Hydrocele and Varicocele
Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management
Definition
- Hydrocele: a collection of fluid within the tunica vaginalis surrounding the testis, leading to scrotal swelling.
- Varicocele: abnormal dilatation of the pampiniform venous plexus, usually in the left scrotum, due to venous reflux.
Aetiology
Hydrocele:
- Congenital (Communicating Hydrocele): patent processus vaginalis allows peritoneal fluid to enter the scrotum.
- Acquired (Non-Communicating Hydrocele): imbalance between fluid production and absorption, often secondary to trauma, infection, or malignancy.
Varicocele:
- Primary: due to incompetent valves in the spermatic veins, causing venous reflux (common on the left side).
- Secondary: compression of the renal vein or spermatic vein by a mass (e.g., renal carcinoma).
Pathophysiology
Hydrocele:
- Increased fluid production or impaired drainage leads to fluid accumulation.
- Communicating hydroceles persist due to patent processus vaginalis.
- Non communicating hydroceles occur due to local inflammation or lymphatic dysfunction.
Varicocele:
- Failure of venous valves leads to blood pooling and venous congestion.
- Increased scrotal temperature affects spermatogenesis, potentially causing infertility.
Risk Factors
- Prematurity (hydrocele).
- Previous scrotal surgery.
- Testicular trauma.
- Renal tumours (varicocele due to compression of veins).
- Chronic venous insufficiency (varicocele).
Signs and Symptoms
Hydrocele:
- Painless scrotal swelling: gradual enlargement.
- Transillumination positive: light passes through the fluid-filled sac.
- Fluctuant mass: non tender, soft cystic swelling.
Varicocele:
- Bag of worms appearance: dilated veins in the scrotum, more prominent when standing.
- Scrotal heaviness or discomfort: worsens after prolonged standing.
- Testicular atrophy: possible in longstanding varicocele.
- Infertility: due to impaired sperm production.
Investigations
Hydrocele:
- Clinical examination: transillumination test positive.
- Scrotal ultrasound: confirms fluid accumulation and excludes underlying pathology.
Varicocele:
- Clinical examination: "bag of worms" appearance, reduces when lying down.
- Scrotal ultrasound with Doppler: confirms venous reflux.
- Renal ultrasound: if varicocele is sudden or right-sided, to exclude renal mass.
- Semen analysis: if infertility is a concern.
Management
Hydrocele:
- Observation: most congenital hydroceles resolve by age 1–2 years.
- Aspiration and sclerotherapy: temporary relief but high recurrence rate.
- Surgical repair (Hydrocelectomy): indicated if large, symptomatic, or persistent beyond age 2.
Varicocele:
- Observation: asymptomatic cases often require no intervention.
- Scrotal support and NSAIDs: for mild discomfort.
- Varicocelectomy: indicated for infertility, significant testicular atrophy, or persistent symptoms.
- Embolisation: an alternative to surgery, especially in recurrent varicocele.
Complication Management:
- Monitor for secondary infection (hydrocele).
- Evaluate persistent or rapid-onset varicocele for malignancy.
- Regular follow-up for patients with fertility concerns.