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Testicular Size and Vascular Resistance Before and After Hydrocelectomy

¹ Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul 34300, Turkey.
² Department of Urology, SSK Istanbul Hospital, Istanbul 34300, Turkey.
³ Department of Biostatistics, Cerrahpasa Medical Faculty, Istanbul University, Istanbul 34300, Turkey.

Received March 1, 2004; accepted after revision April 28, 2004.

 
Supported by the Research Fund of the University of Istanbul (project UDP-243/19032004).

Address correspondence to I. Mihmanli.

Abstract

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OBJECTIVE. We sought to determine whether there is an association between hydroceles and testicular size and vascular resistance.

SUBJECTS AND METHODS. Twenty-three patients with a mean age of 42.8 years who had a unilateral idiopathic hydrocele and who underwent unilateral hydrocelectomy were included in the study. Testicular size and resistive (RI) and pulsatility (PI) indexes of the intratesticular arteries on the involved and uninvolved sides were measured before and after the hydrocelectomy.

RESULTS. We found statistically significant differences in the testicular volumes between the normal side (mean ± SD, 15.40 ± 3.41 mL) and the side with the hydrocele (20.67 ± 4.01 mL) before surgery (p < 0.001) and in the volumes in the side with the hydrocele before (20.67 ± 4.01 mL) and after (16.20 ± 2.99 mL) surgery (p < 0.001). No such a difference in volume was seen in the normal side before (15.40 ± 3.41 mL) and after (15.28 ± 3.24 mL) surgery (p = 0.200). The mean decrease in volume in the testis with the hydrocele after hydrocelectomy was 21%. There were statistically significant differences of RI and PI values between the normal testis (0.59 ± 0.07 and 1.02 ± 0.34, respectively) and the testis with hydrocele (0.79 ± 0.11 and 1.70 ± 0.56, respectively) before surgery (p < 0.001). In the testis with the hydrocele, we found a statistically significant decrease in RI and PI values (0.62 ± 0.05 and 1.00 ± 0.14, respectively) of intratesticular arteries after surgery (p < 0.001). The mean decreases in RI and PI values after hydrocelectomy were 21% and 36%, respectively.

CONCLUSION. There is an association between the development of an idiopathic hydrocele and testicular size and vascular resistance. We believe that the increase in volume and vascular resistance is due to an increase in impedance to venous and lymphatic flow.

Introduction

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Ahydrocele is one of the most common causes of scrotal swelling. It is defined as an abnormal free-fluid collection between the visceral and parietal layers of tunica vaginalis testis [1]. The congenital type of hydrocele results from the patency of the processus vaginalis testis, whereas most of the acquired causes of hydrocele are idiopathic [2]. The exact mechanism of idiopathic hydrocele formation is not known. Factors such as increased serous fluid secretion, lack of efferent lymphatics, and inadequate reabsorption of fluid secreted by the mesothelium are possible explanations [2]. Origins other than idiopathic causes are infection, infarction, torsion, tumors, radiotherapy, tuberculosis, or filariasis [2-5]. It affects approximately 1% of adult men, and the adult type of hydrocele is seen mostly in men older than 40 years [6]. Hydroceles are bilateral in approximately 7-10% of cases.

The effect of a hydrocele on the gonads has not been studied widely. A few studies have suggested that hydroceles may be associated with infertility by interfering with spermatogenesis [7-10]. We are unaware of any published report in the English-language literature dealing with the association of hydrocele on testicular size. The same is true for the intratesticular blood flow. We designed a prospective study in which patients with a unilateral idiopathic hydrocele were examined on gray-scale, color, and spectral Doppler sonography before and after hydrocelectomy. The purpose of the study was to determine whether there is an association between the development of an idiopathic hydrocele and testicular size and blood flow.

Subjects and Methods

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Twenty-three consecutive patients with the diagnosis of unilateral idiopathic hydrocele (noncommunicating and noncongenital) who underwent hydrocelectomy were included in the study. At physical examination, the physician was unable to palpate the testis due to the hydrocele. Patients with a history of severe cardiovascular problems, lymphangitis, previous inguinal radiotherapy, and hypoalbuminemia were not included in the study. The duration of scrotal symptoms ranged from 2 to 18 months (mean, 8 months). No underlying cause for the hydrocele was found in any of the patients. Informed consent was obtained from all patients before the sonographic examinations and surgery.

The patients were examined in the supine position, with the scrotum supported over a towel tightly draped over the thighs. All the examinations were performed in a temperature-controlled room after the patient had rested for 30 min. All examinations were performed by the same examiner with a high-resolution sonography system (Sonoline Elegra, Siemens Medical Solutions) using a 4-9-MHz linear array transducer.

The examination protocol included the preoperative evaluation of the hydrocele and pre- and postoperative evaluations of both testes. Preoperative evaluation consisted of identifying the testis with the hydrocele and characterizing the nature of the hydrocele with gray-scale sonography. We also evaluated the internal septations and loculations within the hydrocele to determine whether it was complicated. The length, width, and anteroposterior diameter of both testes were measured. At least three separate measurements were made on different occasions. The mean of these three separate measurements was used for the calculations. Approximate volume for ellipsoid structures was calculated by multiplying these three diameters by 0.523.

The parameters of color Doppler sonography were optimized to display low-flow velocities for evaluating intratesticular blood flow and low-velocity diastolic arterial flow on both the normal side and the side with hydrocele. Spectral waveforms were obtained from at least three different intratesticular arteries. Resistivity index (RI) and pulsatility index (PI) values were determined from these waveforms. The sonography scanner is supported with proper software for direct and automatic calculation of the hemodynamic parameters based on spectral Doppler waveforms. The spectral waveform was manually traced on the strip with calipers, and the RI and PI values were calculated automatically by the software program. Measurements were obtained from three individual waveforms from separate strips. The mean value of three measurements was calculated for each testis.

Postoperative measurements included testicular volume and the RI and PI values on both sides. All the calculations and measurements were performed by the method that was described earlier. To avoid having early postoperative changes (edema, hyperemia, or inflammation) affect RI and PI values, we performed the sonographic examinations at least 2 months after the hydrocelectomy.

In all of the patients, the indication for surgery was improvement of the cosmetic appearance of the testis or the patient's wish. Hydrocelctomy with tunical incision in which the fluid is drained and the tunica is everted was performed. The specimen volume was measured after being collected in a bowl right after the incision of the tunica. Care was taken to not manipulate the testes.

The program SPSS (version 7.5 for Microsoft Windows, Statistical Package for the Social Sciences) was used for statistical analysis. Testicular volumes and RI and PI values for the normal side and the side with hydrocele were compared before surgery. Both testicular volumes and intratesticular RI and PI values were compared after surgery. The Student's t test for paired samples was used for statistical analysis. Statistical significance was indicated by a p value of less than 0.05. The percentage of difference between the normal and hydrocele testicle measurements (volume and RI and PI values) and the percentage of change in measurements of a single testicle before and after hydrocelectomy were calculated and expressed as mean ± SD. A single analysis of variance (ANOVA) model was created for each measurement. Volume, RI value, and PI value were included as separate dependent variables. The independent variables were the hydrocele (presence or absence), surgery (before or after), and patient number (two observations per patient) for each instance. The interactions between the variables of the hydrocele and surgery were also studied separately using ANOVA. A p value of less than 0.05 was regarded as statistically significant.

Results

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The 23 patients ranged in age from 21 to 72 years (mean age, 42.8 ± 10.8 years). Fourteen patients (60.9%) had right-sided and nine patients (39.1%) had left-sided hydroceles. None of the hydroceles appeared complicated on sonography. All the hydroceles appeared as massive anechoic fluid collections around the testes. The mean volume of hydroceles was 291 mL (range, 242.7-365.4 mL) at surgery. None of the patients was shown to have a testicular tumor, inflammation, a varicocele, or an inguinal hernia on sonography.

Sonography was performed at a mean follow-up of 4.5 months after surgery (range, 2-6 months). None of the patients had recurrence of their hydrocele during this follow-up period.

The volume and RI and PI values for each testis before and after hydrocelectomy and the percentage of differences in measurements are given in Tables 1, 2, 3. Table 4 summarizes the mean values, SDs, and ranges for the volume, RI and PI values, and percentage of differences in measurements before and after hydrocelectomy. Before surgery, a statistically significant difference was found between the testicular volumes of both sides (p < 0.001), and a statistically significant difference in the RI and PI values was found between the normal side and the side with hydrocele (p < 0.001).

After hydrocelectomy, the difference in the testicular volumes before and after surgery on the side of hydrocele was statistically significant (p < 0.001). There was not a significant difference in the testicular volumes before and after surgery on the normal side (p = 0.200). The side with the hydrocele showed a statistically significant decrease in RI and PI values of intratesticular arteries after hydrocelectomy (p < 0.001). A statistically significant difference in RI and PI values was not detected on the normal side (p = 0.549 for RI, p = 0.306 for PI). Figures 1A, 1B, 1C, 1D, 1E, 1F, 1G, 1H, 1I, 1J, 1K, 1L shows an example of the pre- and postoperative changes in the volume and in the RI and PI values.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —49-year-old man with 7-month history of painless swelling of right scrotum. On preoperative sagittal (A) and transverse (B) sonograms of testis on side with hydrocele, testicular volume was measured as 26.7 cm3 (mL).

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —49-year-old man with 7-month history of painless swelling of right scrotum. On preoperative sagittal (A) and transverse (B) sonograms of testis on side with hydrocele, testicular volume was measured as 26.7 cm3 (mL).

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —49-year-old man with 7-month history of painless swelling of right scrotum. On preoperative sagittal (C) and transverse (D) sonograms of testis on side without hydrocele, testicular volume was measured as 14.1 cm3 (mL).

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —49-year-old man with 7-month history of painless swelling of right scrotum. On preoperative sagittal (C) and transverse (D) sonograms of testis on side without hydrocele, testicular volume was measured as 14.1 cm3 (mL).

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E. —49-year-old man with 7-month history of painless swelling of right scrotum. On postoperative sagittal (E) and transverse (F) sonograms of testis on side with hydrocele, testicular volume was measured as 19.7 cm3 (mL).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1F. —49-year-old man with 7-month history of painless swelling of right scrotum. On postoperative sagittal (E) and transverse (F) sonograms of testis on side with hydrocele, testicular volume was measured as 19.7 cm3 (mL).

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1G. —49-year-old man with 7-month history of painless swelling of right scrotum. On postoperative sagittal (G) and transverse (H) sonograms of testis on side without hydrocele, testicular volume was measured as 13.9 cm3 (mL).

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1H. —49-year-old man with 7-month history of painless swelling of right scrotum. On postoperative sagittal (G) and transverse (H) sonograms of testis on side without hydrocele, testicular volume was measured as 13.9 cm3 (mL).

View larger version (39K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1I. —49-year-old man with 7-month history of painless swelling of right scrotum. On color Doppler sonogram of testis obtained on side with hydrocele, preoperative spectral waveform shows resistive index (RI) value of 1.0.

View larger version (39K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1J. —49-year-old man with 7-month history of painless swelling of right scrotum. On color Doppler sonogram of testis obtained on side without hydrocele, preoperative spectral waveform shows RI value of 0.55.

View larger version (43K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1K. —49-year-old man with 7-month history of painless swelling of right scrotum. On color Doppler sonogram of testis on side with hydrocele, postoperative spectral waveform reveals decreased RI value of 0.57.

View larger version (44K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1L. —49-year-old man with 7-month history of painless swelling of right scrotum. On color Doppler sonogram of testis on side without hydrocele, postoperative spectral waveform reveals RI value of 0.50.

The results of the single ANOVA test showed that the volume measurements differed from patient to patient (F = 3.49, p < 0.001). However, the RI (F = 1.51, p = 0.100) and PI (F = 2.60, p = 0.566) values did not. Therefore, although the amount of change in volume varied among individual patients, the changes in RI and PI values were more constant. Also, the presence or absence of hydrocele and the surgical status (before or after) affected all three measurements (p < 0.001). When the presence or absence of a hydrocele and surgical status were taken into account, the measurements in the normal testicle did not change after surgery, whereas the measurements in the testicle with the hydrocele did (F = 67.53 for volume, F = 75.13 for RI value, and F = 25.15 for PI value; p < 0.001 for all three measurements).

Discussion

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A hydrocele, a common chronic condition in men, causes physical, psychological, social, and economic distress. Many men with a hydrocele think that they will never be cured, are often embarrassed by the condition, and frequently lose hope of living a normal life [11]. Hydroceles are generally painless. However, if pain is present, it may interfere with daily activities, and large hydroceles can even cause patients to have difficulty with sexual intercourse [12].

Large hydroceles are readily diagnosed on clinical grounds and with sonography. For this reason, hydroceles have not received much attention. On the other hand, few reports have shown that hydroceles may affect spermatogenesis, which may be partially or totally absent [7-10]. The pathophysiologic mechanisms that probably cause decreased spermatogenesis may be the pressure effect of the hydrocele on the testis, the reaction of testicular cells to the highly proteinaceous fluid, or whatever cause led to the formation of the hydrocele. The hydrostatic pressure of a hydrocele has been shown to surpass the pressure of blood vessels within the scrotum [13]. The pressure of fluid as a mechanical factor plays an important role in the malfunction of spermatogenesis. Histopathologic changes observed are interstitial fibrosis, thickening of the basement membrane, and disorganization of spermatogenic cells [7-10].

Indications for treating a hydrocele include pain, the cosmetic appearance of the scrotum, or the patient's wish [11, 12]. Conservative management of a hydrocele includes observation, aspiration, and sclerotherapy [14]. Of these conservative methods, sclerotherapy has been most favored, and it may be indicated in patients who have a small to moderate hydrocele, who are unwilling to undergo surgery, or who are poor surgical candidates. The conventional surgery for an idiopathic hydrocele is an excision and subsequent eversion of the sac, and this procedure remains the most popular surgical method [15]. Other techniques for treating a hydrocele in adults are the plication technique and internal drainage of the hydrocele [16].

In the first part of our study, we sought to determine the effect of a hydrocele on testicular morphology using sonography. We found a statistically significant increase in testicular volume on the affected side compared with that on the uninvolved side. Also, the postoperative volume of the involved side was significantly lower than the preoperative volume. The difference in volume can be explained by the same pathophysiologic mechanisms that were mentioned earlier [7-10, 13]. We think that the pressure of the hydrocele causes an obstruction in the vessels of the testis, thus creating stasis in the venous and lymphatic outflow. This stasis is in turn reflected as swelling and an increase in the size of the testis. After hydrocelectomy, the mean volume of the testis on the side with hydrocele was measured as 16.20 ± 2.99 mL. When compared with preoperative values, the postoperative measurements showed a statistically significant decrease (p < 0.001) of approximately 21%. We believe that this decrease is related to the removal of the pressure on the testis and regression of the swelling.

In the second part of our study, we evaluated the effect of a hydrocele on vascular impedance. Impedance is the interaction of resistance with compliance. Spectral Doppler sonography is a good method for identifying flow in the testes, with use of the time-velocity spectrum to quantify blood flow [16]. The spectral waveform of the intratesticular arteries characteristically has a low-resistance pattern, with a mean RI value of 0.62 (range, 0.48-0.75). In our study, a low-resistance flow within the intratesticular arteries was seen pre- and postoperatively on the side without the hydrocele (percentage of change, 0.4%). In contrast to that finding, a high-resistance flow was present preoperatively in the testis with the hydrocele, but the postoperative flow showed a low resistance after the elimination of the pressure effect. The mean percentage of postoperative decreases in the RI and PI values were approximately 21% and 36%, respectively. Nye and Prati [17] presented a case in which they evaluated spectral waveform characteristics of a capsular testicular artery after aspiration of the hydrocele fluid. Similar to our results, no diastolic flow was present before the aspiration, but after aspiration, antegrade diastolic flow was seen.

The increase in vascular resistance in patients with a hydrocele could be explained by two possible mechanisms. One possible mechanism could be the obstruction of the venous or lymphatic outflow tract caused by the pressure effect of the hydrocele, which in turn may increase the vascular resistance. The other possible mechanism could be histopathologic changes in the testes. Patients with a hydrocele may have interstitial fibrosis, thickening of the basement membrane, and disorganization of spermatogenic cells [7-10]. These histologic changes might cause an increase in vascular resistance by decreasing the compliance as a result of fibrosis. Neither of these pathophysiologic mechanisms has been clearly documented in the literature. Our findings, however, do not support the second theory because the vascular resistance decreased significantly after hydrocelectomy.

In conclusion, an idiopathic hydrocele is associated with an increased testicular volume and vascular resistance. We think that the increase in volume and vascular resistance is due to an increase in impedance to venous and lymphatic flow.

References

Top Abstract Introduction Subjects and Methods Results Discussion References

 

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