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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 http://www.ayubmed.edu.pk/JAMC/Past/20-2/Johar.pdf 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. Complications
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 DISCUSSION
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 http://www.ayubmed.edu.pk/JAMC/Past/20-2/Johar.pdf 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 REFERENCES
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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]
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