Hydrocele and Varicocele

Hydrocele

Definition

Incidence

• Affects ~1% of adult men

• 80% of newborns have a patent processus vaginalis, but most close spontaneously within 18 months

Types (Structural Classification)

Clinical Features

• Usually painless, may grow to a large size before presentation
• Can get "above" the swelling (unlike inguinal hernia)
• Testis/epididymis may be impalpable within the fluid
• Transilluminates (fluid-filled = translucent)
• Scrotal ultrasound is the key adjunct to assess the underlying testis

Treatment

• Small hydroceles: no treatment needed
• Congenital: herniotomy (ligation of patent processus vaginalis)
• Sizeable/symptomatic acquired hydroceles - three surgical options:
  1. Plication (Lord's operation) - suitable for thin-walled sacs; minimal dissection, low haematoma risk
  2. Eversion (Jaboulay's operation) - sac is everted behind the testis
  3. Excision - for thick-walled sacs

Varicocele ("Vercio Veins")

Definition

Incidence

• Affects 10-20% of adult males
• Found in ~40% of infertile males
• ~90% are left-sided (left testicular vein drains into the higher-pressure left renal vein; right drains directly into the IVC)
• If a solitary right-sided varicocele is found, always image the kidney to exclude a retroperitoneal mass or renal tumour

Pathophysiology - 3 Theories

1. Absent/incompetent valves at the junction of the testicular vein with the renal vein (left) or IVC (right) - allows retrograde venous reflux
2. "Nutcracker" effect - left testicular vein compressed between the superior mesenteric artery and the aorta
3. Angulation at the junction of the left testicular vein and left renal vein

Grading (WHO / Clinical Classification)

Clinical Features

• Often asymptomatic; may cause dragging discomfort, worse on standing at end of day
• Affected side of scrotum hangs lower
• "Bag of worms" feel on palpation in the erect position
• Veins decompress on lying down (if they do not decompress supine - suspect underlying venous obstruction/renal tumour)
• Longstanding cases: testicular atrophy on the affected side

Varicocele and Infertility - Key Mechanisms

• Elevated intratesticular temperature (primary mechanism) - impairs countercurrent heat exchange in the pampiniform plexus
• Increased oxidative stress and sperm DNA fragmentation
• Testicular hypoperfusion and stasis - hypoxia and toxin accumulation
• Elevated apoptosis-associated microRNA in seminal fluid
• Results: reduced sperm count, motility, morphology, testicular atrophy, and lower testosterone - Campbell Walsh Wein Urology

Treatment

• Percutaneous (radiological) embolisation of the gonadal veins - usual first-line when discomfort is significant
• Varicocelectomy (surgical repair) - recommended in men with low sperm count + clinical varicocele + unexplained infertility
  • Microsurgical (subinguinal) approach using the operating microscope is the gold standard - lowest recurrence, lowest hydrocele rate
  • Open inguinal (Ivanissevich) or laparoscopic approaches also used
• Treatment of subclinical varicocele or men with normal semen parameters does not improve spontaneous pregnancy rates

The Key Connection: Post-Varicocelectomy Hydrocele

• Hydrocele formation is the most common complication of varicocelectomy
• Incidence: 3-33% (average ~7%) after non-microscopic approaches
• Cause: lymphatic obstruction during cord dissection - confirmed by protein concentration analysis of hydrocele fluid
• At least half of post-varicocelectomy hydroceles grow large enough to require surgical excision
• A large post-op hydrocele creates an insulating layer around the testis, which may impair counter-current heat exchange and partly negate the fertility benefit of the varicocelectomy
• Prevention: Using magnification (loupes or operating microscope) to identify and preserve lymphatics almost eliminates the risk - this is the main advantage of the microscopic subinguinal approach - Campbell Walsh Wein Urology

Bailey & Love's Short Practice of Surgery 28th ed. | Campbell Walsh Wein Urology