GIDROTSELE (Greek hydor water + kele tumor, hernia; synonym edema of covers of a small egg) — accumulation of liquid between parietal and visceral plates of a vulval cover of a small egg. This name got a disease in 16 century. Most often (70%) G. occurs at adults, generally at the age of 20 — 30 years; 30% of all cases are the share of children's age (from them 50% up to 5 years). Usually G. — hemilesion, but occurs also bilateral, especially at newborns.
Etiology and pathogeny
Distinguish inborn and acquired. Inborn G.'s emergence is connected with disturbances of an embryogenesis. Owing to not fusion of a vulval shoot of a peritoneum the cavity (fig. 1) is formed, in a cut liquid can accumulate. If this cavity in the proximal direction is not obliterated, then there is a reported edema of covers of a small egg (hydrocele communicans). Multichamber cavities form because of unions of leaves of a peritoneal shoot.
Etiol, factors of the acquired G. consider an injury, inflammatory processes, tumors of a small egg, its appendage and covers, and also the cordial decompensation which is followed by signs of the general venous stagnation (ascites, a hydrothorax, a hydrocardia). Acute infectious processes (gonorrhea, tuberculosis) are complicated by sweating of exudate (an acute edema), an injury — impurity to liquid of blood that is called to a gidrogematotsela or to a gematotsela (see). In G.'s pathogeny the main role is played by the sclerous changes of vulval (own) cover of a small egg (tunica vaginalis testis — PNA) which are followed by disturbances of a lymphokinesis. According to A. P. Frumkin (1963), a zapustevaniye limf, cracks, an obliteration of a considerable part limf, vessels of a small egg, its appendage and covers promote accumulation of liquid, and disturbance of its outflow is favored by a prelum of elements of a seed cord hernia, varicose expanded veins, hems after operations, a bandage, etc.
Morfol, changes at G. testify to the inflammation which is expressed in dystrophic changes of cells of covers of a small egg, arteritis, phlebitis, a periphlebitis. At acute G. the serous cover can be hyperemic, with expanded vessels.
Hron. It is more often characterized by a thickening of a cover, its roughness. The Vodyanochny cavity of usually pear-shaped form, and sometimes at partial accretion of leaves takes a form of hourglasses (hydrocele biloculare). On a visceral layer of a cover find growth of granulyatsionny fabric. On the course of vessels lymphoid infiltrates are visible. The mesothelium is easily exfoliated. The vulval cover consists of the hyalinized, coarse collagenic fibers. The amount of liquid varies from several milliliters to 1 — 3 l, and in casuistic cases reaches 23 — 26 l. Vodyanochny liquid transparent, amber-yellow color, slightly opalestsirut. Its specific weight 1,012 — 1,028, protein content of 4 — 5%, neutral reaction. Under a microscope in it find separate lymphocytes, mesothelial cells, crystals of cholesterol; at the gematotsel — erythrocytes, fibers of fibrin and convolution, sometimes with calcification. At suppuration of liquid (pyocele) that is observed seldom, it becomes muddy, in it polynuclear leukocytes appear. At crops of liquid reveal various microflora: colibacillus, cocci with small virulence. Chemical contents — proteins, sodium, chlorides, cholesterol.
A clinical picture
Allocate acute and hron, G. Ostroye G. is characterized by sudden emergence of pains, a swelling, a dermahemia in one of half of a scrotum. At a palpation tumorous formation of a dense and elastic consistence decides on clear fluctuation, and sometimes and crepitation. The small egg is pushed aside kzad and from top to bottom. Hron. Develops slowly, for a number of years. As a result of gradual fluid accumulation the scrotum gets a pear-shaped form. Usually borders of an edema from above are accurately outlined by the inguinal channel. Skin of a scrotum is not hyperemic, but it is stretched, without folds and shines. The small egg at big and intense G. can palpatorno not be defined. Besides, big G. is followed by maceration, an erythrasma of inguinal areas, difficulty of an urination, sexual intercourse, an atrophy of a small egg, disturbance of a spermatogenesis.
Diagnosis it is based on data of survey and an objective research of a scrotum. The following symptoms are important: emergence of education on one party, clear fluctuation and obtusion over it. At a diafanoskopiya of a scrotum its raying of pink color due to finding of transparent liquid in her cavity (a positive symptom of raying) comes to light; for this purpose use any source of bright light (an electric lamp, the cystoscope, etc.) which is established behind a scrotum. Very typically at the reported edema disappearance of liquid in lying position of the patient, especially if a scrotum to lift. In differential diagnosis with hernia consider a possibility of reposition of contents of a hernial bag in an abdominal cavity and rumbling of a gut at the same time. It is more difficult to differentiate G. with a tumor of a small egg, the positive symptom of raying can give edges, but differs in a dense consistence; in such cases recommend a diagnostic puncture with a research of liquid.
the Acute edema is successfully treated by conservative means (anesthesia, carrying a suspenzoriya, antibiotics, at first cold, and then thermal procedures). All methods of treatment hron. Divide on puncture, injection and operational. At punctures make only removal of liquid, and at injections — after removal of liquid enter various substances causing cicatricial changes of a cover (alcohol, formalin, carbolic to - that, tincture of iodine, quinine-urethane, etc.), and a hydrocortisone. These two methods because of a possibility of a recurrence and some complications (e.g., bleeding, etc.) were not widely adopted.
From numerous ways of surgical intervention the most radical are Vinkelmann and Bergmann's operations.
Vinkelmann's operation it is possible only when the cover has no rough morfol, changes. On a front surface of a scrotum make a slit (6 — 7 cm). Liquid is produced by means of a small trocar. Cut a vulval cover of a small egg and turn out it around a seed cord, and on edges put it separate or continuous stitches so that the cavity (fig. 2) was not formed. The wound is sewn up tightly or enter a drainage for 24 — 48 hour.
Bergmann's operation apply at an edema of the big sizes or with multichamber cavities. After evacuation of liquid the vulval cover is widely otseparovyvat and exsected or coagulated an electroknife. Carefully stop bleeding and for the remains of a cover put separate stitches (fig. 3). The same all other stages, as at Vinkelmann's operation.
Other ways of operation (Alferov, Klappa, Andrews, Ezdilik) are used seldom.
Complications after operation — suppurations and hematomas — are observed rather seldom. In their prevention the leading role belongs to an atravmatichnost of intervention and a careful hemostasis.
The forecast after treatment is usually favorable.
Gidrotsele at children
Gidrotsele at children is more often than inborn genesis and is caused by not fusion of the message between a vulval shoot with an abdominal cavity (A. P. Krymov). Very often (at 10% of boys) G. occurs at newborns.
Existence of not obliterated gleam of a vulval shoot of a peritoneum, an underdevelopment limf, systems of covers of a small egg by the time of the birth, and also features of a water salt metabolism at newborns allow to consider G. which appeared soon after the birth, physiological. Within the first months of life at the child the tendency of a vulval shoot of a peritoneum to an obliteration, and limf, systems to normalization of the function is observed, and G. independently disappears. Quite often there is so-called valve edema, at a cut liquid freely gets to a cover of a small egg, and the return outflow is complicated because of narrowness of a gleam of a vulval shoot and its nek-ry bend.
, appeared after one-and-a-half-year age, usually progresses. At biochemical, mikrobiol., patomorfol, researches of covers of a small egg and vodyanochny liquid at children of inflammatory changes do not find. Occasionally at teenagers of 14 — 15 years G. caused by nonspecific inflammatory processes of a small egg and appendage is observed. More often differential diagnosis of G. at children is carried out with hernia.
Treatment within the first year of life is not necessary. Only when there is considerable (60 — 80 ml) accumulation of liquid, apply punctures (2 — 3 times) and hard swaddling for 3 — 4 days. Resort to these methods at valve more often.
Surgical intervention is shown if G. appeared after one-and-a-half-year age. Most of surgeons refused Vinkelmann's operation at children because of its injury and disturbance of anatomic relationship of a small egg and a seed cord. Pathogenetic and less traumatic operation of bandaging and excision of a vulval shoot of a peritoneum is more reasonable. Under anesthetic a slanting section in inguinal area cut fabrics to a seed cord. The vulval shoot is allocated, tied up and exsected on an extent from a superficial abdominal ring to an upper pole of a small egg. In the postoperative period sometimes there is moderate accumulation of a reactive exudate in covers of a small egg, a cut in several days independently disappears. Long-term results of this operation good.
Bibliography: Norikov L. M. Treatment of the reported edema of covers of a small egg, Klin, hir., No. 2, page 46, 1968; To r and with about Sunday to and I am T. V. A hydrocele and a seed cord at children, in book: Sovr. vopr, hir * children's age, under the editorship of I. K. Murashov, page 42, M., 1965; The Guide to clinical urology, under the editorship of A. Ya. Pytel, page 482, M., 1970, bibliogr.; In about e m i n g-h an u s H. Urologie, Bd 1, S. 208, Miinchen, 1971; R o s s J. G. Treatment of primary hydroceles in infancy and childhood, Brit.J. Surg., v. 49, p. 415, 1962; Urology, ed. by M. F. Campbell a. J. H. Harrison, Philadelphia, 1970; Wallace A. F. Etiology of the idiopathic hydrocele, Brit. J. Urol., v. 32, p. 79, 1960.
H. E. Savchenko; T. V. Krasovskaya (ped.).