|Year : 2004 | Volume
| Issue : 2 | Page : 109-112
Effect of tropical vaginal hydroceles on testicular morphology and histology
C Srinath1, N Ananthakrishnan1, S Lakshmanan2, Vikram Kate1
1 Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
2 Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Department of Surgery, JIPMER, Pondicherry - 605 006
| Abstract|| |
Objectives : Currently data on the effect of long standing hydrocele on the testis is contradictory. A study was carried out to evaluate whether vaginal hydroceles affect testicular morphology andd histology.
Methods : Twenty-five patients with unilateral vaginal hydroceles were prospectively studied. The morphology and histology of the affected testis was studied and compared with the opposite unaffected testis.
Results : It was found that unilateral hydroceles did not affect ipsilateral scrotal temperature or the ipsilateral testicular volume. Histologically there was marked thickening of the tunica albugenia and the basement membrane on the affected side. There was distortion of the seminiferous tubules arrangement with marked intertubular edema. There was also significant reduction in the total seminiferous cell count on the affected side due primarily to a decrease in spermatids. There was premature sloughing of the spermatogenic cells into the lumen of the tubules. .None of these changes correlated with the duration of the hydrocele, volume of the hydrocele fluid or intratunica vaginalis pressure.
Conclusions : It is concluded that vaginal hydroceles significantly affect the morphology of the testis by causing reduction in the number of seminiferous tubules primarily spermatids besides producing changes in the structure and arrangement of the seminiferous tubules. It is not known whether these changes are reversible with treatment of the hydrocele.
Keywords: Hydrocele, testicular histology, sperm count, testosterone.
|How to cite this article:|
Srinath C, Ananthakrishnan N, Lakshmanan S, Kate V. Effect of tropical vaginal hydroceles on testicular morphology and histology. Indian J Urol 2004;20:109-12
|How to cite this URL:|
Srinath C, Ananthakrishnan N, Lakshmanan S, Kate V. Effect of tropical vaginal hydroceles on testicular morphology and histology. Indian J Urol [serial online] 2004 [cited 2013 Jun 18];20:109-12. Available from: http://www.indianjurol.com/text.asp?2004/20/2/109/21523
| Introduction|| |
Vaginal hydroceles are common in young adults in tropical countries particularly in areas endemic for lymphatic filariasis. Often these hydroceles are large and tense and exert considerable hydrostatic pressure on the enveloped testis. The intratunica vaginalis pressure frequently exceeds venous pressure and it is likely that a large hydrocele may compromise the venous drainage from the ipsilateral testis. Simultaneously, stretching of the dartos muscle results in loss of its contractility and thereby its ability to contract and alter the testicular position which is considered important in the thermoregulation of the testis. It is likely therefore, that these combined effects of a tense vaginal hydrocele may affect testicular morphology and histology and perhaps its function. Such and effect, if proved, would strongly call, for early surgical treatment of vaginal hydroceles especially in young men.
This is especially important since WHO has embarked on a global programme on control of lymphatic filariasis, the twin pillars of which are mass drug administration to reduce transmission and morbidity management. This latter particularly refers to lymphedema and hydrocele, which account for the bulk of the morbidity.
Studies that critically evaluate the effects of vaginal hydrocele on the testis are contradictory. These studies do not have controls or lack all necessary data such as size of hydrocele and intratunica pressure besides being qualitative and lacking in quantitative serological data. Some authors have found that hydroceles have no effect on testicular morphology ,, while others have described various changes. , At present, the subject remains controversial. We, therefore, undertook to comprehensively evaluate testicular morphology and histology in patients with unilateral vaginal hydroceles and to correlate the changes, if any, with the parameters such as duration of hydrocele, volume of hydrocele fluid and intratunica vaginalis pressure. The opposite unaffected testis served as a histological control.
| Patients and Methods|| |
Twenty-five young men with unilateral vaginal hydroceles were studied. A detailed history and clinical workup was done. All patients with associated inguinal hernia, varicocele, diabetes or history of mumps in childhood were excluded. Informed consent was obtained for testicular biopsy and ethical clearance was obtained from the Institute's Research Council.
Scrotal skin temperature was measured on both sides of the scrotum separately with a digital thermometer before shaving the part for surgery. All patients underwent eversion of the hydrocele sac on the affected side as the surgical treatment. The intratunica vaginalis pressure and the volume of the hydrocele fluid were measured at the time of surgery. The intratunica vaginalis pressure was measured using an 18 G needle, which was introduced into the hydrocele sac and connected to a manometer filled with saline. Readings were taken with the zero at the level of the pubic symphysis. The testicular length and width were measured with calipers after the testes were delivered out through the incision in the scrotum, and the testicular volume was computed using the formula, volume = π/6 LW 2 , where L is the length of the testis in cm and W the width. p was taken as 3.14.  A bilateral testicular biopsy with a strip of tunica albugenia measuring 6 x 4 mm was carried out. The tissue was fixed in Bouins's fluid and stained with hematoxylin and eosin.
Quantitative assessment of the testicular biopsy was carried out by point count using an eyepiece line grid. The proportionate volume of the seminiferous tubules, intertubular area and blood vessels was estimated using the stereological formula V 1 = P1 /Pt where, V 1 is the volume of that particular histological structure in question per cubic unit, P1 is the number of points against that particular histological structure and Pt is the total number of points in the line grid taken into consideration. 
The circumference of the seminiferous tubules was calculated using a micrometer for noting the longest (dl) and the shortest (d2) diameters of the seminiferous tubules in histological sections. Only the circular or more or less circular tubules in the section were taken into consideration. The circumference was computed applying the formulae 2π(dl+d2)/4.  Twenty-five random seminiferous tubules were evaluated and the total number of seminiferous cells and percentage of spermatogonia, spermatocytes and spermatids were noted per unit circumference. A length of 1000 m was considered as a unit. The data collected was analyzed using the student t test. A probability value of 5% (p<0.05) was taken as significant. No attempt was made to study sperm counts or testicular endocrine function as the study included only patients with unilateral hydrocele.
| Results|| |
The age of patients ranged from 27-48 years (mean 36 years). The duration of hydroceles varies form 1-10 years (mean 4.1 years). The volume of the hydrocele fluid ranged form 200 to 1350 ml with a mean of 520 ml. Eleven of the 25 patients had fluid volumes in excess of 500 ml. The intratunica vaginalis pressure on the side of the hydrocele varied from 11 to 51 cm saline. In as many as 11 patients the pressure exceeded 30 cm of saline.
On an average the scrotal temperature was 3°C less than the axillary temperature and there was no significant difference between the temperatures on the side of hydrocele as compared to the normal side (mean temperature on the affected side was 33.9±0.3°C and on the normal side was 33.9±0.4°C). The volume of the testis on the side of the hydrocele was larger than the opposite side in 17 patients and less than normal in the remaining eight (mean testicular volume on the affected side was 24.0±11.6 ml and on the normal side it was 21.0±9.2 ml). This difference was not statistically significant.
The tunica albugenia of the affected testis was markedly thickened in all patients. There was a distortion of the shape of the seminiferous tubules and the tubules were separated from each other [Figure - 1]. The basement membrane was thickened. Sertoli and Leydig cells were unaffected.
In addition, the testis on the side of the hydrocele showed marked sloughing of spermatogenic cells in division, i.e. pachytene, leptotene and diplotene type of spermatocytes and spermatids from the cells of Sertoli indicating premature release of spermatogenic cells from seminiferous tubules. There was no interstitial fibrosis. These changes , are shown in [Figure - 1].
There was a significant increase in the proportionate volume of the intertubular area and significant reduction in the volume of the seminiferous tubules in the affected testis as compared to the control [Figure - 2] [Table - 1]. There was no significant difference seen for the volume occupied by blood vessels between the two sides showing thereby that the increased intertubular volume is due to venous dilatation consequent by the high intratunica pressure or due to proliferation of blood vessels.
The total seminiferous cell count per 1000 m circumference of seminiferous epithelium was significantly decreased in the affected testis. It as 941.0+138.6 in the affected testis compared to 1106.4±192.1 within the normal testis (p<0.01). The reduction in the germ cell counts in the affected testis was primarily due to reduction in the number of spermatids [Table - 2].
These histological changes did not correlate with the duration of hydrocele, the volume of hydrocele fluid or the intratunica vaginalis pressure [Table - 3].
| Discussion|| |
Local pathophysiological alterations of the testicular milleu have a negative effect on fertility. Such effects have been demonstrated in patients with varicoceles. These include various degrees of oligospermia and histopathological changes such as decreased spermatogenesis. spermatogenic arrest at the primary spermatocyte stage, premature germ cell sloughing with abnormal forms, degeneration of the adluminal sertoli cell compartment, Leydig cell hyperplasia and small vessel fibrosis with luminal narrowing. ,, Such detailed studies on the effects of hydrocele on testis are scanty and contradictory.
In the present study, we found the testis in all patients to be of normal consistency with no evidence of atrophy. Testicular atrophy was found in 8% of patients reported by Dandapat et al.  The slight but insignificant increase in testicular size on affected side is probably due to thickening of the tunica albugenia. The scrotal temperature was unchanged on the side of the hydrocele as reported earlier. 
Qualitatively, the present study showed that the tunica albugenia was thickened in all the patients. Dandapat et al reported this finding in 85% of their patients. Basement membrane thickening was seen in all our patients. This finding was observed in 25%,  87%  and 78%  of patients in other studies. Interstitial fibrosis was not seen by us. Sertoli cells More Details and Leydig cells were normal; a fact in agreement with other reports.  Quantitatively, there was an increase in the intertubular area due to interstitial edema. The mean germ cell count per unit circumference was significantly decreased in patients with hydrocele. This reduction in germ cell count was primarily due to decrease in the spermatids, which are more sensitive to a vascular insult. Quantitative evaluation of testicular biopsy in patients with hydrocele using stereological formulae used by us has not been reported earlier. Also it is necessary in view of marked variations in the histology of the testis to use the patients own opposite testis as control.
| Conclusions|| |
Large and tense vaginal hydroceles significantly affect the morphology and histology of the testis. The testis appears to protect itself against an increased ambient pressure by a thickening of the tunica albugenia. However, this is not sufficient to protect the seminiferous tubules form distortion. There is no relationship between any of these alterations and the size of the duration of hydrocele. It is not known at present whether these changes revert to normal with treatment of the hydrocele as ethical considerations preclude a repeat testicular biopsy sometime after treatment of the hydrocele for recording the fact. However, the fact that such changes occur is a strong argument for advising surgical treatment of all hydroceles particularly in men in the reproductive age group.
| References|| |
|1.||Bhatnagar BNS, Dube B, Shukla AP. Testicular histology in tropical vaginal hydroceles. Int Surg 1970; 57:167-70. |
|2.||Krahn HD, Tessler AN, Hotchhiss RS. Studies of the effect of hydrocele upon scrotal temperature, pressure and testicular morphology. Fertil Steril 1963; 14:226-28. |
|3.||Shiu MH, Van Langenberg A. Adult vaginal hydrocele in Hongkong, a study of 25 cases. J R Coll Surg Edinb 1967; 14:56-61. |
|4.||Dandapat MC, Padhi NC, Patra AP. Effect of hydrocele on testis and spermatogenesis. Br J Surg 1990; 77: 1293-94. [PUBMED] |
|5.||Dedhia MC, Rao SS, Prabhu SR. Role of filariasis in the etiology of idiopathic hydroceles. Indian J Surg 1982; 44: 161-68 |
|6.||Scott AR, Hall Ad, Beepole PA, Crawford JD. Accuracy and reproducibility of clinical measures of testicular volume. J Pediatr 1987; 110: 914-16. |
|7.||Hans E, Hyde DM. An elementary introduction to sterology (quantitative microscopy) Am J Anat 1980; 159: 412. |
|8.||Andres TE, Trainer TD, lapenas DT. Small vessel alterations in the testis of infertile men with varicocele. Am J Clin Pathol 1981; 76: 378-84. |
|9.||Etriby A, Grigis SM, Henowy H, Ibrahim AA. Testicular changes in subfertile men with varicocele. Fertil Steril 1967; 18: 666-71. |
|10.||Jones MA, Gregorly HS, Trainer TD. The adolescent varicocele - a histopathologic study of 13 testicular biopsies. Am J Clin Pathol 1988; 89: 321-28. |
|11.||Saifee IA, Kukreti SC, Godbole VK. Effect of vaginal hydrocele on spermatogenesis. Indian J Surg 1980; 42: 130-33. |
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3]