Hydrocele - Types and Detailed Overview

Embryological Basis

Classification Diagram

Types of Hydrocele

1. Vaginal (Non-Communicating / Primary) Hydrocele

• Most common type globally
• The processus vaginalis is fully closed with no communication to the peritoneal cavity
• Fluid accumulates around the testis within the tunica vaginalis due to excessive production or defective absorption by the tunica (often from disrupted lymphatic drainage)
• When no cause is found, it is called a primary or idiopathic hydrocele
• Occurs most commonly in middle and later life
• The swelling is typically painless and may grow large before the patient seeks treatment
• Can also occur in older children

2. Communicating (Congenital) Hydrocele

• A patent processus vaginalis persists, allowing free communication between the peritoneal cavity and the tunica vaginalis
• Peritoneal fluid flows down into the scrotum
• Associated with indirect inguinal hernia (if the processus is wide enough, bowel can herniate)
• Common in neonates and infants - majority resolve spontaneously by 18 months
• Fluid may drain back into the peritoneal cavity when the child lies down, making the swelling intermittent
• Pressure on the hydrocele does not always empty it completely
• Bilateral swellings should prompt checking for ascites

3. Infantile Hydrocele

• The distal end of the processus vaginalis closes correctly, but the mid-portion remains patent
• The proximal end is open and communicates with the tunica vaginalis
• Fluid fills from the mid-cord level down to the scrotum
• Essentially an intermediate variant between communicating and non-communicating types

4. Hydrocele of the Cord (Encysted Hydrocele of Cord)

• The distal end closes correctly, the mid-portion remains patent, but the proximal end is also closed
• Results in an isolated, encysted fluid collection along the spermatic cord, separate from both the peritoneal cavity and the tunica vaginalis
• Presents as a smooth oval swelling above the testis, near the spermatic cord
• Liable to be mistaken for an inguinal hernia
• Distinguishing sign: the swelling moves downward and becomes less mobile when the testis is gently pulled downward

5. Abdominoscrotal Hydrocele

• An uncommon variant, accounting for approximately 1.25% of all hydroceles
• A large non-communicating scrotal hydrocele that extends upward into the abdomen through the inguinal canal
• Bilateral in about 30% of cases
• The abdominal component may be palpable as an abdominal mass
• Usually manifests in infancy
• Ultrasound is useful to define the proximal abdominal extent
• Managed surgically via inguinal approach to excise both scrotal and abdominal components

6. Secondary Hydrocele

• A hydrocele that is secondary to an underlying disease or injury
• Causes include:
  • Epididymo-orchitis (most common cause of acute secondary hydrocele)
  • Testicular torsion
  • Testicular tumour (important - must be excluded in young men with acute hydrocele)
  • Trauma
  • Filariasis (a major cause in endemic tropical regions - Wuchereria bancrofti)
  • Radiotherapy
  • Post-varicocelectomy (from lymphatic disruption - incidence 3-33%, average ~7%)
• Usually occurs in men over 40 years

Warning: If a tumour is suspected, the hydrocele must NOT be punctured due to risk of malignant needle-track implantation.

Summary Table

Clinical Features

• Can get above the swelling and palpate a normal spermatic cord (distinguishes from inguinal hernia)
• The testis and epididymis are enclosed within the swelling and may be impalpable
• Transilluminates (the classic sign - light passes through the fluid-filled sac)
• Ultrasound is the key adjunct to assess the testis itself and exclude an underlying tumour

Treatment

Pericarditis - Detailed Surgical Overview

Definition and Anatomy

Etiology

• S. aureus is the most common cause of purulent pericarditis after cardiac surgery in adults
• Tuberculosis is the most common cause of chronic constrictive pericarditis globally
• Uremia is the most common systemic disorder associated with pericarditis

Classification / Types

1. Acute Fibrinous Pericarditis

• Granulocytic and lymphocytic infiltration of the pericardium
• Exudate is fibrinous ("bread and butter" or "shaggy" appearance on the pericardial surface)
• In viral or uremic pericarditis: fibrinous exudate
• In bacterial: fibrinopurulent (suppurative) with pus
• In malignancy: exuberant shaggy exudate + bloody effusion

• Chest pain - sharp, pleuritic, retrosternal; radiates to trapezius ridge or back
• Relieved by sitting forward and leaning ahead
• Worsened by lying supine, deep inspiration, swallowing
• Fever and myalgias are common
• Pericardial friction rub - the hallmark sign
  • A "scratchy," leathery sound
  • Best heard at the lower left sternal border with the patient leaning forward in full expiration
  • Has up to 3 components: atrial systole, ventricular systole, ventricular diastole
  • Intermittent and migratory

2. Pericardial Effusion

Panel A: ECG showing diffuse ST elevation with PR depression and reciprocal PR elevation in aVR. Panel B: "Flask-shaped" cardiac silhouette on CXR. Panels C & D: Echocardiography showing circumferential pericardial effusion (PE) surrounding RV, LV, and LA, with abnormal septal motion (blue arrows)

• Any cause of pericarditis can also produce an effusion
• Other causes: aortic dissection (retrograde bleeding), CHF (transudative), blunt/penetrating trauma
• Hemodynamic significance depends on volume AND rate of accumulation
• Bacterial, fungal, HIV, and malignant effusions have a higher risk of progressing to tamponade
• 20% of large symptomatic effusions of unknown cause are due to undiagnosed cancer

3. Cardiac Tamponade

• Tamponade occurs when pericardial pressure exceeds cardiac filling pressure (usually at 15-20 mmHg)
• Right heart filling is affected first, then left
• The y-descent of the JVP is lost (because no blood can be ejected from the heart at this point)

1. Hypotension (low cardiac output)
2. Jugular venous distension (elevated venous pressure)
3. Muffled heart sounds

• Pulsus paradoxus - fall in systolic BP >10 mmHg with inspiration (ABSENT in LV dysfunction, ASD, positive-pressure ventilation, aortic insufficiency)
• Tachycardia, dyspnoea, diaphoresis

4. Constrictive Pericarditis

Panel A: Low voltage ECG. Panel B: CT showing pericardial thickening with calcification (yellow arrows). Panel C: Cardiac catheterization showing the characteristic "square root sign" (dip-and-plateau) with equalization of diastolic pressures

• Most common: Cardiac surgery and radiation therapy (especially breast cancer, Hodgkin lymphoma)
• Tuberculosis (most common cause in developing world)
• Subclinical viral pericarditis, connective tissue disease, uremia, neoplasm
• Can be idiopathic

• Inextensible pericardium causes equalization of telediastolic pressure in all cardiac chambers
• Interventricular septum convexity is inverted
• Normal total intracardiac volume is fixed - respiratory variation causes paradoxical septal motion (enhanced RV filling on inspiration, LV on expiration)

• Elevated systemic venous pressures (JVD, Kussmaul's sign)
• Right heart failure: dyspnea, orthopnea, fatigue
• Hepatomegaly, ascites, peripheral edema
• Low cardiac output
• Pericardial knock - early diastolic sound

• This distinction is critical because constrictive pericarditis is treated surgically while restrictive cardiomyopathy is managed medically
• MRI, cardiac catheterization, and tissue Doppler (annulus reversus) are key discriminating tools

• Pericardial resection (pericardiectomy) is the only definitive treatment
• Should be as complete as possible
• Coronary angiography required preoperatively in patients >50 years to exclude co-existing coronary artery disease
• Benefits are progressive over months post-operatively
• Operative mortality: 5-10% even in experienced centers
• Worst outcomes in radiation-induced disease (deep myocardial penetration by fibrosis/calcification)
• Surgery should be performed as early as possible before severe myocardial atrophy sets in

5. Effusive-Constrictive Pericarditis

• Combination of tense pericardial effusion PLUS constrictive thickening
• After pericardiocentesis, physiology changes from tamponade to constriction
• Intrapericardial pressure and CVP decline but not to normal
• Causes: TB, recurrent acute idiopathic pericarditis, radiation, trauma, renal failure, scleroderma, neoplasm
• Treatment: Wide excision of both visceral and parietal pericardium

6. Purulent (Bacterial) Pericarditis

• Most commonly caused by S. aureus (especially post-cardiac surgery)
• Routes: Contamination at surgery, bacteremic seeding, extension from pneumonia/empyema/lung abscess, complication of endocarditis
• Presentation: Fever + severe chest pain + tachycardia + hemodynamic instability
• Can progress rapidly to septic shock or cardiac tamponade
• Treatment: Surgical drainage (pericardiotomy) + IV antibiotics + pericardiocentesis

7. Tuberculous Pericarditis

• Common cause of chronic pericardial effusion and constrictive pericarditis in developing world, especially with HIV
• Presentation: Chronic systemic illness + weight loss + fever + enlarging cardiac silhouette
• Diagnosis: Pericardial fluid culture, pericardial biopsy (ideally via limited thoracotomy); granulomas with caseation
• Treatment: Anti-tuberculous chemotherapy (4-drug regimen)
• If biopsy shows thickened pericardium after 2-4 weeks of ATT → pericardiectomy to prevent constriction
• Tubercular constriction = surgery performed while patient is on ATT

8. Post-Cardiac Injury Syndromes (Surgical Context)

• Occurs weeks after myocardial infarction
• Due to antibodies against injured myocardium (autoimmune)
• Also occurs after cardiac surgery, pericardiotomy, or trauma

• Specifically post-cardiac surgery
• Fever + pericardial friction rub + chest pain appearing days to weeks after surgery
• Treated with NSAIDs and colchicine

ECG Stages in Acute Pericarditis

• ST elevation in pericarditis is concave (saddle-shaped) vs convex in STEMI
• Simultaneous T wave inversions NOT seen in Stage 1 pericarditis
• Not confined to a single coronary distribution
• No Q wave development
• Ventricular dysrhythmias are rare - their presence should raise suspicion for concomitant myocarditis

Diagnostic Criteria (for Acute Pericarditis)

1. Characteristic chest pain (pleuritic, positional)
2. Pericardial friction rub on auscultation
3. New widespread ST elevation / PR depression on ECG
4. New or worsening pericardial effusion on imaging

Treatment Summary