problem of alcohol abuse. He is on disability and lives alone with poor social and family support. He takes a diuretic for his hypertension but there was no previous history of proteinuria. Surgical consult pointed to a patent hernia sac as the contributing cause of the recurrent hydrocoele. Mesh repair of right inguinal hernia was performed six months ago but the hydrocoele recurred shortly afterwards. Further surgical options including resection, eversion orhydrocoelectomy had been considered but were considered as less favorable in view of the co-existing comorbidities of the patient. A primary or metastatic source of malignancy remained on the list of differentials but could not be excluded. The recurrent hydrocoele would never bothered the patient except when it reached a size that he could not walk smoothly.

Figure 1

(a) Right hydrocoele before 640 ml of straw colored fluid removed (b) Straw colored fluid removed with significant deflation of scrotum

Discussion

Hydrocoeles are painless enlargements of the scrotum and occur when fluid from the peritoneum fills the potential space between the parietal and visceral layers of the tunica vaginalis [Figure 2]. Embryologically, the visceral layer of tunica vaginalis originates from the peritoneum of the abdomen and encompasses the anterior two thirds of the testicle, forming a potential space which is a continuum of the intra-abdominal cavity. Primary hydrocoeles occur as a result of an imbalance of secretion and absorption of fluid inside the tunica vaginalis or the abdomen. Very often, primary hydrocoeles are associated with inguinal hernias. Secondary hydrocoeles are caused by trauma, infection, or neoplastic processes, and yet most hydrocoeles are idiopathic. Neoplasms may include rhabdomyosarcoma (most common), mesothelioma, adenocarcinoma, or neuroblastoma. Clinically, hydrocoeles are differentiated from other scrotal swellings by its cystic nature, brilliant trans-illumination absence of a cough impulse. The gold standard for diagnosis is scrotal ultrasound. Treatment for recurrent hydrocoele includes aspiration followed by sclerotherapy (using phenol,[1] tetracycline,[2] or sodium tetradecylsulfate[3]) or hydrocoelectomy.[4] Hydrocoelectomy, although more invasive and costly, has been shown to have higher success rates, improved outcomes and patient satisfaction as compared with other form of sclerotherapy.[356] In our case, medical and malignant causes for the recurrence of the massive hydrocoele had been exclude, and concurrent inguinal hernia was initially thought to be the culprit. However, after successful repair of the hernia, prompt return of the massive hydrocoele had surprised the management team which led us to consider sclerotherapy or hydrocoelectomy as the next curative procedure.

Figure 2

Anatomical similarities between a complete inguinal hernia and a communicating hydrocoele