quiz management of chronic hydrocele

[Admin]

First one with correct answer with justification win.

A 15-year old male cross country runner presents with painful right scrotal swelling. The swelling is constant and has developed slowly over the past six months. On examination, the inguinal canal is normal. The scrotum transilluminates and its contents cannot be reduced. The testicle cannot be palpated. An ultrasound demonstrates a normal testicle and a large hydrocele.

The best next step in management of this chronic hydrocele is

A observation.

B aspiration.

C scrotal approach with hydrocelectomy.

D inguinal approach with ligation of the processus vaginalis and aspirating the hydrocele from above.

E inguinal approach with ligation of the processus vaginalis and opening a window into the hydrocele from above.

[Admin]

correct answer
C scrotal approach with hydrocelectomy.

Hydrocele is defined as an abnormal collection of fluid in the space between the parietal and visceral layers of the tunica vaginalis. Even in adults, a small amount of fluid can be normally seen. A hydrocele in an infant which persists outside the newborn period suggests the presence of a patent processus vaginalis. Hydroceles in adolescent males are usually not associated with a hernia; most are acquired and are idiopathic. In one study, nearly 90% of boys over age 12 presenting with a scrotal hydrocele did not have an associated hernia. The second most common causes of hydrocele are prior adolescent varicocele ligation (10% incidence) or inguinal hernia repair. In the setting of previous surgery, observation or an attempt at aspiration is reasonable.

The pathogenesis of an idiopathic adolescent hydrocele is thought to be an imbalance in the normal process of fluid production and reabsorption. Since 15% of testicular neoplasms are associated with a reactive hydrocele, an ultrasound is indicated.

A new onset large hydrocele in an adolescent should be approached through the scrotum. Another option is to make a groin incision, deliver the testicle and do a complete hydrocelectomy through the groin, although this can be challenging in a large hydrocele in an adolescent. Making a window from above will likely lead to a recurrence. Needle aspiration of an idiopathic hydrocele is unlikely to result in long term resolution. Observation is not indicated given the symptoms. The treatment of choice is an open hydrocelectomy via a scrotal incision. Several techniques have been described for the scrotal approach: plication of the sac, resection of the sac, resection of the sac and inverting the sac behind the testicle. One can also probe the canal from below to determine if there is a communication above. A penrose drain can be left in place to prevent the development of a hematoma/seroma. This can be removed in a few days. Activity need only be restricted for a few days.

[ashrarur]

From the history itself, this is evident that this not a case PPV which is congenital. Some secondary etiologies are definitely involved. Those should be definitely sought for even if surgical management is contemplated. I'd suggest a srota approach with eversion of the hydrocele sac. But again, the primary cause should be looked for.

[Sharon]

[Sharon]

A

[Admin]

correct answer
C scrotal approach with hydrocelectomy.

Hydrocele is defined as an abnormal collection of fluid in the space between the parietal and visceral layers of the tunica vaginalis. Even in adults, a small amount of fluid can be normally seen. A hydrocele in an infant which persists outside the newborn period suggests the presence of a patent processus vaginalis. Hydroceles in adolescent males are usually not associated with a hernia; most are acquired and are idiopathic. In one study, nearly 90% of boys over age 12 presenting with a scrotal hydrocele did not have an associated hernia. The second most common causes of hydrocele are prior adolescent varicocele ligation (10% incidence) or inguinal hernia repair. In the setting of previous surgery, observation or an attempt at aspiration is reasonable.

The pathogenesis of an idiopathic adolescent hydrocele is thought to be an imbalance in the normal process of fluid production and reabsorption. Since 15% of testicular neoplasms are associated with a reactive hydrocele, an ultrasound is indicated.

A new onset large hydrocele in an adolescent should be approached through the scrotum. Another option is to make a groin incision, deliver the testicle and do a complete hydrocelectomy through the groin, although this can be challenging in a large hydrocele in an adolescent. Making a window from above will likely lead to a recurrence. Needle aspiration of an idiopathic hydrocele is unlikely to result in long term resolution. Observation is not indicated given the symptoms. The treatment of choice is an open hydrocelectomy via a scrotal incision. Several techniques have been described for the scrotal approach: plication of the sac, resection of the sac, resection of the sac and inverting the sac behind the testicle. One can also probe the canal from below to determine if there is a communication above. A penrose drain can be left in place to prevent the development of a hematoma/seroma. This can be removed in a few days. Activity need only be restricted for a few days.