Hydroceles, Spermatoceles & Epididymal Cysts

The front (anterior) part of the testis is covered by a sac called the tunica vaginalis. This sac starts as an extension of the peritoneal cavity in the abdomen but is meant to become separated during fetal development. One part of the sac is adherent to the front of the testis (the visceral layer) and the other to the inside of the scrotal skin (the parietal layer). There is always a thin layer of fluid which allows the testis to slide under the scrotal skin. There is a constant process of secretion of fluid from the visceral layer and absorption by the parietal layer.

Hydrocele: a type of scrotal swelling resulting from excess fluid within the tunica vaginalis. There are 2 mechanisms:

1. Simple hydrocele: an imbalance between absorption and secretion of this fluid. This is the most common type in adults.

2. Communicating hydrocele: excessive fluid from the peritoneal cavity (abdomen) tracts into the scrotum via a patent processus vaginalis - basically a minor type of a hernia. Results from failure of the processus vaginalis from closing during fetal development. The most common types in infants and children.

The epididymis is a structure located behind (posterior to) the testis in which sperm mature. It is essentially a duct system which carries sperm from the testis to the vas deferens (and ultimately the urethra). ‘Leaks’ of sperm from the delicate epididymal tubules result in spermatoceles and epididymal cysts. Obstruction of the epididymal tubules is thought to be the cause. While vasectomy is an obvious risk factor, the epididymal tubules may easily become obstructed with age.

Spermatocele: a type of scrotal fluid collection originating from the epididymis which contains slightly cloudy fluid and sperm.

Epididymal cyst: type of fluid collection containing clear fluid, often originating from the head of the epididymis.

Spermatoceles and epididymal cysts can be difficult to tell apart, even at the time of surgery. However, spermatoceles contain sperm and typically cloudy fluid. They are often ‘amorphous’ and softer as opposed to epididymal cysts which are often tense (firmer) and rounder).

From a practical perspective, the surgical approach is essentially similar and differentiating these two types of fluid collections is unimportant.

While cancer is understandably a concern, it is relatively rare in comparison to the common benign causes. Evaluation will sort out the potential causes. Fluid collections are usually benign but may develop in response to cancers or infections. Testis cancers are most common in younger men and very uncommon in older men.

1. Fluid collections: hydroceles, epididymal cysts, spermatoceles.

2. Varicocele (varicose veins).

3. Testicular infections: epididymo-orchitis.

4. Torsion of the testis or tesiticular appendages..

5. Testicular tumors.

6. Other: hernia, generalized edema.

Perfectly reasonable if one of the indications listed above is not met or if there is a health condition which precludes correction.

Aspiration is the process of draining a fluid collection with needle.

Sclerotherapy is the injection of a sclerosant (chemical that induces scarring) into a cavity with the goal of causing the walls of the cavity to adhere and for the cavity to be obliterated.

Aspiration is not possible for loculated fluid collections - those that have multiple compartments. In addition, aspiration alone does not correct or subvert the underlying mechanism by which these fluid collections arise. Aspiration on its own has a very high failure rate, approaching 100%.

The addition of a sclerosant to irritate the lining of the fluid sac increases the success rate substantially. However, failure occurs in 50-75% of cases when defined as failure to completely eliminate the fluid collection (the same definition as used for surgical failure).

Aspiration and sclerotherapy should never be performed in men where fertility is desired. There is a substantial risk of scarring and obstructing the reproductive tract.

Failed aspiration and sclerotherapy can significantly complicate surgical correction and may result in loss of the testis and/or a prolonged recovery. This has led many urologists to completely avoid aspiration plus sclerotherapy.

Therefore, surgery is considered the gold standard for treatment of scrotal fluid collections.

Types of sclerosants:

• Alcohol.

• Tetracycline.

• Sodium tetradecyl sulfate.

• Polidocanol.

Sodium tetradecyl sulfate solution:

• 4 ml 3% sodium tetradecyl sulfate

• 6 ml 2% lidocaine

• 140 ml. 5% dextrose in 0.45% normal saline

The volume instilled amounted to 25% of volume drained from the spermatocele to a maximum of 150 ml.

doi.org/10.1016/S0022-5347(05)66094-6

doi.org/10.1016/j.juro.2013.11.025

Excision of these fluid collections is considered the gold standard.

See the section on Before, During & After Surgery (below).

Incidence is approximately 1 in 20.

This may occur anytime after surgery but usually within weeks but rarely within the first few days (early fluid collections are often hematomas from bleeding). Some post-operative edema in the skin is to be expected. Recurrent fluid collections, including hematomas, tend to be ‘tense’ and relatively well defined whereas post-operative edema is often boggy and amorphous and will go away on its own over several weeks.

An ultrasound may be helpful in defining the nature of the fluid collection

Prevention may include placement of a temporary drain at the time of surgery.

This amounts to a failure of the surgery. However, the nature of fluid collections that occur after surgery are different. These are not hydroceles but seromas, lymphoceles or spermatoceles. If the fluid collection is a hematoma (contains blood) then it may resolve.

Management is individualized but include:

• Observation for small fluid collections.

• Aspiration with a needle attempts to decompress the collection and have the testicular surface adhere to the inside of the scrotal skin to obliterate the potential space.

• Placement of a temporary drain is a stop up from a needle aspiration.

• Repeat surgery.

Incidence is a approximately 1 in 20.

A hematoma is a collection of blood within the scrotum (as distinct from bleeding from the wound or bruising of the skin).

Typically occurs within 1-2 days of surgery. Usually a tense swelling of the skin and may occur with or without bruising. When bruising is present it will often extend to the base of the penis and inguinal area (groin).

Reduction in this risk requires meticulous surgery, avoidance of vigorous activity after surgery and compressing the operative area as best as possible. Compression of the loose scrotum is challenging so hematomas are more common than with many other types of surgery. Patients should wear tight fitting underpants and will be discharged from hospital with a compressive dressing, athletic support (jock strap) or both. Icing the area can also minimize the risk of bleeding and blood thinners should be avoided as directed by your doctor.

Management includes immediate re-exploration or drainage. In many cases hematomas can be observed and will resolve over 2-3 months. In some cases, hematomas may change into seromas and become permanent.

Incidence is approximately 1 in 25.

Wound infections include superficial and deep wound infections. Progressive redness, pain and discharge of pus are signs of infection. Fever is rare.

All patients are given antibiotics at the time of surgery. Post-operative antibiotics are not considered routine but may be prescribed at the discretion of your surgeon.

Infections are treated with antibiotics. Deep wound infections (abscesses) are rare and may require drainage in addition to antibiotics. They rarely cause any long term disability but will prolong recovery by a few days to weeks.

Good quality data on the incidence of reproductive tract injury is lacking. However, scrotal fluid collections are often intimately associated with the outflow of the ducts that exiting the testis and ultimately carry sperm to the urethra (rete testis, epididymis and vas deferens). Injury to any of these structures may occur with scrotal surgery.

Injuries to the reproductive tract are only relevant to men who have not yet completed their families. These types of injuries generally do not have any other consequences in other circumstances.

Injuries to the reproductive tract rarely become clinically significant unless they occur on bother sides (i.e. are bilateral) or there is a problem with the contralateral reproductive tract (e.g. prior injury from hernia, scrotal surgery, absent or small testis). Therefore, in rare cases, reduction in fertility or even sterility may arise from scrotal surgery.

One study assessed the presence of epididymal tissue in the pathology after hydrocelectomy and spermatocelectomy. One would not expect epididymal tissue in the specimen unless there was an inadvertent epididymal injury. The incidence was 6% in patients undergoing hydrocelectomy and 17% in those undergoing spermatocelectomy. DOI: 10.1097/01.ju.0000125479.52487.b4

Injury to the male reproductive tract is much more common with procedures such as pediatric or adult hernia repair and pelvic surgery.

Reconstruction may be possible.

DOI:10.1016/j.juro.2006.07.042

DOI.org/10.1016/S0022-5347(01)64036-9

Other complications are rare.

• Testicular loss. This is a risk of any type of inguinal or scrotal surgery. The risk is much smaller than 1 in 100.

• Chronic scrotal pain.

You will be provided a date and told to which medications to hold or continue. In general, patients may take all of their regular medications until the time of surgery with the EXCEPTION that blood thinners (anticoagulants and platelets) should be held for 3-7 days prior. The duration of cessation depends on the medication and you will be provided instructions.

Surgery is usually done under a general anesthetic (you will be asleep) augmented with local anesthetic. Some patients may have sedation plus local anesthetic.

Patients are positioned lying on their back. Prophylactic antibiotics are administered. The scrotum is shaved if not already done.

The surgery usually takes about 30 minutes.

Most patients have little to no pain when they awake from surgery.

There are several approaches to this surgery. All require a cut in the scrotum - either in the midline (up and down) or on one side. The incision is usually between 2-5 cm long.

Approaches to the surgery:

1. Excision: removal of part or all of the sac. The edges may be oversewn leaving a window or edges sutured behind the epididymis (the Jaboulay or bottle neck approach).

2. Plication: the edges are gathered like a pleated window blind and sutured in the up position.

The wound is closed with self-absorbing sutures and a dressing may be applied. If the sutures are not visible, they will be under the skin.

This is a day care surgery procedure (there is no overnight hospital stay). The total ‘door to door’ time is 3-4 hours.

Patients must arrange for a ride home accompanied by a responsible adult (i.e. one who can be with them - NOT a taxi or Uber driver).

Pain medications: you only need to take this if you are having pain. Often advil/ibuprofen and plain tylenol will be adequate. A prescription for stronger pain medication will be provided just in case. We generally recommend regular dosing of tylenol and advil (so long as you do not have a contraindication) for the first few days to ensure the pain does not rise to a level where it is difficult to control.

You may resume all of your regular medications unless directed otherwise.

Limit your activity for 2-3 weeks after surgery. Avoid strenuous physical activity (including exercise, sports and the gym). You may walk as much as you are comfortable. No limitations for stairs.

You may resume driving once you feel comfortable conducting the care safely. You are not permitted to drive within 24 hours after receiving sedation or a general anesthetic.

Patients may return to work within the limitations on activity as described above.

Patients may return to sedentary duties with days to a week or so. Those with physically demanding jobs will require 2-3 weeks off of work or on modified duties.

There are no dietary restrictions after scrotal surgery.

Avoid alcohol for 24 hours after surgery and as necessary for any of the prescribed pain medication instructions.

You may leave hospital with a dressing on or wrapped around the scrotum. You will be instructed when the dressing should be removed, usually 24-48 hours after surgery.

Swelling and bruising of scrotum often progress for 24-48 hours before starting to improve.

Scrotum may change colors as it heals for several days and weeks much like a bruise elsewhere.

May experience pain or discomfort around incision site.

You may apply Polysporin or a similar antibiotic ointment to you wound unless you have a skin glue (the skin glue will be apparent as a shiny or flaky area overlying the incision.

You may shower after the dressing is removed. Avoid bathing for about 3 weeks after the surgery and no pools or hot tubs for 4 weeks.

Not all patients will be discharged home with a drain. Drains are used to prevent fluid accumulation in the scrotum which may increase the risk of fluid recurrence.

Care and removal of drains is straightforward and simple. Nursing staff will provide teaching on wound care and how to empty the drain.

Patients will often remove their own drain. The retention suture is cut with the supplied scissors and the drain is pulled. That’s it.

There is usually a small amount of leakage from the skin opening which will close on its own.

You may shower before drain removal but should avoid getting the skin opening wet. Avoid using a bath. The skin may be wet in a shower after drain removal and wound care is the same as for the main wound.

Most patients do not require in person follow up with their surgeon unless an issue arises.

We will contact you 2-4 weeks after surgery to ensure your recovery is progressing as expected and review pathology results (if applicable).