Microsoft word - 22-a-08-07-johar ali-hydrocoele.doc
J Ayub Med Coll Abbottabad 2008;20(2) ASPIRATION AND TETRACYCLINE SCLEROTHERAPY OF PRIMARY VAGINAL HYDROCOELE OF TESTIS IN ADULTS Johar Ali, Waqas Anwar*, Mohammad Akbar**, Syed Ali Akbar, Arshad Zafar** Department of Surgery, *Department of Dermatology, Frontier Medical College, Abbottabad, **Department of Surgery, Ayub Medical College, Abbottabad, Pakistan. Background: Primary Vaginal Hydrocoele of Testis is a common condition which is primarily treated surgically. Many patients with Hydrocoele of testis are either not willing or are unfit for surgery. This study was done to know the safety, efficacy and out come of tetracycline induced sclerotherapy of Primary Vaginal Hydrocoele of Testis in adults. Methods: This quasi experimental study was done in Shahina Jamil Hospital, attached with Frontier Medical College and Ayub Teaching Hospital, Abbottabad from March 2006 to April, 2007. Thirty-seven patients with primary vaginal hydrocoele were included in the study. Aspiration and instillation of Tetracycline was done after spermatic cord block with 2% lignocaine. Procedure time, Peri and Post-procedure complications, number of injections for cure and patients' satisfaction with the procedure were recorded. Patients were discharged home 3 to 4 hours after the procedure and followed up after one week, one month, three months and six months. Direct admission and re-admissions were recorded. Results: The mean age of patients was 47 years. Mean procedure time was 45 minutes. All patients were cured. Mild postoprocedure pain occurred in 12 (40%), moderate pain in 14 (46%) patients and severe pain in 4 (13.3%) patients. No patient developed haematoma or local infection. One patient (3.3%) had micturition problem. Two (6.6%) patients had minimal recurrence. One injection was sufficient for cure in all patients. 28 (93%) patients were satisfied while 2 (6.6%) patients were not satisfied with this procedure. No patient was admitted in the hospital after the procedure. Conclusion: Aspiration and injection of tetracycline in Primary vaginal Hydrocoele of Testis in adults is safe, effective and very economical procedure. Key words: Primary Vaginal Hydrocoele, Aspiration Tetracycline Instillation, Sclerotherapy, INTRODUCTION
secondary cause for hydrocoele. Those who did not give consent for the procedure, age less than 25
The conventional treatment of Hydrocoele of Testis
years, known hypersensitivity to tetracycline,
is surgical.1 It is associated with inconvenience of
coagulapathy, hydrocoele with inguinal hernia, post
hospitalization and complications of anaesthesia and
operative hydrocoele and acutely inflamed scrotum
surgery.2 Simple repeated aspiration of primary
and inguinal region, were excluded from study.
Written consent was obtained and patients were
comfortable but increases the risk of infection and
verbally informed about the procedure, expected
recurrence.3 Kaye in 1982 first described usefulness
post-procedure course and possible complications. In
of tetracycline in the treatment of hydrocoele of
case of complications, immediate access to a surgical
testis which is extensively used for chemical
bed in a local hospital was available as study
pleurodesis in recurrent pneumothorax and malignant
protocol. Under aseptic conditions spermatic cord
pleural effusions.4,5,6 Different sclerosent agents are
was blocked by 2% lignocaine infiltration, a bleb was
now widely used in treatment of hydrocoele
raised off scrotal skin and 20-gauge I/V cannula
including phenol7, ethanolamine oeleate8, sodium
inserted into vaginal sac and hydrocoele fluid was
tetradecyl sulphate9, tetracycline10,11 and fibrin.12 The
aspirated after removing stilette. Leaving cannula in
objective of this study was to know the out come of
situ, two capsules of tetracycline were mixed with 2
aspiration and instillation of tetracycline induced
ml bupivacaine in a 10 ml syringe, needle removed
sclerotherapy of primary vaginal hydrocoele in terms
and the solution was injected into the sac. Scrotum
of safety, efficacy and procedure related morbidity.
was massaged gently for few seconds in order to
MATERIAL AND METHODS
distribute the drug evenly. The patients were observed for 3–4 hours and then were discharged
This quasi experimental study was carried out in
home. They were prescribed Tablets Ibuprofen 600
out- patient department of Shaheena Jamil Hospital,
mg TDS. They were reviewed after one week, one
attached with Frontier Medical College Abbottabad
month, three months and six months. Scrotal
and Ayub Teaching Hospital Abbottabad from March
ultrasound was performed at each follow-up visit to
2006 to April, 2007. All the patients with clinical
see resolution of hydrocoele. Any complications
diagnosis of primary vaginal hydrocoele were
during and after the procedure were noted. On
included in the study. All patients had testicular
follow-up symptomatic improvement and any
ultrasonography was performed to rule out any
complications recorded. Questions were asked about
J Ayub Med Coll Abbottabad 2008;20(2)
their satisfaction with the procedure. If they were not
There were 30 patients in this study who had
satisfied, reasons for dissatisfaction were noted. The
Performa was completed prospectively and the data
hydrocoeles and followed-up for 6 months. All
recorded included the total number of operation
(100%) patients in this study were cured. These
performed in the study period, mean operating time,
results are comparable with other studies in literature
number of injections of sclerosant, complications,
where the success rate were 90 to 100%.13–15 Many
recurrence, and satisfaction with the procedure.
studies have been done comparing sclerotherapy with surgery. Roosen reported cure rate of 89% following
Tetracycline sclerotherapy and 100% following
Out of a total of 37 patients, 7 patients were lost to
surgery after 6 months follow-up but the mean
follow-up and data from 30 patients were included
duration of hospitalization in latter group was 2–5
in the study. The mean ages of patients were 47
days.16 Beiko compared aspiration and sclerotherapy
years. Mean procedure time including spermatic
with hydrocelectomy for the treatment of hydrocoele.
cord block was 45 minutes. All patients were cured
Overall success for aspiration and sclerotherapy was
with a follow-up of six months. A single injection of
Tetracycline was sufficient and no patient required
complication rate of only 8% in aspiration and
re-treatment. Twelve (40%) patients complained of
sclerotherapy group and 40% in surgery group.
mild pain and 14 (46%) patients complained of
Comparative cost per procedure demonstrated that
moderate pain over scrotum. All these patients were
surgery group was almost nine fold more expensive
comfortable with analgesia as needed by oral
than sclerotherapy.17 Mean procedure time in our
analgesics. Four (13.3%) patients had severe post
study was 45 minutes. Roosen reported procedure
procedure pain. They were given supplemented
time of 45 minutes while Beiko reported procedure
parenteral analgesic Diclofenac 75 mg and settled.
Only 2 (6.6%) developed recurrence of mild nature.
The complications in this study were limited
They were offered second injection sclerotherapy
to mild to moderate pain. Severe pain occurred in
but they were satisfied with the improvement and
only 4 (13.3%) patients. This may be because we
did not opt for further treatment. No patient had
used Tetracycline with bupivacaine along with
scrotal haematoma or infection. One patient (3.3%)
spermatic block. These result are comparable with
had micturition problems like hesitancy and
other studies.13,15 However, Ozkan reported severe
dribbling but settled. No patient was admitted
pain in 46.6% patients in their randomized
directly after the procedure or after discharge in the
prospective study.18 No patient in this study had
hospital. Twenty-eight (93%) patients were satisfied
severe pain necessitating admission to a hospital.
with the procedure. Two (6.6%) patients were not
One injection sclerotherapy was sufficient
for cure in our study. Only 2 (6.67%) patients in this study had mild recurrence noticed on six months
Table-1: Complications of aspiration and
follow up. They were satisfied with the overall
tetracycline sclerotherapy (n=30)
improvement and re-treatment was not done.
Reported recurrence varies depending upon the
studies. Most recurrences vanish spontaneously and
re-injection should not be done until 3 months. However in large hydrocoeles, injection can be
repeated. Onu reported up to 5 injections for cure.15
Most patients in our society are reluctant to have surgery
Other studies have also reported that repeat injections
for hydrocoeles and opt for conservative treatments. The
are needed in some patients with recurrence.18,19 No
reasons may be shame, economical, fear of pain and no
patient underwent surgery for recurrence. Renken
hospitalization. Many surgeons consider surgery as the
reported postsclerotherapy surgery in 4% patients.20
last resort because of postoperative complications like
There were no cases of infection or haematoma in
haematoma, infections and urinary retention. A number
this study. Some studies in literature have mentioned
of sclerosants like phenol, sodium tetradecyl sulphate,
orchidectomy after sclerotherapy for infected
polidocanol are used and all are useful for treating
haematocoele.18,20 No patient in this study needed
hydrocoeles. However they are not readily available in
Pakistan. Our choice of tetracycline as sclerosent agent
for sclerotherapy was based on its low cost, antibiotic
patients who stated their satisfaction. If tetracycline
itself and easy availability. Its very low PH (2.0–3.5)
induced sclerotherapy of primary vaginal hydrocoele
results in inflammation and sclerosis of tunica
could be performed in an out-door setting, there is no
inconvenience of hospitalization. Many patients
J Ayub Med Coll Abbottabad 2008;20(2)
would benefit leaving more beds, theatre time and
hydrocoele: a study in 55 patients. J Urol. 1989;142:1500–1.
hospital resources for acute cases. Appreciable
Hellstorm PA, Tammela TL, KoatturimM, LukkarinenO. Ethanolamine oleate as a sclerosant for testicular hydrocele
savings may also be made in patients’ waiting times
and epididymal cysts. Br of Urol 1988;62:445–8.
Stattin P, Karlberg L, Damber JE. Long-term outcome of patients treated for hydrocoele with the sclerosant agent sodium
CONCLUSIONS & RECOMMENDATIONS
tetradecyl sulphate. Scand J Nephrol. 1996;30:109–3.
10. Badenoch DF, Fowler CG, Jenkins BJ, Roberts TV, Tiptaft
We conclude that aspiration and injection of
RC. Aspiration and Instillation of Tetracycline in the
tetracycline in primary vaginal hydrocoele is safe,
treatment of testicular hydrocoele. Br of Urol 1987;59:172–3.
cost effective and is preferred for older patients who
11. Suwan P. Treatment of hydrocoeles by aspirations and
are at risk of anaesthetic complications and having
tetracycline instillations. J Med Assoc Thai. 1994;77:421–5.
12. Cecchi M, Sepich CA, Pagni G, Ippolito C, Minervini R,
Fiorentini L. Painless treatment of hydrocoele: EMLA cream
recommend this as a reasonable first line alternative
and fibrin adhesive sclerotherapy. Int Urol Nephrol,
13. Musa MT, Fahal AH, El Arabi YE. Aspiration sclerotherapy
for hydrocoeles in the tropics. Br J Urol. 1995;76:488–90.
14. Levine LA, De Wolf WC. Aspiration and tetracycline
Lord PH. A blood less operation for the radical cure of
sclerotherapy of hydrocoeles. J Urol. 1988;139:959–60.
idiopathic hydrocoele. Br J Surg 1969;51:914–6.
15. Onu PE. Sclerotherapy for large hydrocoeles in Nigeria. Trop
Swartz MA, Morgan TM, Krieger JN. Complications of scrotal
surgery for benign conditions. Urology, 2007;69:192–3.
16. Roosen JU, Larsen T, Iversen E, Berg JB. A comparison of
Breda G, Giunta A, Gherardi L, Xaysa D, Silvestre P, Tamai
aspiration, antazoline sclerotherapy and surgery in the
A. Treatment of hydrocoele: randomized prospective study of
treatment of hydrocoele. Br J Urol. 1991;68:404–6.
simple aspiration and sclerotherapy with tetracycline. Br J
17. Beiko DT, Kim D, Morales A. Aspiration and sclerotherapy
versus hydrocoelectomy for treatment of hydrocoeles.
Kaye KW, Lange PH, Fraley EE. Spermatic cord block in
Urologic surgery. J Urol 1984;128:720–1.
18. Ozkan S, Bircan K, Ozen H. Treatment of testicular
Dikensoy O, Light RW. Alternative widely available, inexpensive
hydrocoele with tetracycline sclerotherapy. Int Urol Nephrol.
agents for pleurodesis. Respirology, 2005;10:378–84.
Tan C, Sedrakyan A, Browne J, Swift S, Treasure T. The
19. Bullock N, Thurston AV. Tetracycline sclerotherapy for
evidence on the effectiveness of management for malignant
hydrocoeles and epididymal cysts. Br J Urol, 1987;59:340–2.
pleural effusion: a systematic review. Eur J Cardiothorac
20. Rencken RK, Bornman MS, Reif S, Oliver I. Sclerotherapy
for hydrocoeles. J Urol, 1990;143:940–3.
Savion M, Wolloch Y, Savir A. Phenol sclerotherapy for
Address for Correspondence: Dr. Johar Ali, Assistant Professor of Surgery, Frontier Medical College, Abbottabad, Pakistan. Tel: +92-992-383561/68, Fax: +92-992-381053, Cell: +92-300-9110744 E-mail:[email protected]
Proceedings of the New Zealand Society of Animal Production 61: 195-198 Relationships between, milk production, nutrition and reproduction in “benchmark” herds1 J. F. SMITH, G. A. VERKERK1, B. A. CLARK1, B. J. MCKAY2 AND D. M. DUGANZICHAgResearch Ltd., Ruakura Research Centre, Private Bag 3123, Hamilton ABSTRACT Inter-relationships between nutrition, milk production and reproduct