Diagnosis and management of a rare case of encysted hydrocele of spermatic cord: Case report and literature review

Abstract

Introduction and importance

A hydrocele is typically a non-cancerous condition that arises from the accumulation of fluid between the layers of the vaginal process. Diagnosis primarily involves a physical examination. In instances where the condition is mistaken for other pathological conditions, additional investigations may be undertaken. Surgical intervention is typically deferred until after the age of one year, unless the hydrocele is significantly large.

Case presentation

A case was presented of a 4-year-old boy who was referred to the hospital with a suspected deep inguinal hernia. Upon examination, it was determined that the mass was actually an encysted hydrocele of spermatic cord. The patient underwent a minimally invasive surgery to remove the spermatocele, and the procedure was successful.

Clinical discussion

This emphasizes the importance of obtaining a detailed patient history and conducting a comprehensive physical examination, which often provide sufficient information to make a diagnosis. In many instances, these initial steps can spare patients from undergoing additional tests that may be invasive or pose unnecessary risks.

Conclusion

It is important to note that in cases of hydroceles, conservative treatment, such as observation, is the primary approach before the age of one year. Surgery is typically reserved for older children or those with large hydroceles.

Highlights

• •Hydroceles are typically considered non-cancerous conditions.
• •Hydroceles can be broadly classified into two primary types: cystic and funicular.
• •Hydroceles can sometimes be mistaken for other pathological conditions.
• •The necessity of a good clinical examination and avoiding unnecessary surgery.

1. Introduction

A hydrocele is a fluid collection that forms between two layers of the vaginal process, the parietal and visceral layers. This occurs when the vaginal process, which eventually forms the tunica vaginalis [1,2], the protective sac around the testis, fails to atrophy completely. Hydroceles are relatively common, occurring in about 10 % of newborns. In most cases, they spontaneously resolve within the first year of life. Therefore, conservative management, with regular monitoring, is the preferred approach during this period. Hydroceles are typically painless and pose no significant risk to the child, making them not an urgent medical concern [3].

Hydrocele of spermatic cord are typically painless and may or may not be associated with the peritoneum, the lining of the abdominal cavity. The cause of hydrocele of spermatic cord is often unknown, but they may arise secondary to other conditions [3]. There are two main types of hydrocele of spermatic cord: cystic and funicular. Cystic hydrocele of spermatic cord are commonly found in the femoral region and can be suspected based on clinical examination or imaging techniques such as ultrasound [2,4].

This manuscript delves into the various types of hydroceles and the optimal diagnostic and treatment approaches. It also emphasizes the importance of distinguishing hydroceles from other conditions that may share similar symptoms. Although the optimal surgical intervention for hydroceles remains a subject of debate, various minimally invasive techniques are gaining prominence.

This case is described in accordance with the criteria of SCARE [5].

2. Patient information

We present the case of a 4-year-old male child who experienced recurring vomiting, approximately five times daily, two days prior to presentation. Subsequently, one day later, the parents observed a swelling in the right inguinal region prompting them to seek medical attention from an external physician for evaluation. This prompted the external physician to refer the patient to our facility on an urgent basis, raising suspicion of a right Incarcerated inguinal hernia.

3. Clinical findings

3.1. Clinical examination

Upon the child's arrival, his vital signs were within normal range. Physical examination of the abdomen revealed a soft and non-tender abdomen. Clinical examination of the groin revealed a firm mass with well-defined margins (Fig. 1A), distinct from the testis (Fig. 1B). Afterward, the right hemiscrotal was highlighted, where it revealed that transillumination was positive (Fig. 1C).

Fig. 1.

A: Clinical picture showing swelling in the right hemiscrotal.

B: Clinical picture showing a well-defined hydrocele, isolated from the testicle.

C: The right hemiscrotal, showing that transillumination was positive.

4. Diagnostic evaluation

Laboratory testing revealed a hemoglobin of 13.8 g/dL, a total white blood cell count of 5000/mm³, a platelet count of 326,000/mm³.

Ultrasound examination revealed a fluid-filled mass, distinct from the testis, raising the possibility of a hydrocele of the spermatic cord. However, deeper investigation was warranted to rule out the possibility of a deep inguinal hernia.

To determine the exact nature of the mass, surgical intervention was recommended. Under general anesthesia, an incision was made along the right inguinal fold, extending to the external inguinal ring. Upon exploration, a firm mass was identified.

A meticulous dissection was performed to carefully separate the hydrocele of the spermatic cord from the blood vessels within the cord and the vas deferens. The mass was found to be completely detached from the testis and the internal inguinal ring (Fig. 2A).

Fig. 2.

A: Intraoperative image showing the testis separated from the hydrocele, the green arrow indicates to the testicle, the yellow arrow indicates to the hydrocele and the blue arrow indicates the vessels of the spermatic cord.

B: Image after complete removal of the hydrocele.

After confirmation of the diagnosis, the hydrocele was resected (Fig. 2B). The surgical incision was then closed in layers. The child's condition remained stable throughout the procedure and postoperatively. He was discharged the following day.

5. Discussion

To understand the formation of a hydrocele, it is essential to consider its embryonic development. During fetal development, between the 28th and 32nd weeks of gestation, the testes descend from their initial location behind the peritoneum into the scrotum. During this descent, they carry two layers of the peritoneum along with them, forming a structure called the vaginal process.

Normally, the vaginal process should atrophy over time, leaving behind a thin membrane called the tunica vaginalis, which surrounds the testis and epididymis [6]. However, if the vaginal process fails to atrophy completely, it can result in the formation of a hydrocele.

There are three main types of hydroceles based on the extent of the vaginal process's failure to close:

• 1.Continuous hydrocele: This occurs when the vaginal process fails to close completely, allowing fluid to flow freely between the abdominal cavity and the tunica vaginalis.
• 2.Funicular hydrocele: This type of hydrocele develops when the distal end of the vaginal process fails to close, but the proximal end remains intact. This creates a connection between the tunica vaginalis and the abdominal cavity through a narrow passage.
• 3.Encysted hydrocele: This type of hydrocele forms when the vaginal process fails to close completely, but a section of the process, called Cranford's section, between the internal inguinal ring and the distal space above the epididymis and testis, fails to atrophy. This results in a fluid-filled sac within the scrotum, but there is no direct communication with the abdominal cavity.

In some cases, both funicular and encysted hydroceles can occur simultaneously, leading to a mixed pattern [[7], [8]].

A similar condition called hydrocele of the Nuck canal can occur in women, which involves a portion of the vaginal process within the inguinal canal [9]. Hydrocele of the spermatic cord is often idiopathic, but it can also arise from secondary conditions such as testicular torsion, trauma, epididymitis, or tuberculosis [10].

Certain conditions can prevent the vaginal process from retracting, leading to the formation of a spermatocele, such as cystic fibrosis, prematurity, or peritoneal dialysis [11]. This condition typically presents no symptoms and is often discovered incidentally during an examination for another reason [12,13]. However, it can be mistaken for other pathological conditions such as lymphadenopathy, undescended testis, or incarcerated inguinal hernia [14].

Diagnosis of a spermatocele is primarily based on clinical examination. In cases of diagnostic uncertainty, imaging studies such as ultrasound or CT scan can be performed [7]. The standard approach to hydroceles in children is observation until the age of one, unless the hydrocele is large. In cases where the hydrocele persists beyond one year, surgical intervention is recommended. The surgical approach remains controversial, with options including inguinal crease incision, scrotal incision, or laparoscopy. In the past, inguinal crease incision was the preferred method for children with indirect inguinal hernia and associated hydrocele [15], but over time, scrotal incision has gained favor among surgeons.

The presence of a short inguinal canal allows for retraction of the cyst, providing excellent access to the PPV and its ligation [16]. This incision also circumvents the need to penetrate the inguinal canal, enabling adequate access to the PPV with minimal dissection and risk of injury to the ilioinguinal and genital-femoral nerve [17].

Furthermore, this approach offers a more cosmetic outcome compared to the scrotal incision. The combined advantages of these factors lead to reduced post-operative pain, faster recovery, and shorter hospital stay. However, direct inguinal hernias cannot be addressed through this incision as it can lead to scrotal edema, which is typically managed with anti-inflammatory medications.

Studies have demonstrated that access through the inguinal crease is the preferred method for continuous hydroceles [18]. In one study comparing trans-scrotal and trans-inguinal crease incisions, no significant differences were observed in the rates of complications or recurrence [19]. Surgical treatment of hernias and hydroceles in children has also been conducted via laparoscopy, offering the advantage of bilateral evaluation and treatment [15]. However, its higher cost and scarring compared to the trans-scrotal incision may limit its use.

In our case, we opted for the inguinal crease incision due to the child's age and the potential for an accompanying incarcerated inguinal hernia. The shorter inguinal canal in children facilitates retraction of the cyst and access to the PPV, while also reducing the risk of injury to the ilioinguinal and genital-femoral nerve.

6. Conclusion

It is important to focus on the clinical examination before taking any steps towards requesting radiological investigations or making a decision for surgery, especially under the age of one, thereby avoiding unnecessary surgery for the child.

Abbreviations

CT

computed tomography

MRI

magnetic resonance imaging

US

ultrasound

PPV

patent processus vaginalis

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

S.J: Conceptualization, resources, who wrote, original drafted, edited, visualized, validated, literature reviewed the manuscript, and the corresponding author who submitted the paper for publication.

M.J and M.T.M: Supervision, visualization, validation, resources, and review of the manuscript.

S.A, A.A and M.M.: Visualization, validation, and review of the manuscript.

All authors read and approved the final manuscript.

Guarantor

Shkri Jaweesh.

Research registration

N/A.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Consent of patient

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Declaration of competing interest

The authors declare that they have no competing interests.

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available because the data were obtained from the hospital computer-based in-house system. Data are available from the corresponding author upon reasonable request.