Print ISSN: 2321-6379 Online ISSN: 2395-1893 Original Article Cystic Swellings of the in Adults – A Clinical Study

Soundarya Yamakanamardi, Thammegowda Kemparaj

Department of General Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Abstract

Introduction: Cystic swellings of the scrotum are commonly encountered by general surgeons in daily practice. These are presented by males of all ages with varying heterogeneity in the treatment. This study aims at identifying the pattern of presentation of cystic scrotal swelling along with the appropriate surgical management. Methods: A retrospective observational study was undertaken from January 2019 to December 2019. A total of 264 patients fulfilling the inclusion criteria were included in the study. Retrospective data regarding the patient population, presentation, and management were collected and analyzed. Results: Majority of cases (21%) were observed between 51 and 60 years (mean age 54.9 years). About 68% presented with a painless, progressive swelling, with a mean duration of symptoms was 18.2 months. Primary was the most common swelling encountered (in 70.3%). Jaboulay’s procedure was undertaken in 70% of patients, but Lord’s plication was associated with a shorter operative time and hospital stay. Epididymal accounted for 17.9% and were managed by excision. The most common complication was scrotal edema (in 36%). Hematoma and infection were less frequently observed. Follow-up was done for 2 months and no recurrences seen. Conclusions: Cystic swellings of the scrotum are common conditions affecting middle ages men, among which primary is the most common. Lords plication is less commonly performed, although it was associated with shorter operative time and hospital stay and lesser incidence of post-operative scrotal edema.

Key words: Scrotum, Swelling, Hydrocele, Jaboulay’s, Lord’s placation.

INTRODUCTION patients rarely seek medical attention during the early stages. This causes physical, psychological, and social ystic swellings of the scrotum are one of the most distress to these patients and they often present late Ccommon clinical entities; a surgeon comes across in with a massive swelling. The mortality associated with daily practice.[1] They are defined as abnormal collections the conditions may be negligible; however, there can be of fluid within the scrotal cavity. They affect males of all significant morbidity and deterioration in the quality age groups and account for the majority of all scrotal of life. swellings. Most of the scrotal swellings are benign. The etiology is Vast majority of the scrotal swelling remain asymptomatic, diverse and ranges from the commoner swellings such and attain a considerable size before causing discomfort as hydroceles, spermatoceles, and epididymal cysts to to the patient.[2] Combined with the social stigmata, less common ones such as , pyocele, and chylocele. Access this article online Acute conditions such as pyoceles and hematoceles Month of Submission : 05-2020 require immediate intervention and treatment to prevent Month of Peer Review : 06-2020 irreversible testicular injury. Some conditions such as Month of Acceptance : 07-2020 old clotted hematoceles may clinically mimic testicular Month of Publishing : 08-2020 malignancy. While, testicular malignancy itself may www.surgeryijss.com present as secondary hydrocele.

Corresponding Author: Dr. Thammegowda Kemparaj, Department of General Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India.

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The ultimate treatment for cystic swellings of the The data obtained were recorded in a predesigned pro scrotum remains surgery, irrespective of the etiology forma. Diagnosis was clinical and was supported by or pathogenesis.[3] A number of operative interventions imaging. All patients underwent surgical treatment. have been advocated each of them. Each intervention has The specific surgical intervention to be undertaken and their unique post-operative complications and rates of the required were decided by the attending recurrences. The principal in treating primary hydroceles surgeon based on the clinical and radiological findings. includes variations of three primary procedures, namely, excision, eversion, or internal drainage. Pre-operative antimicrobial prophylaxis was given in all patients, using intravenous ceftriaxone. Relevant The commonly performed that operative interventions intraoperative findings were noted such as the time taken such as Jaboulay’s partial excision and eversion, Lord’s for completion of the procedure. Rubber corrugated placation, radical excision, and vaginal fenestration drains were used when indicated and removed within are nothing but modifications of the above mentioned 48 h. principle.[4] Epididymal cysts and spermatocoeles are treated by excision. Pyoceles and hematoceles are All patients received scrotal support and appropriate managed by incision and drainage when they present antibiotics, analgesics, and anti-inflammatory medication. early. Post-operative course and the incidence and management of surgical complications if any were obtained; descriptive The common intra-operative complications include statistics were calculated for all variables. Statistical hemorrhage, injury to cord structures and torsion testis significance was set at P < 0.0.5 for all comparisons. due to faulty positioning. Post-operative complications include edema hematoma formation, infection, and RESULTS recurrence.[5] In the present study of 256 patients, the mean age of This study aims at identifying the patient distribution, presentation was 53.9 years. patterns of clinical presentation, and the varied predisposing factors for different types of cystic swellings The maximum number of subjects was seen in the 51–60 of scrotum in adults. The different modalities of surgical years age group (n = 58) accounting for 21%, followed treatment presently available were also compared with closely by the 41–50 years age group (n = 56) )[Table 1 respect to post-operative complications, duration of and Figure 1]. About 71% had no symptoms apart from the hospital stay, and recurrence rates. swelling. In 23.1% of subjects, swelling was associated with heaviness). Right-sided swellings were found to be more METHODS common, with 81 patients having a right-sided swelling. Seventy patients had a left-sided swelling and 35 had This study was undertaken at Bowring and Lady Curzon bilateral. Of the cases of secondary hydrocele, four developed and Victoria Hospital which is tertiary health care centers following previous episodes of -. One attached to Bangalore Medical College and Research patient with a hydrocele was found to have an underlying Institute, Karnataka, India. testicular malignancy on scrotal ultrasound [Figure 2].

Patients admitted for the treatment of cystic swellings of The most commonly performed surgery was Jaboulay’s the scrotum were retrospectively analyzed from January procedure, a total of 126 patients underwent Jaboulay’s 2019 to December 2019. A total of 256 cases were procedure. Lords plication was performed in 58 patients included in the study. The study design was retrospective presenting with primary hydrocele. Fifty patients underwent and observational. excision and these patients primarily presented with spermatocele or epididymal [Table 2 and Figure 3]. Inclusion Criteria Patients presenting with swellings of the scrotum were Post-operative complications included scrotal wall edema, included in the study, who were above the age of 18 years hematoma formation, and infection. Mild edema and willing to give a valid consent to take part in the study. hematoma were seen in 20% of patients undergoing Jaboulay’s procedure and 16% of those undergoing Lord’s Exclusion Criteria plication. Patients aged <18 years, not willing to give informed consent, swellings arising from the skin of the scrotum, One of the 50 patients who underwent excision and one of inguinoscrotal swellings, and patients with severe the five patients who underwent orchidectomy developed infection or seriously ill, were excluded from the study. complication.

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The mean duration of hospital stay for the various surgical with pain in 28% in the majority comprising 46% of modalities of treatment was 5.18 days. The average patients the mean duration of swelling before presentation duration of follow-up was 2 months (ranging from 0 to was 1–2 years in 17% the duration of symptoms was 4 months) [Table 3]. for more than 2 years. In our study, we found that the average duration of symptoms before presentation was DISCUSSION 17.3 months. Secondary hydrocele, hematocele, and pyocele had a more acute presentation which prompted [10] Scrotal masses may occur at any age from infancy to old patients to seek medical advice early. age. In this study, it was evident that around half the population was in the economically productive age group. Surgical management under spinal anesthesia was As these are chronic conditions, having a certain amount employed in all patients in the study population of morbidity, this poses a significant economic burden for intraoperatively. The appearance of the testis epididymis the patient and his dependents. This is addition to the and spermatic cord was noted. Although orchidectomy psychosocial implications, which cannot be neglected. is not the standard of treatment in cases of hematocele Comparing with similar studies, a study conducted by Ku and pyocele, long standing cases are often associated et al. (2001), reported that the majority of the patients with atrophy and devitalization of the testes. The testes belonged to the age group of 41–50 years with a range of in these instances are not variable also a number of cases 16–83 years. Subith et al. (2014) observed 170 cases of treated with broad spectrum antibiotics and surgical cystic scrotal swellings and reported that 40% of patients drainage ultimately requires orchidectomy in the present were between 31 and 40 years of age.[6] study, scrotal ultrasound was used to assess pre-operative status of the tests in all patients. The testes were found The diagnosis can be confidently established with clinical to be atrophic and avascular in eight patients. These examination alone. However, all patients should undergo subjects were counseled regarding the nature of disease a scrotal ultrasound to confirm the diagnosis and rule and the need for orchidectomy. Prior informed written out concomitant testicular pathology. Hydrocele was the consent was taken from the patient and his relatives most common cystic swelling and no precipitating cause before this procedure one patient with relatives before could be detected in 122 cases (primary hydrocele). Of the this procedure one patient and his relatives before this cases of secondary hydrocele, four developed following procedure. One patient with a hydrocele secondary previous episodes of epididymis-orchitis. One patient with to testicular malignancy underwent a high inguinal a hydrocele was found to have an underlying testicular orchidectomy.[11] malignancy on scrotal ultrasound.[7] Primary vaginal hydrocele was managed by either Lord’s The mean age of presentation was 53.3 years which is placation or Jaboulay’s procedure based on the merits similar to that reported by Leung et al., in their study of the case and the discretion of the attending surgeon. involving scrotal sonological imaging in asymptomatic Jaboulay’s excision and eversion of the sac were the most subjects they concluded that hydroceles affect commonly performed surgical procedure in this study: approximately 1% of adults and the primary variety It was undertaken in 106 patients with large, floppy was seen most commonly in men older than the age of hydrocele sacs, of which four were secondary hydroceles. 40 years. The other swellings commonly encountered Lord’s placation was performed in 32 patients with small, were epididymal cysts. Primary vaginal hydroceles are thin walled sacs.[11] more commonly right sided. The difference in average age at presentation was statistically insignificant.[8] As far as complications are concerned, according to a retrospective study conducted by Kiddoo et al. (2004), About 71% of patients had no symptoms apart from the overall complication rate following outpatient scrotal swelling. About 23.1% of subjects swelling complained surgery was 19.2% and the most common complications that the swelling was associated with a dragging sensation post-surgery for hydroceles and spermatoceles were more appreciable after exertion or toward the end of persistent scrotal swelling, inflammation, and post- the day. This feature was associated with the larger operative infection. Other less frequent ones include swellings and long-standing swellings. Pain and fever recurrence, injury to spermatic vessels, and chronic pam. were associated with acute infective conditions of the In another retrospective study comparing the frequency of scrotum. The mode of presentation has been compared complications after surgery for benign scrotal conditions, with other similar studies.[9] Swartz et al. reported that the overall complication rate was 20% and included recurrence or persistent swelling Subith et al. (2014) found that scrotal swelling was the (6%), hematoma (5%), and infections (3.6%); 95% of presenting complaint in 59% of cases. It was associated complications were seen after hydrocelectomy.[12]

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Studies have shown that techniques involving extensive the hydrocele sac from the dartos layer had a 10% rate dissection to mobilize the hydrocele sac are most likely to of post-operative edema.[16] Ku et al. also found a similar result in scrotal edema. Incidence of scrotal swelling was variation in the rates of scrotal edema after sac excision also found to correlate with the volume of the hydrocele. and Lord’s procedure (74% and 8%, respectively).[14] In our study too, the most common complication observed irrespective of the operation performed was scrotal Hematoma formation and surgical site infection are other edema. On comparing the procedures for hydrocele, common complication after scrotal surgery. The various edema was observed more frequently in patients producers have different rates of hematoma formation; undergoing Jaboulay’s procedure (20%) possibly due the degree of dissection involved while mobilizing the to the extent of dissection undertaken to mobilize the hydrocele sac is pivotal in pathogenesis. In the present sac. Edema was seen in only 16% who underwent Lord’s study, seven of the 106 patients (6.6%) who underwent placation.[13] Jaboulay’s procedure developed hematoma formation. This complication was not seen in patient undergoing Theses findings are similar to observations made by other Lord’s placation. Five of the 106 patients (4.7%) in authors. Rodriguez et al. compared the complication rates the Jaboulay’s procedure group developed surgical site of various techniques and found that hydrocele excision was infection whereas two patients who has undergone followed by marked edema in 76% of cases and Jaboulay’s Lord’s placation developed this complication (6.3%) in technique to have rate of 91%. Both procedure involved this conservatively broad spectrum antibiotics. Scrotal support and analgesics were used and any hematoma or extensive mobilization of the sac. In contrast, Lord’s pus collection was evacuated.[15] placation technique which does not require dissection of

140

15 7 120 37 37 100 80

60

40 46 20

58 0

56

<20 21-30 31-40 41-50 51-60 61-70 >70 Figure 3: Figure depicting the various surgical proceudres Figure 1: The age distribution of the patient population used to treat the patients

200 20%

180

160 15% 140

120 10% 100

80

60 5%

40

20 0% 0 JABOULEYSLORDS EXCISONORCHIEDECTOMY primary secondary epidydemal spermatocele hematocele pyocele PLACATION hydrocele hydrocele cyst Figure 4: Incidence of surgical complications with respect to Figure 2: Frequency of various cystic swellings in the study each procedure

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Table 1: Age-related clinical presentation of various cystic scrotal swelling Age Primary hydrocele Secondary hydrocele Epididymal cyst Spermatocele Hematocele Pyocele Total <20 4 0 3 0 0 0 7 21–30 30 0 5 0 0 2 37 31–40 32 2 6 1 2 3 46 41–50 38 3 7 2 4 2 56 51–60 40 0 12 1 0 5 58 61–70 28 2 6 0 0 1 37 >70 8 0 7 0 0 0 15 Total 180 7 46 4 6 13 256

Table 2: Table depicting the surgical procedures with respect to the etiology Etiology Type of surgery performed Jaboulay’s Lords plication Excision Incision and drainage Orchiectomy Total PH 122 58 0 0 0 180 SH 4 0 0 2 1 7 EC 0 0 46 0 0 46 SP 0 0 4 0 0 4 HE 0 0 0 6 0 6 PY 0 0 0 9 4 13 Total 126 58 50 17 5 256

Table 3: Table depicting the mean duration of hospital stay Type of surgery Number Mean duration of hospital stay (days) SD Minimum (days) Maximum (days) Jaboulay’s 126 4.6 1.11157 3.8 8 Lords plication 58 3.5 1.18458 2.6 7 Excision 50 3.5 1.09473 3 4 Incision and drainage 17 9 7.2 12 Orchiectomy 5 5 0.9718 3 6 Total 256 5.18 1.3706

Although, Lord’s placation appears to be more risk of recurrence. Sixteen of 17 patients were discharged advantageous than Jaboulay’s procedure in terms of after an average of 4.3 days in the hospital. The average post-operative complication and duration of hospital duration of follow-up was 1.8 months (ranging from 0 to stay. It may not by appropriate in all cases of hydrocele 4 months). No recurrences were noted during this period. Plication of thick walled secondary and long-standing hydrocele sacs can result in a residual mass of plicated CONCLUSION tissue in the scrotum. These cases are best managed with partial excision and eversion of the sac. Hence, Jaboulay’s Cystic swellings of the scrotum are common conditions procedure is considered the surgical modality of choice that surgeon comes across in daily practice. They are for management of hydroceles.[16] often associated with considerable morbidity in terms of physical, psychological, social, and economic outcomes Epididymal cysts were the second most common cystic Males of all age groups may be affected, the most swellings noted in this study. Theses cystic lesions of common mode of presentation being painless, gradually the scrotal cavity were treated by excision. Two cases of progressive swellings in the scrotum. Hydrocele was the spermatocele were diagnosed following histopathological most common swelling encountered in all age groups. examination of the specimen. As for the complications The other swellings uncounted were epididymal cysts three patient developed scrotal edema and of these, and pyoceles. one was associated with a hematoma formation. One case of pyocele was incised and drained with supportive All patients were managed surgical primary vaginal antibiotics and analgesics.[17] hydrocele was managed by either Jaboulay’s procedure or Lord’s placation based on the merits of the case, Lord’s Recurrence rate has been historically similar among the placation was associated with lesser post-operative various procedures. Of the three basic techniques for complications and a shorter hospital stay. However, it may hydrocele, excision and eversion procedures have a 0–4 % not be appropriate in cases of thick walled, secondary, and

14 IJSS Journal of Surgery | Jul-Aug 2020 | Volume 6 | Issue 4 Yamakanamardi and Kemparaj: Clinical Study of Cystic Swelling of Scrotum in Adults along-standing hydroceles. Such cases are best managed 6. Ku JH, Kim ME, Lee NK, Park YH. The excisional, placation with partial excision and eversion of the sac. Hence, and internal drainage techniques: A comparison of the Jaboulay’s procedure is considered the surgical modality results for idiopathic hydrocele. BJU Int 2001;87:82-4. of choice for management of hydroceles. 7. Kiddo DA, Wollin TA, Mador DR. A population based assessment of compliments following outpatient hydrocelectomy and spermatoceletomy. J Urol 2004;171: Epididymal cysts and spermatoceles were treated by 746-8. excision. An orchidectomy was undertaken in cases where 8. Woodward PJ, Schwab CM, Sesterhenn IA. Form the archives the testis was found to atrophic, devitalized or when it of the AFIP: Extratesticular scrotal masses: Radiologic- was suspected to be harboring malignancy. pathologic correlation. Radiographics 2003;23:215-40. 9. Rubenstein RA, Dorga VS, Seftel AD, Resnick MI. Benign The most common complication observed in the study intrasctotal lesions. J Urol 2004;171:1765-72. population was persistent scrotal edema. Other commonly 10. Kumar SK, Sasikumar J, Seetharamaiah, T, Kumar AB, observed ones were hematoma and surgical site infection. Venugopalacharyulu NC. Cystic swellings of scrotum: All complications were managed conservatively. Follow- Management. Int J Med Res Health Sci 2014;3:338-41. up for up to 4 months was undertaken. No recurrences 11. Leung ML, Gooding GA, Williams RD. High-resolution were detected during this period. sonography of scrotal contents in asymptomatic subjects. Am J Roentgenol 1984;143:161-4. 12. Slavis SA, Kollin J, Miller JB, Pyocele of the scrotum: REFERENCES Consequence of spontaneous rupture of testicular abscess. 1989;33:313-6. 1. Valentino M, Barozzi L, Pavlica P, Rossi C. Imaging 13. Bruner DI, Venture EL, Devlin JJ. Scrotal phocele: scrotal lumps in adults 2: Cysts and fluid collections. In: Uncommon urologic emergency. J Emerg Trauma Shock Bertolotto M, Trombetta C., editors. Scrotal Pathology, 2012;5:206. Medical Radiology. Diagnostic Imaging. Berlin Heidelberg: 14. Swartz MA, Morgan TM, Krieger JN. Complications of scrotal Springer-Verlag; 2012. p. 180-7. surgery for benign conditions. Urology 2007;69:616-9. 2. Lasheen A. Hydrocelectomy through the inguinal approach 15. Kim JK, Shin JH, Lim JS. A 10-year retrospective study of versus scrotal approach for idiopathic hydrocele in adults. the operative treatment results of adult type hydrocele. J Arab Soc Med Res 2012;7:68-72. Korean J Urol 2008;49:82-7. 3. Nesbit JA. Hydrocele and spermatocele. In: Graham SD 16. Rodriguez WC, Rodriguez DD, Fortuno RF. The operative Jr., Keane TE, Glenn JF, editors. Glenn’s Urologic Surgery. treatment of hydrocele: A comparison of four basis 7th ed. Philadelphia, PA: Lippincott Williams and Wilkins. techniques. J Urol 1981;12:804-5. 2004;528-32. 17. Jahnson S, Johansson JE. Results of window operation for 4. Kavoussi PK, Costabile RA. Surgery of the scrotum and primary hydrocele. Urology 1993;41:27-8. . In: Wein AJ, Kavioussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell Walsh Urology. 10th ed. Philadelphia, PA: Saunders Elsevier; 2012. p. 1008-11. How to cite this article: Yamakanamardi S, Kemparaj T. Cystic 5. Rochelle JC, Levine LA. Complications of benign adult penile Swellings of the Scrotum in Adults – A Clinical Study. IJSS Journal of Surgery 2020;6(4):10-15. and scrotal surgery. In: Loughlin KR, editor. Complications of Urologic Surgery and Practice: Diagnosis Prevention, and Management. Boca Raton FL: CRC Press; 2007. p. 229-30. Source of Support: Nil, Conflicts of Interest: None declared.

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