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Treatment of cystic swelling of scrotum: a clinical analysis

Cystic swellings are the most widespread surgical dilemma of the scrotum. They affect the physical well being and ensuing in mental anguish for him. They can be the grounds for sexual and marital life of subjects. They can also augment the economic and psychological weight of subjects and their families. They are defined as irregular collections of fluid within the scrotal cavity. They influence males of all age groups and relation for the widespread of all scrotal swellings.


INTRODUCTION
Cystic swellings are the most widespread surgical dilemma of the scrotum. They affect the physical well being and ensuing in mental anguish for him. They can be the grounds for sexual and marital life of subjects. They can also augment the economic and psychological weight of subjects and their families. They are defined as irregular collections of fluid within the scrotal cavity. They influence males of all age groups and relation for the widespread of all scrotal swellings. 1,2 The scrotum is a sac of skin and instinctive muscles enclosing the testis, epididymis, vas dissimilarity and spermatic vessels. It is a phylogenetic sophistication of the genito urinary system. The scrotum functions to offer apt surroundings to the testis for optimal spermatogenesis, which is so significant for perpetuation of a race. In other words scrotum is the thermo regulator of spermatogenesis. 3,4 Most of the scrotal swellings are benign. The etiology is assorted and ranges from the commoner swellings such as hydroceles, spermatoceles, and epididymal cysts to less widespread ones such as hematocele, pyocele, and chylocele. 5 Cystic swellings of scrotum are frequently trouble-free and can achieve a very big size devoid of causing much uneasiness to subject. The mortality from this state is insignificant. The scrotum is liable to traumatic injury owing to their hanging down place and mobility important on to hematocele. 6 Hence, although mortality connected with this situation is insignificant, morbidity can be noteworthy. The etiology of the cystic grounds of scrotal enlargement is assorted, it ranges from hydrocoele, to spermatocoele and epididymal cyst to less ordinary ones like haematocoele, pyocoele and chylocoele. Most of these swellings are benign. 7 The cystic swellings comprise a broad spectrum of etiopathology and can present in any age group. The ample spectrum of the condition demands the significance to discover he most widespread cause and their age wise allocation and so better thoughtful for a determined and particular management of the form. 8 Present research aims to look into the different pathologies of the scrotum and its contents, which present as scrotal swelling; and to emphasize upon the finest way to loom them; in order to reinstate the anatomy and physiology to the most possible level. Management of cystic swelling of a meticulous type can be completed in diverse ways; hence there is a requirement to study the ultimate modality of management for each type of cystic swelling of scrotum possible in our setup of rural hospital.

Study type, study place and study period
In the present Hospital Based observational study, a total of 100 cases were selected from the patients who were admitted in different surgical units in GMERS Medical College and Hospital Ahmedabad, for a period of two years from March 2019 to February 2021.

Inclusion criteria
Patients aged up to 70 years, cystic swellings from testis, and its coverings, epididymis, spermatic cord and from the scrotal skin are included in this study.

Exclusion criteria
Acute swellings of the testis, inguinoscrotal swelling, torsion of testis, congenital hydrocele are excluded in this study.

Method of collection of data
After the approval by the Institutional Ethical Committee of the Medical College and Hospital, 100 patients aged upto 70 years were enrolled in this clinical study with written informed consent. Patients admitted with symptoms of swelling, pain, discomforts in the scrotal region were studied with facilities available in the hospital, through a preformed proforma comprising of:

Detailed history
Patient's age and occupation was recorded, duration of swelling and pain or associated fever, trauma were asked.

Local examination
Skin and swelling itself with two cardinal signs fluctuation and translucency, testis, epididymis and spermatic cords are examined along with regional lymphnodes and findings were noted.

Systemic examination
Respiratory and per abdomen examination were done.

Routine laboratory investigations
Blood investigations were done to rule out eosinophilia and microfilaria, lymphocytosis and increased E.S.R.

Urine examination
It is done to rule out associated any urinary tract infection.

Scrotal ultrasound was done in all cases
It was done to see any changes in testis and other structures in scrotum. Pre anaesthetic evaluation and fitness for surgery was by done anaesthesiologist. Surgical procedure was tailored according to the patient's disease by the attending surgeon under suitable anaesthesia given by anaesthesiologist. Intraoperative findings as color of the fluid if any testicular changes epididymis condition are recorded.
Corrugated rubber drain was placed in most cases and removed after 48-72 hours depending on the clinical situation. Postoperative scrotal support was given in all the cases. Histopathological study of the specimen and biochemical analysis of the fluid was done in relevant cases. Postoperative course and management of postoperative complications like fever, scrotal edema, hematoma, and infection were recorded. At discharge, all the patients were educated about the disease and were requested to come for follow-up at the outpatient department. Finally follow up was carried out for 1-4 months.

Statistical analysis
The recorded data was compiled and entered in a spreadsheet computer program (microsoft excel 2007) and then exported to data editor page of Statistical package for social sciences (SPSS) version 15 (SPSS Inc., Chicago, Illinois, USA). For all tests, confidence level and level of significance were set at 95% and 5% respectively.

RESULTS
This was a clinical study to observe the distribution of types of cystic swellings of scrotum and pattern of clinical presentation and to study the different treatment modalities.   A total of 66 patients were discharged between 0-5 days, earliest was among excision for sebaceous cyst, 32 patients were discharged between 6-10 days and 2 patient was discharged between 11-15 day. Patients who underwent Lord's procedure had a record of early discharge than compared to eversion of sac for primary vaginal hydrocoele.

DISCUSSION
The swelling in the scotum area occurs in all age groups.
In the present research total of 100 patients were included in the research work. The maximum numbers of patients were seen in age group of 51-60 years followed by age group of 41-50 years. There are no predisposing factors found in the above cases. Most of the patients presented with the only complaint of swelling of the scrotum. A few patients complained of scrotal swelling with pain.
These complain are similar to the report of Subith et al in which swelling alone was the main presenting complain. 2 On comparison of side for the swelling, maximum numbers of patients were seen on right side as compared to left side. Only 10 cases were seen on bilateral sides. The results were in accordance with the study done by Agbakwuru et al in 2008 and Subith et al in 2014. 2,9 The conditions were confirmed with scrotal ultrasonography. The swellings were either ovoid or globular in shape. Primary hydrocele was seen as the common cause for the scrotal swellings. Next cause for swelling was found to be epididmal cysts. The other causes encountered in the study were spermatocele (6%), sebaceous cysts of the scrotum. Similar distribution of cystic swelling of scrotum was reported by Agbakwuru et al in their study of 50 cases where 94% and Subith et al in 55% were primary vaginal hydrocele respectively. 2,9 These findings are also in agreement of various studies. [10][11][12][13][14] All the cystic swellings of scrotum were treated with surgical treatment. For the surgical treatment maximum patients were administered spinal anaesthesia and only 4 cases were given general anaesthesia. The general anaesthesia was administered only in younger patients.
Local anaesthesia was employed only in 2 cases.
Three procedures were employed in the treatment of primary vaginal hydroceles-Jaboulay's procedure, Lord's plication and Partial excision and eversion of the sac. Jaboulay's eversion of sac was done for primary vaginal hydrocele in 60% cases with a large and tense swelling with thin sac. Excision was done for epididymal cysts and spermatoceles.
For primary vaginal hydroceles, Lord's plication had no postoperative complications with as compared to Partial exision and eversion of sac and Jaboulay's procedure. Patients were then followed up for 2-4 months, there was no recurrence of lesion in the patients followed up during this period. As the sample size of the study is less we can not generalized the results to other population.

CONCLUSION
A cystic swelling of the scrotum poses a common surgical problem. Primary vaginal hydrocoele was the commonest cystic swellings of scrotum. Most of the cystic swellings were treated surgically with good results. Lord's procedure was the least to have post-operative complication.