Clinical features

1 The testis arises at the level of the mesonephros at the level of L2/3 vertebrae and drags its vascular, lymphatic and nerve supply from this region. Pain from the kidney is often referred to the scrotum and, conversely, testicular pain may radiate to the loin.

2 When searching for secondary lymphatic spread from a neoplasm of the testis, the upper abdomen must be palpated carefully for enlarged para-aortic nodes; because of cross-communications, these may be present on either side. Mediastinal and cervical nodes may also become involved. It is the beginner's mistake to feel for nodes in the groin; these are only involved if the tumour has ulcerated the scrotal skin and hence invaded scrotal lymphatics which drain to the inguinal nodes.

3 Rarely, a rapidly developing varicocele (dilatation of the pampiniform plexus of veins) is said to be a presenting sign of a tumour of the left kidney which, by invading the renal vein, blocks the drainage of the left testicular vein. Most examples of varicocele are idiopathic; why the vast majority are on the left side is unknown, but theories are that the left testicular vein is compressed by a loaded sigmoid colon, obstructed by angulation at its entry into the renal vein or even that it is put into spasm by adrenalin-rich blood entering the renal vein from the suprarenal vein!

4 The testis may fail to descend and may rest anywhere along its course— intra-abdominally, within the inguinal canal, at the external ring or high in the scrotum. Failure to descend must be carefully distinguished from retraction of the testis; it is common in children for contraction of the cremaster muscle to draw the testis up into the superficial inguinal pouch—a potential space deep to the superficial fascia over the external ring. Gentle pressure from above, or the relaxing effect of a hot bath, coaxes the testis back into the scrotum in such cases.

Occasionally the testis descends, but into an unusual (ectopic) position; most commonly the testis pass laterally after leaving the external ring to lie superficial to the inguinal ligament, but it may be found in front of the pubis, in the perineum or in the upper thigh. In these cases (unlike the undescended testis), the cord is long and replacement into the scrotum without tension presents no surgical difficulty.

5 Abnormalities of the obliteration of the processus vaginalis lead to a number of extremely common surgical conditions of which the indirect inguinal hernia is the most important.

This variety of hernia may be present at birth or develop in later life; in the latter circumstances it is probable that the processus vaginalis has per

Infantile Hydrocele

Fig. 91 Types of hydrocele. (a) Vaginal hydrocele, (b) congenital hydrocele, (c) infantile hydrocele, (d) hydrocele of the cord. (The tube at the upper end of each diagram represents the internal inguinal ring. Yellow = hydrocele, Brown = vas and epididymis)

Fig. 91 Types of hydrocele. (a) Vaginal hydrocele, (b) congenital hydrocele, (c) infantile hydrocele, (d) hydrocele of the cord. (The tube at the upper end of each diagram represents the internal inguinal ring. Yellow = hydrocele, Brown = vas and epididymis)

sisted as a narrow empty sac and that development of the hernia results from some sudden strain due to a cough, straining at micturition or at stool, which forces abdominal contents into this peritoneal recess.

In infants, the sac frequently has the testis lying in its wall (congenital inguinal hernia) but this is unusual in older patients.

The closed-off tunica vaginalis may become distended with fluid to form a hydrocele which may be idiopathic (primary) or secondary to disease in the underlying testis. The anatomical classification of hydroceles is into the following groups (Fig. 91):

• Vaginal—confined to the scrotum and so called because it distends the tunica vaginalis.

• Congenital—communicating with the peritoneal cavity.

• Infantile—extending upwards to the internal ring.

• Hydrocele of the cord—confined to the cord.

Notice that, from the anatomical point of view, a hydrocele (apart from one of the cord) must surround the front and sides of the testis since the tunica vaginalis bears this relationship to it. A cyst of the epididymis, in contrast, arises from the efferent ducts of the epididymis and must therefore lie above and behind the testis. This point enables the differential diagnosis between these two common scrotal cysts to be made confidently.

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Responses

  • diamond
    What are clinical features and diagnosis of hydrocele?
    1 year ago
  • bartosz
    What are the clinical feature of vaginal hydrocoele?
    5 months ago

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