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REVIEW ARTICLES |
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| Year : 2005 | Volume
: 21
| Issue : 1 | Page : 35-38 |
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Surgery for vaginal hydroceles: an update
N Ananthakrishnan1, SP Pani2
1 Jawaharlal Institute of Medical Education, Research,Pondicherry,Tamil Nadu, India
2 Vector Control Research Centre (ICMR), Pondicherry,Tamil Nadu, India
Correspondence Address:
S P Pani
Vector Control Research Centre (ICMR),Pondicherry - 605 006, Tamil Nadu.
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-1591.19549
 Abstract | | |
In men, vaginal hydrocele is the most common morbidity due to Wuchereria bancrofti . Diagnosis is straightforward most of the time but when the swelling is not transilluminant, patients in whom the diagnosis is in doubt, children with hydroceles and those with co-morbid conditions should have ultrasonography to differentiate these swellings. Studies on the effect of medical treatment with diethylcarbamazine on the size of hydroceles are inconclusive. The only effective treatment for hydrocele is surgery as the minimally invasive therapy like aspiration and sclerotherapy are known to have high recurrence rates. Several surgical options are available for managing hydrocele but the recommended operation is hydrocelectomy, i.e. a subtotal excision of the parietal layer of the tunica vaginalis leaving a rim of approximately one-centimeter width around the testis and epididymis.
Keywords: Filariasis; Hydrocele; Surgery
How to cite this article:
Ananthakrishnan N, Pani S P. Surgery for vaginal hydroceles: an update. Indian J Urol 2005;21:35-8 |
In men, vaginal hydrocele is the most common morbidity due to Wuchereria bancrofti .[1],[2] The only effective treatment for hydrocele is surgery, but safe surgery requires adherence to strict standards for diagnosis, preoperative, intraoperative and postoperative care of the patient. Other scrotal conditions such as chylocele (collection of chyle in the tunica vaginalis), hematocele (collection of blood) or a pyocele (collection of pus) may be mistaken for a hydrocele. These require appropriate management and need to be excluded when making a diagnosis of simple uncomplicated hydrocele. The latter three conditions are characterized by the fact that the contents of the tunica vaginalis sac are nontransilluminant. This test can be used at the peripheral level for differentiating uncomplicated hydroceles from other scrotal swellings. The test is easy to perform, does not require costly equipment other than a good flashlight and an opaque tube of approximately 6' in length and 1' in width. The skill of transillumination can easily be taught to physicians at the appropriate peripheral level. Although there is a report from India suggesting that diethyl carbamazine (DEC) therapy could reduce the size of hydroceles, a recent double blind study in Tanzania showed that DEC has no effect on the size of hydroceles.[3],[4] Hence, surgery remains the treatment of choice for management of filarial hydrocele. Although there are several publications on surgery of hydrocele and the complications of surgery, this article presents the consensus obtained in a global meeting called under the auspices of the WHO.[4],[5],[6],[7],[8],[9],[10],[11]
| Levels of health care facilities | |  |
For management of hydroceles, the levels of health care facilities are classifiable into the following three levels (flow chart):
1.Level I: this is at the community level and is meant for detection of patients with scrotal swellings either by the community health worker or the patient presenting himself. Once detected the patient would be referred to a level II facility.
2.Level II: this is a centre at which surgery for un-complicated hydroceles can be performed. In different countries it would be equivalent to a community health centre or sub-district level hospital with provision for minor surgery. In addition to oxygen and resuscitative facilities there should also be facilities for observation of patients for 24-48 h where required. A trained surgeon or an MBBS physician who is already performing minor surgical procedures can then be trained to perform surgery on patients with hydrocele at the level II facility.
3.Level III: this would be equivalent to District Hospitals where patients with more serious medical problems or complicated hydroceles can be referred for surgery.
| Diagnosis | | |
It is essential to examine a patient with a scrotal swelling and differentiate between a hydrocele and other causes of inguino-scrotal or scrotal swellings other than hydroceles as per the algorithm [Figure - 1]. For this purpose the skill of performing and interpreting a transillumination test is mandatory. All inguino-scrotal swellings and scrotal swellings that are not transilluminant, patients in whom the diagnosis is in doubt, children with hydroceles and those with co-morbid conditions should have ultrasonography to differentiate these swellings [Figure - 2]A.
| Indications for hydrocele surgery | | |
- Indications for hydrocele surgery at the level II facility would include
- Medical disqualification due to un-treated hydroceles;
- Interference with work;
- Interference with sexual function;
- Interference with micturition due to the penis getting buried in the scrotal sac;
- Negative impact on the patient's family;
- Dragging pain;
- Liability to trauma in view of nature of patient's work or mode of transportation such as cycling;
- Possible effect on the testis of long standing hydroceles;
Patients with large hydroceles should be given priority in situations where resources may be limited. However, if resources are not an issue, and where the patient may be limited in employment opportunities due to a hydrocele of any size being considered a disqualification for Government jobs (as in India) then, surgery should be offered to all.
Preoperative assessment procedures
These would include
- Evaluation for systemic illnesses such as history of Diabetes Mellitus, other systemic illnesses such as angina, drug allergies, sickling tendency and other problems likely to increase the risk of surgery;
- Hemoglobin, urine and blood sugar;
- Ensuring adequate scrotal hygiene by preoperative bath and scrotal washing with soap and water two times daily for 3 days before surgery, which could reduce the infection rate;
- Surgery should be rescheduled to at least 4-6 weeks after an acute adenolymphangitis;
Anesthesia
It is recommended that all the operations for uncomplicated hydrocele in patients with out serious comorbidity should be performed under local anesthesia using either bupivacaine or lignocaine (lidocaine). The procedure should consist of a spermatic cord block with the drug, combined with infiltration along the line of incision.
Surgical procedure
The procedure for hydrocele should preferably be done as an outpatient procedure. However, observation of the patient for 24-48 h after surgery should be done whenever the situation warrants. The surgeon who performs the operation should be competent to perform hydrocelectomies. It is recommended that the operation performed should be a hydrocelectomy, i.e. a subtotal excision of the parietal layer of the tunica vaginalis leaving a rim of approximately 1-cm width around the testis and epididymis [Figure - 2]B. Aspiration with or without injection of sclerosants was not recommended due to the high recurrence rate and the potential damage to the testis due to the sclerosant. Likewise the procedure of eversion of the hydrocele sac (Jaboulay's procedure) is best avoided due to the following reasons:
1. In hydroceles, which are larger than tennis balls, the procedure of eversion of the sac is likely to leave the patient with a significant residual swelling of the scrotum;
2. In hydroceles smaller than tennis balls both procedures, (eversion and excision) are likely to run the same risk of complications;
3. The tunica vaginalis is abnormal in patients with filarial hydrocele and is best excised. If left behind there are fears in some quarters of possible complications such as a lymph scrotum or a filarial scrotum in some patients. It was, however, accepted that there is insufficient published material to record the instance of such complications, if any;
4. If improperly performed the procedure of eversion of the sac is associated with a greater risk of recurrence.
Use of chromic gut sutures was recommended to minimize the cost.
Postoperative care
1.Analgesics should be administered starting from the morning of surgery and continued for 48-72 h. The choice of recommended analgesic was oral acitaminophen or NSAIDs other than aspirin.
2. Antibiotics should be administered starting from the night before surgery for a total duration of 5 days. This is to forestall the risk of infection since the patient would return to his home environment to an ambience, which may be conducive to infection. The recommended antibiotic in view of cost and the type of bacteria likely to be involved in infection was amoxicillin and metronidazole.
3. Patients may be allowed to return to their homes a few hours after surgery except under the following circumstances in which case they should be observed for 24-48 h.
- Placement of a drain, which has to be removed after 24-48 h,
- Undue swelling, pain or oozing from the wound,
4. Hydrocele wounds could be exposed on the third postoperative day and kept dry resulting in less infection from wet dressings and sweating,
5.Patients should be asked to return to the centre 7-10 days later for a follow up visit.
Access issues
The issue of patient access for surgery, particularly for hydrocele needs to be addressed. It is felt that the current level of access to surgery in most countries is inadequate. The following are the most possible reasons for the same:
1. Ignorance of patients to the fact that they can be cured of their condition;
2. Fear of surgery and its consequences;
3. Lack of facility or long distance between such a facility and the patient's home;
4. Cost of surgery, hospitalization, transport, loss of wages during and in the postoperative stage.
Training
1. Trainers for training of level II surgeons are to be identified by National Governments/Country co-ordinators. The trainers could be qualified surgeons with experience in hydrocele surgery working in endemic areas (they could also be surgeons attached to teaching or training institutions with experience of hydrocele surgery). The identified trainers need to be trained on the following through a workshop (but case demonstration and actual performance of surgery need not be done during the training),
- Surgery protocol for Level II medical officers;
- To acquire the ability of Level III surgeons (to be able manage scrotal swelling cases referred to them from level II);
- To acquire the ability to tackle any complications developed in hydrocele cases operated at level II;
2. The trainers will then train the Level II surgeons identified by national/local health systems. Level II Medical officers need to be trained on diagnosis, testing for fitness for surgery, all aspects of the protocol for surgery, postoperative care and follow up.
3. It would be advantageous to encourage actual performance of surgery during the trainings. This ensures agreement regarding what is meant by certain terms. When actual surgery cannot be done, videotapes of surgery may be substituted.
4. Continuing medical education programmes for medical school teachers, residents and other surgeons, private practitioners on 'Newer developments in the pathogenesis and management of filariasis, protocol for hydrocele management and available information on management of other uro-genital manifestations of filariasis through workshops, round tables, symposia, seminars and exchange visits.
| Conclusion | | |
In men, vaginal hydrocele is the most common morbidity due to Wuchereria bancrofti . Diagnosis is straightforward most of the time but when the diagnosis is in doubt ultrasonography is a useful tool to differentiate these swellings. As the effect of medical treatment with diethylcarbamazine on the size of hydroceles are doubtful, double blind randomized clinical trials are required to generate evidence on the effect of diethylcarbamazine on hydroceles of different grades. The only effective treatment for hydrocele is surgery as the minimally invasive therapy like aspiration and sclerotherapy are known to have high recurrence rates.
| References | | |
| 1. | Pani SP, Balakrishnan N, Srividya A, Bundy DA, Grenfell BT. Clinical epidemiology of bancroftian filariasis. Effect of age and gender. Trans R Soc Trop Med Hyg 1991;85:260.  [PUBMED] |
| 2. | Sivam NS, Jayanthi S, Ananthakrishnan N, Elango A, Yuvaraj J, Hoti SL, et al. Tropical vaginal hydroceles. Are they all filarial in origin? Southeast Asian J Trop Med Public Health 1995;26:739. [PUBMED] |
| 3. | Kar SK, Mania J. Filarial hydrocele and its treatment with DEC. Progress in Lymphology. XIV. In : Proceedings of the XIV International Congress of Lymphology: Washington, D.C; 1993; 364. |
| 4. | Bernhard P, Magnussen P, Lemnge MM. A randomized, double-blind, placebo-controlled study with diethylcarbamazine for the treatment of hydrocoele in an area of Tanzania endemic for lymphatic filariasis. Trans R Soc Trop Med Hyg 2001;95:534-6. [PUBMED] |
| 5. | Albrecht W. Holtl W, Aharinejad S. Lord's procedure - the best operation for hydrocele. J Urol 1991;68:187-9. |
| 6. | Dandapat MC, Mohapatro SK, Dash DM. Management of chronic manifestations of filariasis. J Indian Med Assoc 1986;84:210-5. [PUBMED] |
| 7. | Das S, Tuerk D, Amar AD, Sommer J. Surgery of male genital lymphedema. J Urol 1983;129:1240-2. [PUBMED] |
| 8. | Gotttesman JE. Hydroceletomy: evaluation of technique. Urology 1976;7:386-7. |
| 9. | Hass JA, Carrion HM, Sharkey J, Politano VA. Operative treatment of hydrocele: another look at Lord's procedure. Urology 1978;12:578-9. |
| 10. | Ku HJ, Kim ME, Lee NK, Park YH. The excisional, placation and internal drainge techniques: a comparison of the results for idiopathic hydrocele. BJU Int 2001;87:82-4. |
| 11. | Report on WHO/CEE "Informal consultation on surgical approaches to the uro-genital manifestations of lymphatic filariasis" held at WHO head quarters, Geneva on 15th and 16th April 2002. |
[Figure - 1], [Figure - 2]
| This article has been cited by | | 1 |
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| Rajeev RANJAN KUMAR, Vikram TREHAN, Hari MOHAN, Anurakshat GUPTA, Tinku ANTONY, Amit CHHIKARA, Suraj KUMAR S, Kishore K | | Journal of Surgery and Medicine. 2022; 6(4): 1 | | [Pubmed] | [DOI] | |
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