HYDROCELE Defined as a collection of fluid within the tunica vaginalis of the testis

CASSIFICATION 1. Congenital 2. Primary 3. Secondary

1. CONGENITAL Communicating (“vogbreuk”) Infantile Interstitial Cord

2. PRIMARY HYDROCELE Idiopathic (aetiology not known) Imbalance between the fluid secretion and absorption of the tunica vaginalis

3. SECONDARY HYDROCELE Infection Trauma Tumor Abnormalities in inguinal lymph nodes

DIFFERENTIAL DIAGNOSIS: SCROTAL CYSTIC MASSES Indirect inguinal hernia Epididymis cyst Hydrocele Varicocele Spermatocele Piocele Hematocele

TREATMENT Communicating Tying off the patent processus vaginalis Primary Hydrocelectomy Aspiration + injection of sclerosing agent Secondary Treat underlying pathology

DIFFERENTIATION HYDROCELE INGUINAL HERNIA Palpate cord above mass YES NO Translucent Fluctuate Fluid thrill

DIFFERENTIATION HYDROCELE INGUINAL HERNIA Testis palpable NO YES Cough impulse Reducible Bowl sounds

FLUID ASPIRATED FROM CYSTIC MASSES SUPRA TESTICULAR CYSTIC MASS COLOR OF FLUID Cord hydrocele Straw color Spermatocele Milky or Grey opaque (barley-water) Epididymis cyst Clear

VARICOCELE Defined as an abnormal dilatation and distension of the veins of the pampiniform plexus

INCIDENCE 15% in the general population (8% - 23%) 16,3% in adolescents (12,4% - 25,8%) 33% in infertile men (19% - 41%) 58% - 93% left sided

ETIOLOGY Abnormality of the venous valves Left spermatic vain joining the left renal vein directly at a 90° angle Longer left spermatic vein with increased hydrostatic pressure Pressure of superior mesenteric artery on the left renal vein (Nutcracker phenomenon)

PRESENTATION Complaints of a scrotal mass (“Bag of worms”) Complaints of scrotal discomfort Fertility problems Incidental diagnosis with clinical examination Smaller left testis

CLACCIFICATION Primary Abnormality of valves in the spermatic vein Secondary Tumor of the left kidney Retro-peritoneal masses Trauma

GRADING GRADE 0 Venous noise on doppler with Valsalva maneuver GRADE 1 Distended veins can be palpated with Valsalva GRADE 2 Distended veins can be palpated without Valsalva GRADE 3 Distended veins can be observed

INFERTILITY THEORIES Stases of blood with testicular hypoxia Reflux of renal and adrenal metabolites Increased intra-testicular temperature

INDICATIONS FOR FURTHER MANAGEMENT Symptomatic * Pain * Mass (discomfort) Infertility Testicular atrophy

TREATMENT Spermatic venography plus embolisation with heated contrast/resin/coils Surgery Open Ivanissevitch Paloma Laparoscopic