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A clinical study of analysis of cystic swellings of the scrotum.

BACKGROUND

Cystic swellings of scrotum are one of the commonest clinical entities, which surgeon comes across in daily practice.

There are various reasons for scrotum to become swollen ranging from hydrocele the commonest cause, to some rare causes like malignant tumours of the epididymis.

Cystic swellings of scrotum are usually painless and can attain a very big size without causing much discomfort to patient. The scrotum is liable to traumatic injury due to their hanging down position and mobility leading on to haematocele.

Primary hydrocele is an abnormal collection of serous fluids in some part of the processus. Vaginalis, usually the tunica. (1) Epididymal cysts represents cystic degeneration of the epididymis and are filled with crystal clear fluid. (2)

Spermatocele is a retention cyst arising from either the vasa efferentia of the testis or from the epididymis. (3) The gold standard of treatment continues to be surgical. (4)

Cystic swellings of scrotum are a common entity in day to day clinics. Because of varied aetiology, their mode of presentation and management is unique for each. There is a necessity to study the ideal treatment modality for a given type of cystic swelling.

Aims and Objectives of Study

* To study the different clinical pattern of presentation of patients with cystic swellings of scrotum and their incidence.

* To study the age wise and side wise distribution of the cystic swelling of scrotum.

* These scrotal swellings occur in all age groups. Hence, there is a necessity to study the age wise distribution and the cause and predisposing factors related to these age groups.

* To study the different treatment modalities for a given type of cystic swelling of scrotum and their advantages and disadvantages.

* To study the postoperative complications of surgical procedures.

Pathophysiology

Tunica vaginalis testis is an invaginated serous sac and like any other serous cavity in the body it has a visceral and parietal layer. These two layers are separated by a potential cavity. The opposed surfaces are smooth and glistening. The cavity contains a thin layer of fluid to reduce friction.

The lining membrane is composed of a single layer of flattened endothelial cells supported by delicate areolar tissue. It forms a smooth glistening surface, opt to perform the function of preventing injury to the testis by constant rubbing with the medial aspect of the thigh. The fluid in the tunica vaginalis is kept in balance by the osmotic pressure, the colloid oncotic pressure of the blood. An increase in the intracapillary blood pressure or damage to the capillary endothelium increases the amount of fluid, which is of non-inflammatory origin and is called the transudate. (5) Normally, fluid from the sac is drained by the lymphatics in the parietal layer of the sac, as there are no or few epididymis. Lymphatics in the parietal layer of the sac, as there are no or few lymphatics in the subserosa over the testis and any hindrance with this normal mechanism either in the form of increased production or decreased absorption leads to the formation of hydrocele. (6)

MATERIALS AND METHODS

This study was undertaken in the Chengalpattu Medical College and Hospital. The cases admitted to the surgical wards from April 2014 to April 2016 formed the material for this study. During this period, 100 cases admitted in various surgical units were studied in detail as per the proforma.

Inclusion Criteria and Exclusion Criteria

1. Cystic swelling arising from the testis and its coverings, epididymis and spermatic cord are included in this study.

2. In Exclusion criteria, the inguinoscrotal swellings and swellings from scrotal skin are excluded in this study.

Methods

Patients admitted with symptoms pertaining to the scrotal swelling were studied making use of the available facilities in the hospital.

The Methods of Study consists of

* Detail history taking.

* Clinical examination.

* Routine laboratory investigations.

* Relevant special investigations in some cases.

* Evaluation of preoperative status and appropriate preparation for surgery.

* Surgical treatment according to the merits of the case as decided by attending surgeon under suitable anaesthesia as decided by the anaesthesiologists.

* Operative findings.

* Post-operative course and management of post-operative complications.

* Fluid analysis and histopathological examination in relevant cases.

* Followup.

RESULTS

Analysis of Data and Results

Observations and Discussion of Cases

Present study includes 100 cases, cases admitted to Chengalpattu Medical College Hospital between April 2014 and 2016.

The youngest is 1% years child and the oldest being 82 years. The maximum number of cases seen in the age group of 31-40 years, whereas minimum number of cases were seen after 70 years and above.

In this study, cystic swelling of the scrotum were more common in ryots followed by agriculturists and students. Most of them were from poor social-economic class.

In this study in 41% of cases the duration of the swellings was 6-12 months followed by 0 to 6 months in 36% of cases, 16% of cases presented between 1-2 years, majority of the patients presented within 2 years of onset of symptoms.

Sidewise distribution of the swelling showed a higher incidence on the right side of the scrotum 54%, when compared with the left side of the scrotum 37%; bilateral swelling were present in 9% of the cases.

In our study of cystic swelling of scrotum, the commonest presentation was primary vaginal hydrocele (57%) followed by congenital hydrocele (14%) and epididymal cyst 11% and least was spermatocele and secondary hydrocele with 2% each.

85% of patients were given spinal anaesthesia followed by 13% of patients with general anaesthesia and 2% of patients with local anaesthesia.

Treatment

Jaboulay's eversion of sac was done for primary vaginal hydrocele, which accounts for 40%. Lord's Plication operation was done for 9% of the cases. Partial/subtotal excision and eversion of sac was done for bigger hydroceles, which accounts for 14% of the cases; excision of epididymal cyst and encysted hydrocele of the cord accounts for 19% of the cases; herniotomy was done in 12% of the cases; incision and drainage in 4% of the cases; evacuation of clot and eversion of sac in 2% of the cases.

Per-operatively, normal testis was observed in 88 cases; 9 cases showed flattening of testis in primary vaginal hydrocele. Inflamed testis was seen in 3% of cases.

DISCUSSION

Study of 100 cases of cystic swelling of scrotum was done between April 2014 and April 2016 over a span of 48 months in Chengalpattu Medical College, Tamilnadu. The study was compared with other studies.

Cystic swellings of the scrotum occur in all the age groups, but in present study of 100 cases most of the patients were in the 31-40 years' age group (22%) followed by 11-20 years of age group (20%), most of them presented with scrotal swelling with pain.

Clinical examination was found to be very important for diagnosis. (7) Majority of the swelling were cystic in consistency, fluctuant and translucent and transillumination was negative in cases of secondary hydrocele, spermatocele, haematocele, pyocele and because of the opaque nature of their contents. The diagnosis confirmed by scrotal ultrasonography. (8)

The commonest cause for cystic swelling for the scrotum was primary vaginal hydrocele, (9) which accounts for 57%. The other causes were epididymal cyst 11%, congenital hydrocele 14%, encysted hydrocele of cord 7%, secondary hydrocele 2%, haematocele 3%, pyocele 4% and spermatocele 2%.

Maximum number of cystic swelling of scrotum were seen in the age group of 31-40 years, i.e. 22%.

The incidence of hydrocele was more common on the right side of the scrotum when compared to the left side.

A similar incidence was observed in a study done by C. Mahalingam (1985).

While no cause could be detected for primary vaginal hydrocele and epididymal cyst, secondary hydrocele was due to disease of the testis and epididymitis of the 2 cases of secondary hydrocele, both were secondary to tuberculous epididymo-orchitis. The cause for haematocele was recent trauma in 2 cases and in one case it was post-hernioplasty operation and for pyocele was infection of hydrocele.

Surgery was gold standard and was employed in all the cases.

Spinal anaesthesia was used in most of the cases i.e. 85%, general anaesthesia in 13% and local anaesthesia in 2% as per the merit of the patient. (10)

In primary vaginal hydrocele Lord's plication was found to be simple, effective and associated with least post-operative complications. The other conventional techniques like partial/sub-total excision and eversion of sac and eversion of sac were associated with increased incidence of complications like haematoma, scrotal oedema and infection. The results of present study are comparable to that of the previous series.

The results of this study are comparable to that of previous series. Of the nine cases of hydrocele treated by Lord's plication, none developed haematoma. Haematoma was observed in 15 cases out of 48 cases treated by partial/subtotal excision and eversion/eversion of sac. This is high compared to Campbell series, low compared to Rai et al series, but comparable to Effron et al and Dahl et al series.

Lord's plication gave rise to less complications and postoperative morbidity. May be because Lord's plication procedure avoids the opening of the cleavage between the sac and surrounding tissue, thus reducing the oozing and subsequent haematoma formation. (11)

O. P. Agarwal in 1983 did a comparative study on radical cure of hydrocele.

In this study he showed that among 50 cases who were operated by Lord's plication, none of them developed haematoma or infection, whereas in 50 cases who underwent eversion of sac 14 (28%) cases developed haematoma and 8 (16%) cases developed infection. In our study, among 48 cases underwent eversion of sac only 15 (31.6%) developed haematoma and 9 (18.7%) cases developed infection.

This study shows that Lord's plication for hydrocele is simple, effective, safe and economical. It is the procedure of choice for management of small-to-moderate sized primary hydrocele. The only factor against this procedure is a large hydrocele or a thick walled hydrocele where eversion subtotal excision of sac is the operation of choice. (12) The common postoperative complications observed were pain, scrotal oedema and haematoma, managed conservatively by analgesics, scrotal support and antibiotics.

Minimal tissue dissection and with maintaining haemostasis during surgery are important for prevention of post-operative complications. Post-operative scrotal support helps to relieve pain, minimise scrotal oedema and prevent haematoma.

Discharge and Followup

While discharging each patient was educated about the disease and the study; and was requested to attend the outpatient department for followup.

Followup was done for 2-4 months. In general it was poor, may be due to their work at fields or for daily earnings. Cases which were followed regularly showed no recurrence.

Most of our patients were discharged between 5-7 days, but some patients who developed scrotal oedema and infection were kept till 10 days.

Earliest patients discharged was on 3rd post-operative day after herniotomy.

The result of present study are comparable to that of the previous series.

CONCLUSION

Majority of the patients with cystic swelling of the scrotum belonged to the 31-40 years of age group 22% followed by 11-20 years of age group 20%. Primary vaginal hydrocele is the commonest cause of cystic swelling of the scrotum with 57%. The most common presenting feature is asymptomatic swelling of the scrotum. The exact cause of primary vaginal hydrocele is not known. Secondary hydrocele is due to some underlying disease of the testis and epididymis. Big primary vaginal hydrocele of long duration can produce pressure effects on the testis. Surgical treatment is the gold standard for management of cystic swelling of the scrotum. Lord's plication for hydrocele is simple, effective, safe and economical; proper preoperative preparation of scrotum and surrounding area and with good personal hygiene. Most of the post-operative infections could be controlled. Minimal tissue handling and good haemostatic control are the key to prevention of postoperative complications. Hydrocele in infants is practically always congenital and associated with hernia. Maximum number of cases were ryots in occupation followed by Agriculturists and students respectively. Most of them were from poor socioeconomic class. Cystic swelling of scrotum was most common on right side of scrotum.

Haematomas were very common in postoperative period; i.e. after subtotal/partial excision of sac in hydrocele, no haematoma in Lord's procedure. Followup was generally poor in this study; most of them followed up till 2 months; only few followed up till 4 months. No recurrence was observed in these cases.

DOI:10.14260/jemds/2016/1669

REFERENCES

(1.) Fowler C. The testis and scrotum. Chapter No: 68. In: Russel RCG. Bailey and loves short practice of surgery. 23rd edn. London: Arnold Publishers 2000:1270-80.

(2.) Goldstin M. Surgical management of male infertility and other scrotal disorders. In: Walsh PC, Retik AB, Vaughan ED, et al. 7th edn. Wein campbells urology. WB Saunders Company 1998;2:1332-74.

(3.) Johstone JMS. Hargreave TB. Male urethra and genital organs. In: Rintoul RF. 8th edn. Farquharsons text book of operative surgery. Churchill Living stone 1995:672-83.

(4.) Rodriguez WC, Rodriguez DD, Fortuno RF. The operative treatment of hydrocele: a comparison of 4 basic techniques. Journal of Urology 1981;125(6): 804-5.

(5.) Russel RCG, Williams NS, Bulstrode CJK. Bailey and love short practice of surgery. 24th edn. Arnolds publications 2004:1403-16.

(6.) Wenerth JL, Robertson GN. The male genital system. In: Sabastian DC, Lyerly HK. Sabastion textbook of surgery-the biological basis of morden surgical practice. 15th edn. WB Saunders company 1997:1556-62.

(7.) Testis DS. Epididymis & scrotum. Chapter 60. In: Concise text book of surgery. Das, Calcutta 1994:p 1266.

(8.) Bernd H, Fobbe F, Loy V, et al. Testicular cysts: differentiation with US and clinical findings. Radiology 1988;168(1):19-23.

(9.) Ozdilek S. The pathogenisis of idiopathic hydrocele and a simple operative technique. Journal of urology 1957;77(2):282-4.

(10.) Wilkinson JI. An operation for large scrotal hydrocele. British journal of surgery 1973;60(6):450-2.

(11.) Jawer PK, Sharma LS. Surgery of hydrocele. Indian journal of surgery 1979:700-4.

(12.) Sharlip, Ira D. Surgery of scrotal concerns. Urology clinics of North America 1987:145-8.

C. Srinivasan [1], P. Pandian [2], M. Kiran Kumar [3], M. Ramula [4], M. Vijayanand [5]

[1] Professor, Department of Surgery, Chengalpattu Medical College Hospital.

[2] Assistant Professor, Department of Surgery, Chengalpattu Medical College Hospital.

[3] Assistant Professor, Department of Surgery, Chengalpattu Medical College Hospital.

[4] Associate Professor, Department of Surgery, Chengalpattu Medical College Hospital.

[5] Junior Resident, Department of Surgery, Chengalpattu Medical College Hospital.

Financial or Other, Competing Interest: None. Submission 24-11-2016, Peer Review 07-12-2016, Acceptance 09-12-2016, Published 15-12-2016.

Corresponding Author:

Dr. M. Ramula, A-14, Old GST Road, Alagesan Nagar, Chengalpattu-603001. E-mail: ramuladurai@gmail.com DOI: 10.14260/jemds/2016/1669

Table 1. Age Incidence

Age Incidence of Cystic Swellings of the Scrotum

Sl.     Age Group   No. of   Percentage
No.                 Cases

1         1--10       12        12%
2        11--20       20        20%
3        21--30       17        17%
4        31--40       22        22%
5        41--50       9          9%
6        51--60       10        10%
7        61--70       9          9%
8       71--above     1          1%
Total                100

Table 2. Occupation of the Patients

Types of Occupation of Patients of Present Series

Sl. No.     Occupation     No. of Cases   Percentage

1             Coolie            30           30%
2            Business           13           13%
3         Agriculturists        26           26%
4            Student            24           24%
5             Others            7             7%
Total                          100

Table 3. Duration of Swelling

Duration of Swelling

Sl. No.       Duration        No. of Cases   Percentage

1            0--6 months           36           36%
2           6--12 months           41           41%
3            1--2 years            16           16%
4            2--3 years            1            16%
5            3--4 years            3             3%
6         4 years and above        3             3%
Total                             100

Table 4. Sidewise Distribution of Cystic Swellings

The Distribution of Cystic Swellings in the Present Study

Sl. No.        Side         No. of Cases   Percentage

1            Right (R)           54           54%
2            Left (L)            37           37%
3         Bilateral (B/l)        9             9%
Total                           100

Table 5. Type of Lesions

Sl. No.        Lesion         No. of Cases   Percentage

1          Primary Vaginal         57           57%
              Hydrocele
2            Congenital
              Hydrocele            14           14%
3          Epididymal Cyst         11           11%
4             Encysted             7             7%
          Hydrocele of Cord
5             Secondary            2             2%
              Hydrocele
6            Haematocele           3             3%
7              Pyocele             4             4%
8           Spermatocele           2             2%
Total                             100

Table 6. Type of Anaesthesia

Type of Anaesthesia used in the Present Study

Sl. No.   Anaesthesia   No. of Cases   Percentage

1           Spinal           85           85%
2           General          13           13%
3            Local           2             2%
Total                       100

Table 7. Type of Operations Performed

Type of Operations Performed on the Studied Cases

Sl.           Type of          No. of
             Operations        Cases    Percentage
No.
             Performed

1       Jaboulay's eversion      36        36%
               of sac
2        Subtotal excision       6          6%
        and eversion of sac

3       Partial excision and     6          6%
          eversion of sac
4         Lord's Plication       9          9%
            Excision for
        epididymal cyst and
5        encysted hydrocele      20        20%
             of cord +
            spermatocele
6            Herniotomy          14        14%
7           Incision and         4          4%
              drainage
8        Evacuation of clot      3          3%
        and eversion of sac
        Subtotal excision in
9            secondary           2          2%
             hydrocele
Total                           100

Table 8. Types of Surgical Procedure Employed

Surgical Procedure Employed for Primary Vaginal Hydrocele

Sl. No.           Procedure            No. of   Percentage
                                       Cases

1              Lord's plication          9        15.8%
2         Jaboulay's eversion of sac     36       63.2%
3            Partial excision and        6        10.5%
                eversion of sac
4           Subtotal excision and        6        10.5%
                eversion of sac
Total                                   100

Table 9. Post-Operative Complications

Post-Operative Complications

Post-Operative Complications Noticed in the Present
Study

Sl.        Operation       No. of   Scrotal   Haematoma     Wound
No.                        Cases    Oedema                infection

1          Jaboulay's        36       10         12           5
            eversion

            Subtotal
2         excision and       6         2          2           2
        eversion of sac

        Partial excision
3         and eversion       6         2          1           2
             of sac

4       Lord's plication     9        --         --           --

          Excision for
        epididymal cyst
              and
5           encysted         20        4          1           2
          hydrocele of
              cord
         + spermatocele

6          Herniotomy        14        2         --           --

7         Incision and       4        --         --           --
            drainage

         Evacuation of
8           clot and         3        --         --           --
        eversion of sac

            Subtotal
9         excision in        2         2         --           --
           secondary
           hydrocele
Total                       100       20         16          11

Table 10. Per-Operative Findings of Testis

Per-Operative Findings of Testis

Sl. No.         Findings         No. of Cases   Percentage

1            Normal testis            88           88%
2         Flattening of testis        9             9%
3           Inflamed testis           3             3%
Total                                100

Table 11. Comparison with the Previous Series 1

Sl. No.       Author          Year        Journal

1          Effron et al       1967          SGO
2           Dah et al         1972      Arch Surgery
3          Reddy et al        1972          IJS
4           Rai et al         1978          IJS
5             Lord's          1964          BJS
6            Campbell         1927          SGO
7         Present series   2004--2006        --

Sl. No.   Lord's Plication Procedure

          No. of Cases   Haematoma

1              29            1
2              25            1
3             400        Negligible
4              50            --
5              22            --
6              --            --
7              9             --

Sl. No.   Excision/Eversion of Sac

          No. of Cases   Haematoma

1              30         9 (30%)
2              23         6 (26%)
3              --            --
4              20         15 (75%)
5              --            --
6             502         12 (24%)
7              48        15 (31.6%)

Table 12. Comparative Studies (Agarwal Series)

Sl. No.   Series    Lord's Plication Procedure

                    No. of Cases   Haematoma   Infection

1         Agarwal        50           --          --
          Series
2         Present        9            --          --

Sl. No.   Series    Excision/Eversion of Sac

                    No. of Cases   Haematoma    Infection

1         Agarwal        50         14 (28%)     8 (16%)
          Series
2         Present        48        15 (31.6%)   9 (18.7%)
           Study

Table 13. Comparison of Results of Various Studies

Sl.                               No. of     Post-
No.      Author         Year      Cases    Operative
                                             Stay

1     Efforn et al      1967        29         5
2      Reddy et al      1973       400        5-6
3       Rai et al       1978        50        3-8
4     Present study   2004-2006    100        5-7

Chart 1. Age Incidence among Various Age Groups

1-10       12%
11-20      20%
21-30      17%
31-40      22%
41-50      9%
51-60      10%
61-70      9%
71-above   1%

Note: Table made from pie chart.

Chart 2. Occupation of the Patients

Student          24%
Agriculturists   26%
Business         13%
Coolie           30%
Others           7%

Note: Table made from pie chart.

Chart 4. Sidewise Distribution of Cystic Swelling
The Type of Lesions in the Present Study

Left        37%
Bilateral    9%
Right       54%

Note: Table made from pie chart.

Chart 5. Types of Lesion

Lesion

Primary Vaginal        57
  Hydro cele
Congenital hydrocele   14
Epididymal cyst        11
Encysted hydrocele     7
  of Cord
Secondary hydrocele    2
Hemato cele            3
Pyocele                4
Spermatocele           2

Note: Table made from bar graph.

Chart 6. Types of Anaesthesia

Spinal    85%
General   13%
Local      2%

Note: Table made from pie chart.
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Article Details
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Title Annotation:Original Research Article
Author:Srinivasan, C.; Pandian, P.; Kumar, M. Kiran; Ramula, M.; Vijayanand, M.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Dec 15, 2016
Words:3339
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