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Ultrasound features of spermatic cord hydrocele in children

¹Department of Diagnostic Imaging and ²Unit of Paediatric Surgery, Sapir Medical Center, Tel-Aviv University and ³Kfar Saba and Sackler Medical School, Tel-Aviv University, Israel

	Abstract

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The aim was to evaluate the value of ultrasound diagnosis of spermatic cord hydrocele as a cause of inguinal swelling or mass in children. Clinical and ultrasound (US) findings and surgical procedures of 27 children with spermatic cord hydrocele were reviewed. All children, except one, were referred for US because of suspected inguinal hernia, hydrocele or inguinal mass. In one child, the US examination was performed to confirm the diagnosis of a spermatic cord hydrocele. An encysted hydrocele was diagnosed in 24 out of 27 cases, whereas a funicular type of spermatic cord hydrocele was found in the remaining 3 cases. Internal septa were seen within the fluid mass in four patients. 23 children underwent surgical exploration that confirmed the US diagnosis. Three children with encysted-type hydrocele were only followed clinically and by US, and one was lost from follow-up. US examination is a very sensitive and accurate method for diagnosis of this entity and for exclusion of other lesions in this region.

	Introduction

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Spermatic cord hydrocele (SCH) is a loculated fluid collection along the spermatic cord, separated from and located above the testicle and the epididymis. This entity is a rare congenital anomaly [1, 2] resulting from an abnormal closure of the processus vaginalis. Affected children usually present with a firm groin swelling, andultrasound (US) evaluation of the inguinal region is performed to exclude an incarcerated inguinal hernia, inguinal lymphadenopathy or an extratesticular tumour. Two types of SCH are recognized [1]. The first type is encysted hydrocele (EH) of the cord, where the fluid collection does not communicate with the peritoneum or the tunica vaginalis. The second type is the funicular hydrocele (FH), where there is a fluid collection along the cord, communicating with the peritoneum at the internal ring. This paper presents the US characteristics and clinical data of 27 cases of hydrocele of the spermatic cord.

	Material and methods

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The clinical and US data of 3486 examinations of the inguinal region performed in 1743 children over a 5-year period were reviewed retrospectively. A diagnosis of SCH was made in 27 cases. All children were scanned with a 7 MHz linear transducer, using an Acuson 128X P10 system (Acuson, Mountain View, CA). Patient ages ranged from 6 months to 13 years (mean 3.9 years). All patients presented with a swelling or mass in the inguinal region. 14 masses were on the left side and 13 on the right. The clinical diagnoses were a suspected inguinal hernia in 20 cases, a hydrocele in 3 cases, a mass in 2 cases, an incarcerated inguinal hernia in 1 case and a SCH in 1 case. No patient had signs of infection or bowel obstruction at the time of US examination. Both testicles were located in the scrotum in all patients.

	Results

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In all cases, US disclosed an oval anechoic mass in the groin along the spermatic cord, above and separated from the testis and the epididymis. The fluid masses were well demarcated and avascular when examined by colour Doppler US. In 24 children, the fluid collection was compatible with an EH of the spermatic cord without communication with the peritoneal cavity at the internal ring (Figure 1). In three children the cystic mass communicated with the peritoneum at the proximal end, compatible with a FH (Figure 2).

View larger version (82K): [in this window] [in a new window]   Figure 1. Longitudinal scan of the left spermatic cord of a 4-year-old child with suspected left inguinal hernia. An oval anechoic mass is seen in the distal part proximal to the testis (cursors). The closed internal ring is shown (arrow).

View larger version (86K): [in this window] [in a new window]   Figure 2. Longitudinal scan of the right spermatic cord of a 2-year-old child with suspected bilateral inguinal hernia. The internal inguinal ring (black arrow) is patent, with a proximal cystic mass. The testis (open arrow) is seen distally surrounded by a small hydrocele.

23 children with SCH underwent surgical exploration that confirmed the US diagnosis. Surgery was performed in 20 patients with EH. In 17 cases, a hydrocelectomy was performed, 11 of those associated with herniotomy. In three patients herniotomy only was performed, because the EH was not considered of clinical significance by the surgeon. All three children with a FH underwent herniotomy.

In three cases of EH, only clinical and US follow-up was performed 6–12 months later. In two children the clinical and US findings remained the same and in one child the EH resolved spontaneously. One case was lost to follow-up.

	Discussion

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We found SCH in only 0.77% of the examinations. Because the referring physician suspected a SCH in only one case, our data underscore the importance of being familiar with this entity in order to make the exact US diagnosis.

Few reports have been published in the literature about this rare anomaly [1]. A SCH is a localized patency of the processus vaginalis (PV) with a fluid collection in it. This anomaly is shown on US as a well demarcated anechoic mass. It is separated from the testis and epididymis and displaces them inferiorly [3, 4]. Septations are sometimes seen within the cysts. Two types of septation are recognized [1]. First, the EH of the cord (Figure 1), which may be localized anywhere along the spermatic cord, may be of any size or shape but does not change in its size or shape with increased intraperitoneal pressure and may resolve spontaneously. Second, the FH (Figure 2), which may grow with increased intraperitoneal pressure, such as with crying or straining, or diminish in size during relaxation. In both types of SCH, no peristalsis or bowel loop should be identified in it and no vascularity should be present on Doppler US examination.

During fetal life the parietal peritoneal membrane extends through the internal inguinal ring to form the PV. Between the 28th and 40th weekof gestation, when the testes descend from the abdomen to the scrotum, the PV becomes attached to the testis and remains as the tunica vaginalis [5]. Near to birth, the PV closes and becomes atretic. Normally, no communication remains between the peritoneal cavity and the scrotum. However, in 20% of the population the PV remains patent, but usually without symptoms throughout life [1]. Conditions that may cause delayed closure or non-closure of the PV and thus predispose to a SCH include prematurity, cystic fibrosis, Ehlers–Danlos syndrome, hip dysplasia, peritoneal dialysis or ventriculoperitoneal shunt [3, 5]. Failure of the PV to close may result in a spectrum of pathologies [1, 2]. Complete patency of the PV may cause a communicating hydrocele or an indirect inguinal hernia. On the other hand, patency localized at level of the testis may produce a testicular hydrocele, which is a fluid collection located only at the level of the scrotum between the two layers of the tunica vaginalis.

A SCH produces an inguinal swelling and is sometimes indistinguishable from a mass on palpation. US is important in these children to differentiate this anomaly from other pathologies present in the groin, such as an incarcerated inguinal hernia, a paratesticular mass (cyst or rhabdomyosarcoma), or an inguinal lymphadenopathy [1–3]. US examination is of high sensitivity for differentiating a solid mass from a cystic mass. In the presence of a fluid mass seen on US, the differential diagnosis from an indirect inguinal hernia may be easy if a bowel loop or omentum ispresent at the level of the cord [3], or a communicating hydrocele is seen with fluid surrounding the testis. The US differential diagnosis between a FH and an indirect inguinal hernia may be difficult and sometimes impossible. On the other hand, a FH is considered as a potential indirect hernia and a prophylactic herniotomy is usually performed, so differentiation between the two entities is of clinical importance. Two findings make the US diagnosis of an EH and differentiate this type of SCH from FH; (i) the presence of a loculated fluid collection; and (ii) the presence of a closed internal ring. US examination also excludes the possibility of a loculated hydrocele secondary to fibrous adhesions, an abscess, or a paraepididymal cyst [3, 4].

In conclusion, SCH is an uncommon cause of a lump in the groin in a small child. It must be differentiated from other causes including hernia, ectopic testis and lymphadenopathy. When diagnosed, surgical referral is indicated because of the association of hernias with some form of SCH.

Received for publication February 19, 2001. Revision received May 17, 2001. Accepted for publication June 6, 2001.

	References

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1. Martin LC, Share JC, Peters C, Atala A. Hydrocele of the spermatic cord: embryology and ultrasonographic appearance. Pediatr Radiol 1996;126:528–30.
2. Kogan SJ. Acute and chronic scrotal swellings. In:Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, editors. Adult and pediatric urology. Chicago, London, Boca Raton: Year Book Medical Publishers, 1987:1948–50.
3. McAlister WH. Male genital tract. In: Siegel MJ, editor. Pediatric sonography. New York: Raven Press, 1991:352–3, 360–2.
4. Martin B. Atlas of scrotal ultrasound. Berlin, Heidelberg, New York, Paris: Springer, 1992:4–5, 175–95.
5. Mitchell GAG. The condition of the peritoneal vaginal process at birth. J Anat 1939;73:658–61.[Medline]

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