Dear Sumner:
A very tense young man just left my office, convinced that he has a testicular cancer. Bob is 26 years of age and has been aware of a scrotal swelling since “as long as he can remember.” He states the mass causes him no pain, although it seems to be getting progressively tenderer to touch (his girlfriend expresses her concern every time they are having sex). It was interesting that Bob commented that the swelling sometimes gets larger after he exercises, but soon reverts to its previous size. I believe we are dealing with a hydrocele given the history and the consistency of the mass. And assuming that the underlying diagnosis is, indeed, a hydrocele, is interventional therapy indicated? If it gets larger, can’t you just remove the fluid with a syringe or inject a chemical to destroy the sac?
Dear Craig:
I had a good talk with Bob and his girlfriend re his situation. Most likely we are, indeed, dealing with a hydrocele, since the mass did transilluminate on my physical examination. The cystic nature of the lesion was confirmed on ultrasound study. I believe that the progressive tenderness of the testis is likely secondary to the multiple self-examinations along with a bit of Bob’s “fixation” on this part of his anatomy. Ordinarily unless a hydrocele is sufficiently large as to cause local distress (either physically or psychologically), surgical intervention is not necessary. To answer your question about possible therapy, a hydrocele can be aspirated, but since the lining of the hydrocele sac secretes the fluid, the sac will likely refill within a few weeks, and, therefore, if surgery were to be done, it is best to remove the entire sac. Besides which, sticking a needle into the closed space of the hydrocele runs a risk of secondary infection.
However, in Bob’s case, these points are probably moot. Since the swelling has apparently been present since early childhood and is variable in size, there is very likely a persistent connection between the scrotal and peritoneal cavities: a patent processus vaginalis. (Ordinarily the processus vaginalis, which is the channel through which the testis descends from the abdominal cavity through the inguinal canal into the scrotum, closes spontaneously prior to birth). For practical purposes, I would treat this as a hernia (congenital) and I would advise its repair along with removal of the hydrocele sac (as an encore).
