Page 277 - Medicine and Surgery

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Chapter 6: Disorders of the male genital system 273

Age Varicocele
Congenitalhydrocelesoccurinchildhood,secondaryare
Definition
more common age 20–40 years.
Varicocelesaredilatedveins(pampiniformplexus)along
the spermatic cord.
Aetiology
Most hydroceles are idiopathic but may occur secondary
Incidence/prevalence
to trauma, infection or neoplasm.
As common as 1 in 5 post-pubertal males, but often
asymptomatic.
Pathophysiology
Fluid accumulates between the two layers (parietal and
Aetiology/pathophysiology
visceral) of the tunica vaginalis. It is thought to occur
Thesearetheequivalentofvaricoseveins,duetothevalve
due to imbalance of secretion/reabsorption of peritoneal
leaflets becoming incompetent, blood flows back down
fluid from these layers. Congenital hydrocele is caused
towards the testis. Varicoceles occur more commonly on
by the persistence of the processus vaginalis and can be
the left side due to the perpendicular drainage of the left
associated with herniation of abdominal contents into
spermatic vein into the renal vein, which is compressed
the sac.
between the aorta and superior mesenteric artery. Iso-
lated right-sided varicocele should raise the suspicion of
Clinical features a thrombus in the IVC or right renal vein, possibly asso-
Patients present with an increase in the size of the testis ciated with renal cell carcinoma, because on the right the
or a swelling in the scrotum, which can be massive before spermatic vein drains directly into the IVC and should
becoming uncomfortable. Idiopathic hydroceles gener- remain competent.
ally develop very slowly, whereas secondary hydroceles Varioceles are commonly found in men who are infer-
develop rapidly. Usually the hydrocele covers the testis, tile, but many also have normal sperm counts. The cause
so that it is difficult to palpate. In the upper part of the of infertility is not clear. Testicular atrophy is thought to
swelling, a normal spermatic cord should be palpable occur due to the slightly raised temperature triggering
(this differentiates a hydrocele from an inguinal hernia). germ cell apoptosis.
A simple hydrocele transilluminates well, but if there is
blood (a haematocele) or it is chronic and the wall is
Clinical features
thickened, it does not.
Patients may complain of a dragging sensation or aching
pain in the scrotum, particularly on standing. Infertility
Investigations may be a presenting feature. On palpation there is a soft
If there is any doubt an ultrasound scan confirms the swelling like ‘a bag of worms’ along the spermatic cord,
diagnosisandisusefultoexcludeanunderlyingtesticular which is compressible and disappears on lying flat.
tumour.

Management
Management Surgery is indicated in boys and young males with asym-
1 Anysecondary cause should be identified and treated. metrical growth of the testes/testicular atrophy, and
2 Treatment is by surgical excision or plication of the seems to improve testicular growth. However, in infer-
sac. Aspiration should not be attempted as there is a tile men with a varicocele, surgery has not been shown
risk of infection and bleeding. to improve sperm counts. Ligation of the spermatic
3 If the hydrocele fluid becomes infected or contains vein can be either by open or laparoscopic surgery. In
blood, incision and drainage of pus are necessary, and older males who no longer wish to have more children,
examination of the scrotal contents to exclude an un- treatment with scrotal support and analgesia may be
derlying tumour may be performed at that time. sufficient.