Q-A Scrotal Swelling

Q. What do you mean by transillumination is
opalescent in spermatocoele ?
A. This word means that the cyst is a midway
between translucent and opaque.

Q. How can you explain this type of
transillumination in spermatocoele ?
A. It is due to its content of sperms.

Q. What are the complications of hydrocoele ?
A. complications of hydrocoele include :
1. 1. Rupture by severe trauma
2. 2. Haematocoele (spontaneous, trauma,
aspiration)
3. 3. Infection (----> pyocoele)
4. 4. Calcification of the sac
5. 5. Atrophy of the testis (in long standing
cases)
6. 6. Hernia of the hydrocoele (in long standing
cases, through dartos muscle as a result of
high tension)

Q. What are the lines of treatment of 1ry
vaginal hydrocoele ?
A. 1. Operation : The ideal treatment
2. Aspiration : In unfit patients

Q. What are the operations you know for 1ry
vaginal hydrocoele ?
A. 1. Excision of the tunica (if very large,
thickened or calcified)
2. Evertion of the tunica (if not large, thickened or
calcified)
3. Lord's operation (if not large, thickened or
calcified)

Q. What are the complications of aspiration ?
A. 1. Recurrence (100%).
2. Infection.
3. Haemorrhage.
4. Puncture of the testis.



Q. How did you know that it is a cystic
swelling ?
A. By doing the bipolar fluctuation test ; One
hand's fingers are placed around the neck of the
scrotum, and the other hand's fingers hold the
bottom of the swelling. The latter squeezes the
swelling where an impulse is perceived by the
other hand's fingers at the top of the swelling.

Q. What are the values of transillumination in
hydrocoele ?
A. It differentiates between hydrocoele which is
translucent and other opaque cysts. It also
localizes the testis in case of vaginal hydrocoele.


Q. What is the value of localizing the site of
the testis in hydrocoele ?
A. To avoid its injury if aspiration is done. The
shape and size of the testis also could be assessed

Q. How can you detect secondary vaginal
hydrocoele ?
A. By pinching the tunica vaginalis.

Q. What are the other intrascrotal cysts you
know ?
A. Spermatocoele, Pyocoele, Acute heamatocoele,
Encysted hydrocoele of the cord, Cystic teratoma,
Breaking down gumma, Cysts of embryonic
remnants of the epidedymis.

Q. What is spermatocoele?
A. It is a retention cyst situated in the head of the
epidedymis due to obstruction of the vasa
efferentia.

Case 1. PRIMARY VARICOCOELE

Q. What is your diagnosis ?
A. Left primary varicocoele.


Q. Why this is varicocoele ?
A. Because there is an inguinoscrotal swelling
characterized by ;
* By inspection : Varicose veins are seen just
beneath the skin of the scrotum (bag of worm
appearance)
* By palpation : There are multiple soft,
compressible swellings with impulse and thrill on
cough. They decrease in size on lying down and
disappear on elevation of the scrotum.


Q. What is the definition of varicocoele ?
A. It is dilatation, elongation, and tortuosity of the
pampiniform plexus of veins.

Q. What are the types of varicocoele ?
A. Primary and secondary varicocoele.

Case 2. VAGINAL HYDROCOELE

Q. What is your diagnosis ?
A. Rt. primary vaginal hydrocoele.

Q. What are the types of hydrocoele ?
A. 1. Congenital hydrocoele 2. Infantile hydrocoele
3. Vaginal hydrocoele 4. Encysted hydrocoele of
the cord
5. Hydrocoele of the canal of Nuck 6. Hydrocoele
of hernial sac
N.B. The so called diffuse hydrocoele of the cord is
one of the forms of chronic filarial funiculitis. It is
not a true hydrocoele but it is just a lymphoedema
of the cord making it soft gelatinous in consistency.

Q. What is vaginal hydrocoele ?
A. It is accumulation of serous fluid between the
two layers of the tunica vaginalis.

Q. What are its types ?
A. It is of two types :
1. 1ry vaginal hydrocoele : of unknown
aetiology
2. 2ry vaginal hydrocoele : 2ry to any disease
of the testis, epidedymis or spermatic cord.


Q. How did you know that it is purely scrotal ?
A. By grasping the neck of the scrotum by two
fingers; the thumb infront and the index finger
behind the neck, it was found that the swelling is
completely below the fingers.

Q. What are the complications of 1ry
varicocoele ?
A. 1. Recurrent attacks of thrombophlebitis.
2. 2ry hydrocoele.
3. Infertility (if there is serious depression of
sperm count).
4. Neurosis (pain).
5. Testicular atrophy (from prolonged congestion).

Q. What are the different lines of treatment
of 1ry varicocoele ?
A. 1. Conservative treatment for all cases.
2. Operative treatment for some cases.

Q. What are the indications for surgery in 1ry
varicocoele ?
A. 1. Serious depression of spermatic count
(oligospermia).
2. Big painful varicocoele.
3. Employment and acceptance in military & police
academies.

Q. Do you know the different approaches for
varicocoele ?
A. Yes, there are 4 approaches :
1. Scrotal 2. Inguinal
3. Pelvic (Palomo op.) 4. Laparoscopic

Q. How does hypernephroma produce
secondary varicocoele ?
A. By extension of tumour thrombus into the renal
vein leading to obstruction of the testicular vein.

Q. On which side is 2ry varicocoele more
common and why ?
A. On the left side, because the left testicular vein
drains into the renal vein, while the right testicular
vein drains into the inferior vena cava. So, 2ry
varicocoele on the left side occurs when there is
tumour thrombosis of the left renal vein, whereas
on the right side, thrombosis should extend to the
IVC to occlude the right testicular vein.

Q. Why 1ry varicocoele is more common on
the left side ?
A. Because of the following reasons :
1. 1. The left testicular vein is longer than the
right one (left testis lies at a lower level than
the right one)
2. 2. The left testicular vein opens at right angle
into the left renal vein and no protective
valve at this site
3. 3. The left testicular vein lies beneath the
sigmoid colon and may be liable to
compression
4. 4. The left renal vein passes in the angle
between the aorta and the superior
mesenteric vein and this angle may be
narrow and acts as a nutcracker causing
compression of the vein.
5. 5. The left common iliac vein is crossed by
the right common iliac artery