HYDROCELE, SPERMATOCELE
A hydrocele is an accumulation of serous fluid greater in amount than the
amount normally present between the parietal and visceral testis tunica
vaginalis layers. As the testis descends (see Plate 3-5) from the
retroperitoneum to the scrotum, it carries with it two layers of peritoneum.
Abnormalities of these coverings and of the processus vaginalis communicating
with the peritoneal cavity may lead to several kinds of hydrocele. The most
common type is simple hydrocele, in which the normally formed tunica vaginalis
is distended with fluid. In infantile hydrocele, the fingerlike processus
vaginalis fails to close and extends upward to the upper scrotum or inguinal
canal but does not communicate with the peritoneal cavity. In congenital or
communicating hydrocele, with or without hernia, a lumen in the processus
vaginalis permits communication with the abdominal cavity, so that bowel and
peritoneal fluid may extend to the scrotum and hydrocele fluid may reach the
peritoneal cavity. Congenital hydrocele may or may not be associated with
descent of the bowel and inguinal hernia.
Hydrocele of the cord occurs
as a localized collection of fluid in an encysted sac of peritoneum within the
spermatic cord. It does not communicate with either the tunica vaginalis space
below or the peritoneum above. Hernial hydrocele (not illustrated) is an
accumulation of fluid within the tunica vaginalis as a result of a limited
projection of the processus vaginalis from the peritoneal cavity inferiorly
into the scrotum. However, the hernia pouch terminates before reaching the
tunica vaginalis and does not communicate with it. Usually, neither bowel nor
omentum is present in the sac, and the hydrocele fluid in the sac can be pressed
back into the peritoneum. Rare types of localized hydroceles can also occur,
involving either a portion of the epididymis or the testis. Acute hydrocele is
usually secondary to trauma, tumors, or underlying infection of the testicle or
epididymis. Chronic hydrocele may be the end result of the acute form, but in
many cases no history of an acute phase exists, nor are underlying diseases
found, in which case it is termed idiopathic hydrocele. Hydroceles can
follow trauma and occur after inguinal herniorrhaphy, varicocele ligation, or
other retroperitoneal surgery that blocks lymphatic
flow through the spermatic cord.
Hydrocele fluid is generally
straw-colored and odorless and resembles serum. In acute cases, the fluid may be
fibrinous, bloody, or even purulent. The parietal layer of the tunica vaginalis
is usually thin, but it may become thickened and even calcified in chronic
cases. Hydroceles are generally situated anterior to the testicle, which it
displaces posteriorly in the scrotal cavity. Hydroceles should be
differentiated from hernia, testicle tumors, hematocele, and spermatocele.
Transillumination of the scrotum should reveal a “glowing” fluid sac with
hydrocele. Aspiration of the hydrocele fluid for cytologic or chemical
assessment should only be performed when coexistence of hernia has been
excluded. The treatment is watchful waiting, repeated needle aspirations (as
the fluid recurs quickly), or operative excision of the parietal tunica
vaginalis. Aspiration followed by injection of sclerosing solutions is not as
effective as tunica vaginalis excision. In long-standing hydroceles in which
the tunica has become thick, some degree of testicular atrophy may result from
chronic pressure.
A spermatocele is an
intrascrotal cystic mass resulting from partial obstruction or diverticula of
the efferent ductule system near the caput epididymis (see Plate 3-3). When
small, they can be confused with epididymal cysts (which generally remain
small) and appendices of the
testis and epididymis, but
these latter structures do not contain sperm, unlike spermatoceles. The cyst is
lined by pseudostratified epithelium and contains turbid, milky fluid, with
immotile sperm and lipid granules. On palpation, spermatoceles appear as a
round mass distinct from the testis, with a narrower “waist” between the testis
and the cyst attached to it. Spermatoceles are located within the tunica
vaginalis space, but an extra-vaginal variety can occur that lies posterior to
the testis. Spermatocele and hydrocele can occur concomitantly, in which case the former remains unrecognized unless the fluid is observed
on aspiration. Most spermatoceles are asymptomatic, except for a slight
dragging sensation in the scrotum due to a “mass effect.” Spermatoceles tend to
become symptomatic when they enlarge to the size of a normal 20-mL testis.
Excision is the treatment of choice and should be only judiciously considered
in reproductive-age men, as scarring in the epididymal bed of the excised
lesion could obstruct the remaining efferent ducts and lead to duct obstruction
and infertility.
