Rosen & Barkin's 5-Minute Emergency Medicine Consult (357 page)

• 982.3 Toxic effect of other chlorinated hydrocarbon solvents
  
• 987.1 Toxic effect of other hydrocarbon gas
  
• 989.2 Toxic effect of chlorinated hydrocarbons
  

BASICS

• Most common cause of painless scrotal swelling.
  
• Classified as congenital or acquired (secondary):
  
  • Congenital result from a patent process vaginalis and communication between tunica vaginalis and peritoneal cavity:
    
    • Normally occurs spontaneously and most are closed by 2 yr of age
      
  • Acquired occur secondary to interscrotal infection, neoplasm, inguinal or scrotal surgery, or regional or systemic disease.
    
• Communicating hydrocele:
  
  • Patent processus vaginalis
    
  • Scrotum fills and empties with peritoneal fluid depending on body position and intraperitoneal pressures.
    
• Noncommunicating hydrocele
  is due to production of serous fluid by a disease process or impaired absorption within the scrotum itself
  

• Imbalance between production and resorption of fluid within the space between tunica vaginalis and tunica albuginea.
  
• Disease processes causing adult noncommunicating hydrocele include:
  
  • Epididymitis
    
  • Hypoalbuminemia
    
  • TB
    
  • Trauma
    
  • Mumps
    
  • Spermatic vein ligation
    
  • In developing world, hydrocele is primarily caused by infections such as
    Wuchereria bancrofti
    or
    Loa Loa
    (filariasis is the cause of most hydroceles worldwide)
    
  • Rarely malignancy (1st-degree testicular neoplasm or lymphoma)
    
• Rare etiology is the abdominoscrotal hydrocele that may cause hydroureter or unilateral limb edema owing to compression:
  
  • US reveals single sac extending from scrotum into abdominal cavity via the deep inguinal ring.
    

• Congenital in 6% of newborn boys
  
• Usually diagnosed in newborn nursery
  
• Caused by patent processus vaginalis, a structure that remains patent in 85% of newborns
  
• May vary in size owing to position or crying:
  
  • Patients may present with history of scrotal mass that has resolved.
    
• Most close by the age of 2 yr
  

DIAGNOSIS

Painless scrotal swelling with a sensation of pulling, dragging, or heaviness.

History and exam with special attention to identifying torsion of testicle.

• Mass may be soft and doughy or firm depending on the amount of fluid present.
  
• Initial evaluation includes transillumination of affected side (looking for a homogeneous area without internal shadows):
  
  • This is rapidly being replaced as diagnostic test of choice by bedside US.
    

• Bedside US:
  
  • Allows visualization of hydrocele as well as of testicle
    
  • Especially in cases of massive fluid collection, bedside US should be the diagnostic test of choice.
    
  • May help to identify an underlying mass
    
• Because of possibility in adults that a hydrocele may be owing to a primary neoplasm, the testicle must be palpated in its entirety.
  

No specific lab testing is indicated unless underlying cause demands it (UA, AFP, hCG).

US is diagnostic and allows visualization of testicular anatomy:

• Appears as large anechoic fluid-filled space surrounding the anterolateral testicle
  

• Epididymitis
  
• Indirect inguinal hernia
  
• Orchitis
  
• Testicular neoplasm
  
• Testicular torsion
  
• Varicocele
  

TREATMENT

Stabilization should focus on underlying cause (e.g., trauma).

Appropriate exam of testicle to exclude primary neoplasm and referral.

Treat underlying cause.

FOLLOW-UP

Patients with secondary hydrocele may need admission for further evaluation of underlying pathology (e.g., neoplasm, trauma).

• Otherwise healthy patients without comorbid illness may be referred for further evaluation to urologist.
  
• Hydrocele is usually repaired if cosmesis is a factor or in cases where it causes discomfort.
  
• Repair can be:
  
  • Surgical:
    
    • Aspiration or sclerotherapy are alternatives to open hydrocelectomy.
      
  • Medical:
    
    • Aspiration of hydrocele contents and sclerotherapy to prevent recurrence.
      

• Most hydroceles in infant population will spontaneously resolve by 12 mo of age:
  
  • Referral and observation are appropriate once diagnosis is made.
    
• After the age of 12–18 mo, refer for surgical repair as communicating hydroceles usually have hernia that needs repair.
  

Patients should be referred to Urology.

The mass may fail to transilluminate due to thickening of the tunica vaginalis.

• Bedside US should visualize both the fluid-filled mass and the testicle.
  

• Cokkinos DD, Antypa E, Tserotas P, et al. Emergency ultrasound of the scrotum: A review of the commonest pathologic conditions.
  Curr Probl Diagn Radiol.
  2011;40(1):1–14.
  
• Hoerauf A. Filiariasis: New drugs and new opportunities for lymphatic filiariasis and onchocerciasis.
  Curr Opin Infect Dis
  . 2008;21:673–681.
  
• Rabinowitz R, Hulbert WC Jr. Acute scrotal swelling.
  Urol Clin North Am
  . 1995;22:101–105.
  
• Wampler SM, Llanes M. Common scrotal and testicular problems.
  Prim Care
  . 2010;37(3):613–626.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Epididymitis/Orchitis
  
• Hernia
  
• Testicular Torsion
  

CODES

• 603.1 Infected hydrocele
  
• 603.9 Hydrocele, unspecified
  
• 778.6 Congenital hydrocele
  

BASICS