Hydrocele, spermatocele: clinical guidelines

List of Abbreviations

MRI – magnetic resonance imaging

GR – grade of recommendation

LE – level of evidence

US – ultrasound examination

CDU – color duplex ultrasonography

Terms and Definitions

Isolated hydrocele is an excessive accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis of the scrotum with an obliterated processus vaginalis.

Communicating hydrocele is an excessive accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis of the scrotum with an unoblittered processus vaginalis.

Tense hydrocele is an excessive accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis of the scrotum, leading to increased pressure in its cavity. It is accompanied by tension of the scrotal membranes and may cause pain.

Infected hydrocele (pyocele) is accompanied by bacterial infection of the scrotal cavity.

Epididymal cyst is a benign cystic lesion of the epididymis filled with serous fluid.

Spermatocele is an epididymal cyst containing spermatozoa.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Hydrocele is an excessive accumulation of fluid between the parietal and visceral layers of the tunica vaginalis of the scrotum.

Funicular hydrocele (cyst of the spermatic cord) is an accumulation of fluid along the spermatic cord when the processus vaginalis remains unoblittered at that level [1].

Epididymal cyst is a benign cystic lesion of the epididymis filled with serous fluid.

Spermatocele is an epididymal cyst containing spermatozoa.

In practice, these two terms are interchangeable, as they can only be reliably differentiated by analyzing the contents of the cyst [2].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Hydrocele

The anatomical prerequisite for congenital hydrocele is the failure of the processus vaginalis to close [3]. Incomplete obliteration results in a communicating hydrocele. If obliteration occurs at the level of the internal inguinal ring and fluid accumulates in the scrotal cavity, a non-communicating hydrocele develops. Residual unoblittered cavities at the level of the spermatic cord can lead to funicular hydrocele [4].

Acquired hydrocele may be due to pathological production of effusion into the serous cavity of the scrotum.

Predisposing factors for acquired hydrocele may include:

- inflammatory process,

- scrotal trauma,

- history of surgical interventions on the scrotal organs and inguinal region (varicocelectomy, inguinal herniorrhaphy),

- neoplasms,

- filariasis.

Isolated hydrocele occurs predominantly in adolescents and is associated with trauma, orchiepididymitis, or prior ligation of the testicular veins for varicocele [5]. The etiology of hydrocele cannot always be determined, in which case an idiopathic nature of the condition is assumed [6].

Spermatocele

The etiology of spermatocele is not reliably known. The cyst may develop due to obstruction in the epididymal efferent ductules following an inflammatory process or trauma, with their subsequent dilation [7].

1.3 Epidemiology of the Disease or Condition

Hydrocele

There are no reliable data on the prevalence of the disease in children.

In ultrasound examinations of children aged 8 to 36 months, the detection rate of hydrocele is 2.8% [8]. During routine preventive examinations of children and adolescents, the detection rate of hydrocele reaches 0.96% [9].

Spermatocele

According to literature data, the incidence of epididymal cyst in children ranges from 5 to 20%, increasing in adolescents [10].

1.4 Features of Coding the Disease or Condition

N43.0 – Encysted hydrocele

N43.1 – Infected hydrocele (an additional code B95-B98 may be used to specify the infectious agent)

N43.2 – Other forms of hydrocele

N43.3 – Hydrocele, unspecified

N43.4 – Spermatocele

P83.5 – Congenital hydrocele

1.5 Classification of the disease or condition

Hydrocele

There is no universally accepted classification of hydrocele and spermatocele. Based on a generalized analysis of the literature, it seems appropriate to distinguish the following gradations of hydrocele:

1. By genesis:

- congenital

- acquired

A. primary (idiopathic)

B. secondary (symptomatic)

2. Presence of communication with the abdominal cavity

- isolated

- communicating

3. Course of the disease

- acute

- chronic

4. Complications

- tense

- infected (pyocele)

5. Location

- unilateral

- bilateral [4,11,12,13].

Spermatocele

There is no universally accepted classification of spermatocele. Based on a generalized analysis of the literature, it seems appropriate to distinguish the following gradations of spermatocele:

1. Location

- unilateral

- bilateral

2. By number

- single

- multiple

3. Complications

- infected

- tense

- cyst torsion [14].

1.6 Clinical presentation of the disease or condition

Hydrocele

Enlargement of one or both sides of the scrotum is noted (in bilateral cases). Palpation is painless; the scrotum has a soft-elastic consistency. The testis can be palpated only when the hydrocele volume is small. In funiculocele, an elastic formation is palpated along the spermatic cord. With a large cyst volume, it may extend to the scrotal part of the spermatic cord and resemble a hydrocele, with the testis being palpable separately from the cyst.

In communicating hydrocele, the fluid volume can change, increasing with prolonged upright posture of the patient.

Infected hydrocele is accompanied by hyperemia and edema of the scrotum and is painful upon palpation [4,6,15,16].

Spermatocele

The epididymal cyst is usually asymptomatic. Palpation may reveal a rounded, elastic, painless mass in the projection of the epididymis, most commonly in the region of the epididymal head. In rare cases of epididymal cyst torsion, the clinical picture may include the following symptoms: edema, scrotal hyperemia, and pain in the epididymis region. Tenderness may be noted in tense spermatocele. Upon infection, an inflammatory process develops, mimicking the presentation of the "acute scrotum syndrome" [14,17].

2. Diagnostics, medical indications and contraindications for diagnostic methods

2.1 Complaints and Anamnesis

Criteria for diagnosis establishment: the diagnosis is established based on the patient's history, complaints, results of physical examination, and instrumental examination data.

Hydrocele

Patients may present with complaints of enlargement of one half of the scrotum; a significant hydrocele volume can lead to stretching of the membranes and skin of the scrotum, resulting in pain syndrome. In spermatic cord cysts, complaints may include a visible or palpable mass along the spermatic cord. In infected hydrocele, hyperemia and edema of the scrotum, as well as pain syndrome, are noted.

Complaints in secondary hydrocele will correspond to the underlying disease.

Spermatocele

Comment: patients with an epididymal cyst typically do not present with complaints, and the condition is frequently discovered during examination for other pathology of the scrotal organs. In rare cases of epididymal cyst torsion, the complaints will be characteristic of the acute scrotum syndrome [2].

2.2 Physical Examination

Hydrocele

Comment: with a sufficient accumulation of fluid, palpation of the testis may be difficult. Secondary hydrocele will be accompanied by symptoms of the underlying condition (orchitis, epididymitis, testicular torsion).

Spermatocele

Comment: an epididymal cyst is most commonly located in the region of the epididymal head as a rounded, painless mass.

2.3 Laboratory Diagnostics

There are no specific laboratory tests for diagnosing the disease. In secondary hydrocele associated with inflammatory diseases of the scrotal organs, an increase in leukocyte count may be observed [18].

2.4 Instrumental Diagnostics

Hydrocele

Comment: when performing a scrotal ultrasound, it is necessary to assess the amount of fluid, its characteristics, and the presence of communication with the abdominal cavity. It is also necessary to rule out an inguinal hernia. In secondary hydrocele, diagnosis of the underlying condition is performed [1,11].

Spermatocele

Comment: scrotal ultrasound is the primary instrumental diagnostic method for an epididymal cyst. It evaluates the structure of the testis and epididymis, the size of the cyst, and its location [2,19].

2.5 Other Procedures

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

Hydrocele

• Observation of acquired non-tense hydrocele, including a follow-up consultation (examination, consultation) by a pediatric urologist-andrologist, is recommended for 12 months [24,25].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: surgical treatment of congenital hydrocele before the age of 12 months may be performed in cases of combination with an inguinal hernia, or in tense or infected hydrocele.

Spermatocele

• When an asymptomatic epididymal cyst is detected, observation is recommended — including a follow-up consultation (examination, consultation) by a pediatric urologist-andrologist for 12 months in order to assess the size of the spermatocele in the absence of active growth [19].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comment: in a number of cases, involution of the epididymal cyst is possible [26].

3.2 Surgical Treatment

Hydrocele

Comment: the main principle of surgical treatment for communicating hydrocele is ligation of the processus vaginalis at the level of the internal inguinal ring via an inguinal canal approach (Ross procedure) or a laparoscopic approach. For non-communicating hydrocele, excision of the tunica vaginalis is performed.

Comment: currently, there is no convincing evidence of the superiority of laparoscopic versus inguinal approaches for communicating hydrocele; due to comparable outcomes, both methods can be used with equal efficacy [31,32].

Laparoscopic closure of the processus vaginalis of the peritoneum and video-assisted ligation of the processus vaginalis of the peritoneum may be used in cases of communicating hydrocele combined with an inguinal hernia, bilateral communicating hydrocele, or communicating hydrocele combined with a contralateral inguinal hernia [32,33,34].

Comment: as a rule, the presence of these complaints and symptoms corresponds to a hydrocele volume of at least 40-50 milliliters in an adolescent.

Comment: currently, the main techniques used for non-communicating hydrocele are: Bergman, Winkelmann, and Lord procedures. In the Winkelmann procedure, the tunica vaginalis is everted and sutured behind the epididymis. The Bergman procedure involves the excision of a portion of the tunica vaginalis and is preferred for large-volume hydroceles. The Lord procedure involves plication of the tunica vaginalis using sutures [5,13,36].

Following hydrocele excision, regardless of its form, the following complications are possible:

- hematoma,

- local infection of the postoperative wound,

- injury to spermatic cord elements,

- iatrogenic cryptorchidism,

- injury to the inferior epigastric or external iliac vessels [31,36].

Spermatocele

Comment: the epididymal defect after cyst removal is closed with interrupted sutures [2].

Sclerotherapy is not used for spermatoceles in children as there is no evidence regarding its efficacy and safety [2,14].

Following excision of an epididymal cyst, the following complications are possible:

- scrotal hematoma,

- local infection of the postoperative wound.

3.N Other treatment

Not applicable.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• Specific rehabilitation methods are not indicated.

• Sanatorium-resort treatment is not indicated.

5. Prevention and Dispensary Observation

Hydrocele

Spermatocele

6. Organization of Medical Care

Indications for hospitalization in a medical organization:

1) Elective hospitalization: for surgical treatment;

2) Emergency hospitalization: in case of complications or pain syndrome.

Indications for patient discharge from a medical organization:

1) Patient discharge is possible on days 1–7 after surgical treatment if the patient's condition is satisfactory, with no signs of surgical site infection, hyperthermia, or testicular ischemia;

2) Patients may be discharged from the hospital with subsequent outpatient follow-up according to the recommendations.

7. Additional Information

Not applicable.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Kozyrev German Vladimirovich – D.Sc. in Medicine, Professor at the Department of Pediatric Surgery and Urology-Andrology named after L.P. Alexandrov, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Director of the Association of Pediatric Urologists-Andrologists (APUA).

2. Shchedrov Dmitry Nikolaevich – D.Sc. in Medicine, Associate Professor at the Department of Urology with Nephrology, Yaroslavl State Medical University of the Russian Ministry of Health, Head of the Department of Pediatric Uroandrology, Regional Children's Clinical Hospital, Yaroslavl.

3. Garova Daria Yuryevna – Ph.D. in Medicine, pediatric urologist-andrologist, Central City Hospital, Yaroslavl.

4. Kharchilava Revaz Revazovich – Ph.D. in Medicine, Director of the Praxi Medica Medical Training Center, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow.

Conflict of interest: none.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Pediatric urologists-andrologists

2. Pediatric surgeons

3. Pediatricians

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

No information available.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Hydrocele is a pathological accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis of the testis. This condition can be congenital or acquired. Funicocele (spermatic cord cyst) occurs when an excessive accumulation of serous fluid is located along the spermatic cord.

Congenital hydrocele is caused by the persistence of communication between the scrotal cavity, inguinal canal, and peritoneal cavity. It is diagnosed in 1–2% of newborns. It can be unilateral or bilateral. There is an enlargement of one or both sides of the scrotum. Palpation is painless, and the scrotum has a soft-elastic consistency. The volume of fluid can vary, increasing after prolonged upright posture. In funicocele, an elastic mass is palpable along the spermatic cord.

The condition requires monitoring by a pediatric urologist-andrologist. In most cases, congenital hydrocele resolves spontaneously during the first year of life and requires only dynamic observation. Surgical intervention may be required in the following cases:

- infection of the hydrocele,

- tense hydrocele leading to elevated pressure within the scrotal cavity,

- progressive increase in fluid volume during the observation period,

- combination with an inguinal hernia,

- combination with other scrotal pathologies on the affected side.

Acquired hydrocele occurs predominantly in adolescents. Causes may include previous inflammatory diseases of the scrotal organs, trauma, previous surgeries on the scrotal organs and inguinal canal, or the cause may remain idiopathic. Initial presentation requires monitoring by a pediatric urologist-andrologist for 6–12 months and scrotal ultrasound. Surgery is indicated in the presence of pain or discomfort caused by enlargement of one half of the scrotum. Following surgery and hospital discharge, outpatient follow-up by a pediatric urologist-andrologist is indicated.

Spermatocoele (epididymal cyst) is a benign fluid-filled lesion of the epididymis. It is usually asymptomatic and most often detected during evaluation for other scrotal conditions or during a routine health check. When diagnosed, monitoring by a pediatric urologist-andrologist and scrotal ultrasound are indicated. Spontaneous involution of the cyst over time is possible. If the cyst is large, actively growing, painful, infected, or undergoes torsion, surgical treatment involving excision of the lesion is necessary.

Following surgery and hospital discharge, outpatient follow-up by a pediatric urologist-andrologist is indicated.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.