Hydrocoele - Erler Zimmer
Clinical History
A 40-year-old male presents with shortness of breath and swelling of his lower limbs. He is a smoker with a history of diabetes and previous myocardial infarctions. On examination, bilateral pleural effusion, peripheral pitting oedema, and a swollen scrotum were noted. Transillumination of the swelling transmitted red light. Chest x-ray showed radiological features of congestive cardiac failure. Despite the initiation of appropriate treatment for heart failure, the patient later died during this admission.
Pathology
The specimen is a testis and its coverings, sliced to display the cut surface. The cavity bounded by the visceral and parietal layers of the tunica vaginalis is distended due to the accumulation of serous fluid. This is an example of a hydrocoele, secondary to generalized oedema due to congestive cardiac failure.
Further Information
A hydrocele is an accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis around the testes. Hydroceles can be categorized as communicating with the peritoneal cavity or non-communicating with the peritoneal cavity.
Communicating hydroceles result from the failure of the processus vaginalis to close after the descent of the testes into the scrotum. They may present as congenital hydroceles or later in life due to an increase in intra-abdominal pressure, such as cardiac failure in this case. Non-communicating hydroceles are caused by imbalances in fluid secretion and reabsorption (e.g. orchitis, epididymitis, testicular tumour, physical trauma like hernia, testicular torsion) or defective lymphatic drainage (e.g. filariasis, elephantiasis).
Patients typically present with a scrotal mass, which may be uni- or bilateral. Communicating hydroceles may be reducible and increase in size with raised intra-abdominal pressure, while non-communicating ones are usually non-reducible swellings. The swelling is usually non-tender unless there is an underlying infection or torsion causing the hydrocele. Larger hydroceles may be cumbersome and cause erosion and skin infections on the scrotum.
Diagnosis can be made through physical examination. Serous fluid allows the passage of light shined through the scrotum when examined: this is called transillumination. Ultrasound may be used to consolidate diagnosis and exclude other testicular pathology. Testicular cancer serum markers, such as alpha fetoprotein and B-HCG, may be taken to rule out testicular cancer.
Many congenital hydroceles resolve spontaneously before the age of 2. If communicating hydroceles persist beyond 2 years, surgical repair is recommended due to the risk of developing incarcerated hernias. Surgical repair of communicating hydroceles in older patients may be offered if they are symptomatic. Treatment of the underlying cause of reactive hydrocele may lead to resolution.
