Prevention and treatment of hydrocele and epididymitis: A guide to men's health.

Hydrocele

In normal human anatomy, as the testis descends from the retroperitoneal space, the processus vaginalis, composed of two layers of peritoneum, also enters the scrotum through the inguinal canal. Around birth, the upper two-thirds of the processus vaginalis completely closes, forming a blind sac surrounding the testis, known as the tunica vaginalis. A small amount of fluid accumulates within the tunica vaginalis, acting as a lubricant to facilitate testicular movement.

If there is a congenital abnormal increase in the amount of fluid within the tunica vaginalis or abnormal closure of the processus vaginalis, causing fluid accumulation, a hydrocele forms. Additionally, even when the processus vaginalis closes normally, acquired factors such as testicular or epididymal infections, tumors, filariasis, or trauma can increase the amount of fluid within the tunica vaginalis, also leading to hydrocele.

Hydrocele is classified into four types:

First, spermatic cord hydrocele, characterized by closure at both ends of the processus vaginalis, forming a localized hydrocele in the spermatic cord portion, not communicating with the abdominal cavity or the tunica vaginalis cavity of the testis;

Second, testicular hydrocele, this is the most common type, where the processus vaginalis is normally closed, and it forms due to the accumulation of fluid within the tunica vaginalis;

Third, communicating hydrocele, characterized by complete opening of the processus vaginalis, allowing fluid from the abdominal cavity to enter the tunica vaginalis cavity through the open processus vaginalis passage, with the fluid flowing with changes in body position.

This type of hydrocele needs to be differentiated from inguinal hernia, the difference being that the passage between the tunica vaginalis sac and the abdominal cavity is narrow, preventing the greater omentum and intestinal loops from entering the tunica vaginalis sac, allowing only fluid from the abdominal cavity to enter;

Fourth, spermatic cord-testicular hydrocele, where the processus vaginalis closes only at the internal ring, the spermatic cord portion remains open and communicates with the tunica vaginalis cavity of the testis.

Hydrocele usually occurs only on one side of the scrotum. When the fluid is small, it is only discovered during a physical examination and is asymptomatic. Only when the fluid increases to a certain size will the patient experience discomfort such as scrotal heaviness, swelling, and traction pain. In cases of large hydrocele, the penis and glans may retract into the foreskin, affecting urination and sexual intercourse, and causing inconvenience during walking and labor. Hydrocele secondary to acute epididymitis or orchitis presents with significant local pain.

【Treatment Methods】 The treatment method for hydrocele should be determined based on the patient's age, physical condition, and the type of hydrocele.

Because hydrocele in infants and newborns may resolve spontaneously, except in cases of severe infection or other complications, treatment may be temporarily postponed until after 1 year of age (12-18 months). Primary hydrocele typically has a short course, small fluid volume, low intracystic tension, no obvious symptoms, and no testicular atrophy or male infertility, thus requiring no treatment.

For secondary hydrocele, the primary disease should be treated simultaneously. If it is secondary to inflammation of the testis or epididymis, the inflammation should be controlled before treating the fluid. Local application of heat and physical therapy can promote fluid absorption; if absorption fails, further treatment is necessary.

Aspiration is used for young men, those who refuse surgery, or those with contraindications to surgery. However, aspiration often results in recurrence, requiring repeated aspiration.

Surgical methods include: incising the tunica vaginalis to drain the fluid, removing excess tunica vaginalis, and suturing the tunica vaginalis margin. For communicating hydrocele, in addition to removing the tunica vaginalis, the processus vaginalis communicating with the inguinal canal must be ligated at the internal inguinal ring. For spermatic cord hydrocele, the fluid-filled portion of the tunica vaginalis should be carefully separated from the spermatic cord and then completely removed.

Epididymitis

Acute epididymitis has three common causes.

First, it can be secondary to prostatitis or urinary tract infection.

Second, prostatectomy, especially transurethral procedures, can lead to epididymitis because bacteria may remain in the urine for 8-12 weeks post-surgery. During urination, urine can reflux into the ejaculatory duct, causing retrograde infection. Infection can also invade the epididymis through surrounding lymphatic vessels.

Third, sterile urine reflux into the ejaculatory duct can cause chemical epididymitis. Recent studies have found that urine can reflux into the seminal vesicles.

Acute epididymitis often occurs after strenuous physical labor (such as lifting heavy objects) or after intense sexual arousal. Injury caused by transurethral instrumentation can also lead to epididymitis. Epididymitis can be a complication after prostatectomy. Epididymitis is often secondary to prostatitis. Scrotal pain often occurs suddenly and may radiate along the spermatic cord to the groin and lumbosacral region. The pain is usually severe, with significant tenderness and aversion to pressure. Swelling progresses rapidly, doubling the size of the epididymis within 3-4 hours, and body temperature can reach around 40°C. Urethral discharge may be present, and cystitis and cloudy urine may also be present.

Patients experience tenderness in the groin area, scrotal enlargement, and local skin redness and swelling. If an abscess forms, the skin becomes dry and thin, easily sloughing off; the abscess may also rupture spontaneously. If medical attention is sought promptly, the boundary between the swollen and hardened epididymis and testis is relatively clear; however, after several hours, the testis and epididymis become a single hard mass, the spermatic cord thickens due to edema, and secondary hydrocele develops several days later. Urethral discharge may also be present.

The irreversible terminal stage of severe acute epididymitis is chronic epididymitis, at which point symptoms are often milder than those of acute epididymitis. Due to fibrosis, the entire epididymis hardens in chronic epididymitis, resulting in very prominent scarring under microscopy. Epididymal duct obstruction is often visible, and the tissue is infiltrated with lymphocytes and plasma cells.

Chronic epididymitis is usually asymptomatic unless there is an acute exacerbation. At this stage, local discomfort may occur; the patient may feel a mass in the scrotum; the epididymis is thickened and enlarged, with or without tenderness, and is easily distinguishable from the testis upon palpation; spermatogonium is often thickened, and sometimes the diameter of the vas deferens is enlarged; the prostate becomes hardened and fibrotic, and pus cells are often seen in the prostatic fluid; urinalysis may show an infection secondary to prostatitis.

Tuberculous epididymitis is very similar to chronic epididymitis. The vas deferens appears beaded, and the seminal vesicles are thickened. Urine tests show "sterile urine" or "tuberculous urine," suggesting tuberculous epididymitis. Cystoscopy may reveal bladder ulcers, and urinary tract X-rays can also aid in diagnosis. Testicular tumors may present as testicular masses; palpation may reveal a thickened and hardened epididymis and a testis with reduced sensation (tumor). Epididymal tumors are relatively rare, and differentiation from epididymitis requires pathological examination. If chronic epididymitis is bilateral, it can lead to infertility.

【Treatment Methods】 Prostatitis and urinary tract infections should be treated thoroughly. If necessary, bilateral vas deferens ligation should be performed to prevent recurrent acute epididymitis.

If the patient seeks medical attention within 24 hours of onset, diffuse anesthesia of the spermatic cord above the testicle using 20 ml of 1% procaine or lidocaine may completely relieve the condition. Body temperature usually drops rapidly, pain disappears completely, and the inflammatory mass may be absorbed within a few days; otherwise, it generally takes 2-3 weeks to absorb. If one injection is insufficient, a second injection can be given the following day.

Antibiotics are helpful in treatment, and secondary cystitis will heal quickly. Antibiotic selection should be based on bacterial culture and drug sensitivity testing. Commonly used drugs include second- and third-generation quinolones such as sulfamethoxazole, norfloxacin, and cephalosporins, all of which have good efficacy.

During the acute phase (3-4 days), patients should rest in bed. Using a scrotal support can alleviate symptoms. A larger, homemade scrotal support with a cotton pad will be more comfortable. For severe pain, analgesics can be used. Local heat therapy can relieve symptoms and promote inflammation resolution. However, premature use of heat therapy can worsen pain and increase the risk of infection spread; therefore, ice packs should be applied locally in the early stages. Sexual activity and strenuous physical labor can aggravate infection and should be avoided.

Treatment of chronic epididymitis often requires adequate antibiotic treatment alone. Prostatitis must be controlled. If recurrent epididymitis leads to prostatitis, vasectomy should be performed during non-acute periods, which can cure the prostatitis. Epididymectomy may also be performed in some cases.