Hydrocele

A hydrocele is accumulation of serous fluid between the parietal and visceral layers of the tunica vaginalis.

Hydroceles are divided clinically into:

Communicating hydrocele

Persistent processus vaginalis allows peritoneal fluid to enter the scrotum.

Common in children.

Noncommunicating hydrocele

Processus vaginalis is closed and fluid remains confined around the testis.

Secondary hydrocele

Occurs because of:

Epididymo orchitis
Testicular tumour
Trauma
Torsion
Previous surgery

A newly developed adult hydrocele should not be accepted as idiopathic until the testis has been adequately examined.

In infants, many noncommunicating hydroceles resolve spontaneously.

Observe during the first 12 to 18 months when no hernia or other pathology is present.

Operate earlier for:

Communicating hydrocele
Associated inguinal hernia
Very large symptomatic hydrocele
Persistence beyond expected spontaneous closure

Paediatric treatment is high ligation of the patent processus vaginalis through an inguinal approach.

Adult hydrocele

Observe if:

Small
Painless
Underlying testis normal

Operate when:

Large
Painful
Functionally inconvenient
Cosmetically unacceptable

Procedures include:

Lord plication

Suitable for thin walled hydroceles.

Jaboulay eversion

Opens and everts the tunica vaginalis.

Large thickened sacs may require partial excision.

Aspiration alone has a high recurrence rate and is reserved mainly for patients unsuitable for surgery, sometimes combined with sclerotherapy.

Benign Prostatic Hyperplasia

Also known as: BPH

Non-malignant hyperplasia of prostatic transition zone tissue causing bladder outlet obstruction, increasing in prevalence with age from the 40s onward.

Lower urinary tract symptoms (LUTS): storage (frequency, urgency, nocturia) and voiding (hesitancy, weak/intermittent stream, straining, incomplete emptying, terminal dribble). DRE: smooth, symmetrically enlarged, firm-elastic prostate (irregular/hard/asymmetric nodularity raises malignancy concern). Complications: acute urinary retention, recurrent UTI, bladder stones, chronic retention with overflow incontinence, hydronephrosis/renal impairment.

IPSS score: mild (0-7), moderate (8-19), severe (20-35) — guides management
DRE: size, consistency, nodules
PSA: discuss risks/benefits first; elevated in BPH, prostatitis, and cancer — not diagnostic alone
Urinalysis: exclude infection/hematuria
U&E/creatinine: if chronic retention/hydronephrosis suspected
Post-void residual (bladder scan): assesses incomplete emptying
Uroflowmetry: objective flow assessment (specialist)

Differentials: prostate cancer, urethral stricture, bladder neck dysfunction, overactive bladder, UTI, neurogenic bladder, prostatitis.

Mild (IPSS <8): watchful waiting, reduce evening fluids/caffeine/alcohol, bladder training
Alpha-blockers (first-line, rapid relief): tamsulosin 400mcg od, alfuzosin 10mg od, doxazosin 1-8mg od (titrate) — side effects: postural hypotension, retrograde ejaculation, intraoperative floppy iris syndrome (inform ophthalmologist pre-cataract surgery)
5-alpha reductase inhibitors (larger prostates, reduces volume over months): finasteride 5mg od, dutasteride 0.5mg od — 3-6 months for effect, reduces PSA ~50% (adjust interpretation), side effects: ED, reduced libido, gynecomastia
Combination therapy: superior long-term outcome for larger prostates with moderate-severe symptoms
Tadalafil 5mg od: alternative/add-on, particularly with comorbid ED
Antimuscarinic/beta-3 agonist (mirabegron): add-on for persistent storage symptoms — ensure adequate voiding first
Acute retention: urgent catheterization, trial without catheter after alpha-blocker initiation; urology referral if fails
Surgery (severe/refractory, complications): TURP — gold standard; laser enucleation/vaporization, minimally invasive options (UroLift, Rezum) for selected patients

Referral: urology for refractory symptoms, complications, or suspected malignancy.

Hydrocele

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management