Health: Should I worry about big scrotum?

Dear mirror doctor, I have noticed a swelling of my two month olds right scrotum which sometimes reduce in size when he lies down flat and it increases in size when I pick him to play with. I sent him to see a doctor who diagnosed a hydrocoele and advised me not to worry about it because it will go away with time. Please should I not worry about this?

kosua, Bantama

Dear  Akosua, A hydrocele is a fluid collection within the  covering of the testis itself. This cover is called tunica vaginalis. 

It is made up of two layers, an internal  and an external one. When there is a fluid collection between these two layers, then hydrocoele develops. 

The reason for the fluid collection is one of two. The testis is produced deep within the abdominal cavity close to the kidneys and they migrate from there into the scrotum around 28 weeks of gestation.

Sometimes, there may be persistent developmental connections along the pathway of the testis migration. 

In migrating, a channel is created which can become filled with fluid causing a hydrocoele. 

It can also be from an imbalance of fluid production versus absorption in these two layers. In rare cases, similar fluid collections can develop along a canal called canal of Nuck in females even though females do not have testes. 

By themselves, hydrocoeles pose little risk as your doctor told you. However, there is a potential for more than fluid to appear within developmental connections between the abdominal cavity and the scrotum. 

Structurally, hydroceles are classified into three principal types.

In a communicating (congenital) hydrocele, the space between the two coverings of the testis permits flow of fluid from the abdominal cavity into the scrotum. 

In a noncommunicating hydrocele, the space between the covering is present, but no communication with the abdominal cavity occurs. 

In a hydrocele of the cord, the closure of the covering of the testis is defective. The abdominal end of the covering closes correctly, but the mid portion remains patent. The proximal end may be open or closed in this type of hydrocele. 

Hydroceles can also occur in adults. These are usually late-onset and may result acutely from local injury, infections, and radiotherapy; they may present chronically from gradual fluid accumulation. Unlike hydrocoels in children, those that develop in adulthood  can adversely affect fertility. 

More than 80 per cent of newborn boys have the tendency to develop hydrocele, but most close spontaneously within 18 months of age. The incidence of hydrocele is rising with the increasing survival rate of premature infants and with increasing use of the peritoneal cavity for dialysis, and renal transplants. 

Apart from the scrotal swelling associated with a hydrocoele, other signs characteristic of the condition include: 

A bluish discolouration of the skin if the hydrocoele is large. 

Fluctuation in the size of the swelling (mainly in infants as in your case). 

The area of the hydrocoele is clearly defined. 

Hydrocoeles are not painful but may cause discomfort if they are large.

Aids to diagnosing hydrocoeles include simple tests such as transillumination where alight source shines brightly through a hydrocele. Doppler ultrasound flow study is recommended to assess perfusion especially in adults where a complication needs to be excluded

In infants, most hydrocoeles resolve without treatment by the age of one. If the hydrocoele persists for longer than 18 months, treatment is usually recommended.

In adolescents and adults, treatment may not be required if the hydrocoele is small, the testes can be examined easily, and the amount of fluid remains constant. Treatment may be recommended ,however, if the hydrocoele is causing discomfort or embarrassment.

A hydrocoele can be treated by draining the fluid with a needle (aspiration), or by a minor surgical procedure.

To drain a hydrocoele, a needle is inserted into the hydrocoele and the fluid is removed. To prevent fluid reaccumulating after it has been drained, a special fluid called a “sclerosing” fluid may be injected into the scrotum after the hydrocoele had been drained. The sclerosing fluid helps to seal off the passage from the abdomen to the scrotum, preventing fluid from re-entering the scrotum.

Surgical removal of the hydrocoele may be recommended in cases where the hydrocoele is large and painful or where it has recurred after aspiration. 

This is a minor surgical procedure performed on a day stay basis. In infants, a general anaesthetic is used. In adults, a regional anaesthetic may be used.

A small incision is made in the scrotum, the hydrocoele is drained of fluid and the layers accumulating the fluid are removed. The incision is closed with small stitches. Surgery usually ensures permanent resolution of the hydrocoele. 

astom2@yahoo.com

A member of Paediatric Society of Ghana