Funiculocele is a cyst of the spermatic cord located between the leaves of its own shells and filled with serous fluid. The size of the formation (from 2-3 mm to 8-10 cm) correlates with clinical manifestations. A small funiculocele is asymptomatic, with a large cyst there are complaints of discomfort in the scrotum, which increases after physical exertion, a feeling of bursting, soreness during sexual intercourse. Diagnosis is based on palpation and ultrasound scanning of the scrotum. MRI is performed as an additional imaging method if there are unresolved issues after ultrasound. Treatment of symptomatic funiculocele is operative.
ICD 10
N43.2 Other forms of hydrocele
Meaning
Funiculocele (dropsy of the spermatic cord) is diagnosed in men of any age. Pathology can be congenital or acquired (2:3), accounts for about 7-10% of all diseases of the scrotum. The spermatic cord is formed by the vas deferens, vascular, lymphatic and nerve structures delimited by loose connective tissue. When palpated, it feels like a rounded elastic weight 2-2.5 cm long. The cyst formed between the membranes is not connected with the testicle and its appendage, does not affect spermatogenesis, provided that blood circulation is preserved. The non-inflamed funicular is filled with a transparent yellowish transudate.
Causes
Various factors lead to the formation of congenital and acquired cysts. The appearance of funiculocele in a newborn is due to dysembriogenesis ‒ non-infection of the proximal part of the vaginal leaf of the peritoneum. This developmental anomaly is a consequence of infectious diseases suffered by the mother during gestation, contact with poisons, and taking certain medications. Among the reasons for the acquired funicular are:
- Injuries and operations. Interventions on the structures of the scrotum can lead to the formation of a cyst: vasectomy, operations for varicocele, hydrocele. Damage to blood vessels and lymphatic pathways leads to impaired lymph outflow and fluid sweating. Scars formed as a result of bruising, injury to the scrotum, prevent the outflow of secretions and contribute to its accumulation in a closed cavity.
- Urological pathologies. Funiculocele can develop as a consequence of the transferred inflammatory processes of the urogenital tract of a man: epididymitis, orchitis, funiculitis of a specific (more often gonorrhea, chlamydia) and non-specific etiology. Sometimes a secondary cyst accompanies the tumor process: fluid accumulates as a result of compression of blood and lymphatic vessels due to the growth of the neoplasm.
Pathogenesis
In the pathogenesis of congenital dropsy of the spermatic cord, the leading role belongs to the violation of the involution of the vaginal leaf of the peritoneum as a result of dysembriogenesis. Its closure occurs gradually, by the time of birth this channel is closed (transformed into a bundle) in most newborns. In some children, the closure process is completed by the age of 1.5 years. The cause of congenital funiculocele is a gradual accumulation of fluid due to complete or partial non–obliteration of the canal, loss of reabsorption of the vaginal process wall, underdevelopment of the lymphatic apparatus.
The mechanism of development of the acquired funiculocele is as follows: against the background of inflammation or injury, blood and lymph circulation is disrupted due to the adhesive process. Since there is no adequate outflow of lymph and blood from the inguinal region, the secret accumulates and stretches the wall of the spermatic cord with the formation of a cyst.
Classification
By origin, funiculocele can be congenital (primary) and acquired (secondary, symptomatic). There is an acutely developed hydrocele of the rope (within a few days due to injury, acute inflammation) and chronic (formed 5-7 weeks after funiculitis, orchitis). The etiological classification of funiculocele takes into account the alterating factor: trauma, iatrogenic damage, lymphostasis, etc. The state can be one-sided or two-sided. The most interesting is the assessment of obliteration of the vaginal process of the peritoneum:
- Absence of overgrowth throughout. A communicating hydrocele of the testicle and the cord develops. When the body position changes to horizontal, part of the fluid flows into the peritoneum, which makes the water cyst less tense.
- Partial non-contamination of the duct. The closure of the distal part of the canal and the absence of obliteration in the proximal section leads to a communicating funicular.
- Partial obliteration in the distal and proximal parts. This anomaly causes an unreported (isolated) funiculocele or cyst in the projection of the passage of the spermatic cord. The position of the body does not affect the elasticity and volume of the formation. Typical growth is with blood congestion in the pelvis and in the post-puberty period.
- Neobliteration in the distal part. This type of violation of the involution of the vaginal process leads to the appearance of dropsy of the testicle (hydrocele).
Symptoms
A small formation has no clinical manifestations and is detected accidentally by ultrasound of the genitals. A cyst of significant size leads to a change in the contours of the scrotum due to swelling. Patients complain of heaviness, discomfort, which increases during physical activity and during sexual contact. The communicating funicular decreases in size after sleep, the isolated one remains tense regardless of the change in the position of the body in space.
Often a man independently discovers a water cyst during hygienic procedures or during self-examination of the scrotum organs. Funicocele is palpated in the form of a rounded formation isolated from the testicle and appendage, of a tightly elastic or elastic consistency. There may be slight soreness when pressing. Pain, redness of the skin, an increase in regional lymph nodes indicate inflammation.
Complications
Funiculocele is a consequence of suppuration of the cyst of the spermatic cord. Phlegmon of the spermatic cord is more common in patients with immunosuppression (HIV infection, decompensated diabetes, condition after organ transplantation, etc.). A strained funicular with a large volume of fluid has a compression effect on the vessels feeding the testicle, which can cause its atrophy and violation of spermatogenesis. Other complications include the development of an inflammatory process in the structures of the scrotum – epididymitis, deferentitis, funiculitis. Pathology often develops after injury and attachment of secondary microflora. A direct blow to the genital area leads to rupture of a large cyst and bleeding.
Diagnostics
The diagnosis is established by a urologist based on the data of palpatory examination, analysis of the medical history. During the examination, attention is paid to the condition of the regional lymph nodes, discharge from the urethra. Laboratory tests are non-specific (they are examined for STIs with an appropriate clinical picture, concomitant acute inflammation). To confirm the funicular, they resort to instrumental diagnostics, which includes:
- Diaphanoscopy. Visual assessment of the scrotal organs using a light source (diaphanoscopy) can be used as a preliminary diagnosis. The watery cyst of the rope freely and evenly passes the rays, but with diagnostic manipulation it is impossible to assess the condition of the structures with high reliability.
- Scrotal ultrasound. Ultrasound scanning locates a cyst in the form of a round or oval formation, with clear contours, located in the projection of the spermatic cord. Uncomplicated funiculocele is filled with a homogeneous liquid; the formation of cavities, the deposition of calcinates, the appearance of inclusions is suspicious of a tumor process or tuberculosis etiology. Ultrasound shows the connection of funiculocele with the abdominal cavity, features of blood flow.
- MRI. The most informative imaging study remains MRI of the scrotum organs. It is performed when a neoplastic process is suspected in the cord or testicle. Tomograms show the difference between a cyst and a malignant neoplasm, the relationship of the tumor with surrounding tissues (the degree of invasion). MRI is justified for the diagnosis of purulent-destructive complications.
Differential diagnosis is carried out with a number of diseases: inguinal-scrotal hernia (the contents of the intestine can be corrected, the funiculocele does not change its position), testicular tumor, appendage (malignant neoplasm is soldered to tissues, final verification is possible only after morphological examination). Deferentitis, funiculitis, epididymitis have painful manifestations and in most cases are accompanied by hyperthermia. The exception is autoimmune lesions, but in these cases there is always a connection with the underlying disease.
Treatment
Treatment of uncomplicated forms is not carried out, for these patients they choose the tactics of active observation with the control of ultrasound of the scrotum once a year. In children, an assessment of the condition is applicable in dynamics up to 1.5-2 years of age, however, with acute funiculocele, the child is hospitalized in the department of urology. General indications for surgery: an increase in neoplasm, suspicion of a malignant process, the appearance of complaints, deterioration in the quality of life. With a strained funicular, surgical intervention is performed to preserve normal spermatogenesis. Types of interventions used:
- Puncture. Under local anesthesia, the contents of the cyst are eliminated, followed by the appointment of antibacterial therapy to prevent secondary infection. Manipulation can be useful for the study of the obtained fluid (cytology, bacposev, PCR) in the process of differential diagnosis. The high probability of relapses and complications does not allow us to recommend this method for widespread use.
- Aspiration with sclerosing. After fluid aspiration, a sclerosant is injected into the cyst cavity, which causes its walls to stick together. The efficiency is higher than with simple aspiration, but significantly lower than after surgical exfoliation of the cyst. There is a possibility of an inflammatory process joining, which can have an impact on fertility. Intervention can be performed if cancer of the spermatic cord or testicle is completely excluded.
- Operation. Surgical treatment of pathology is possible with the help of open or endoscopic intervention. The latter is considered less traumatic and applies to all age groups. The efficiency is close to 95%. A biopsy may be performed during the operation. The essence of surgery is the separation of the abdominal cavity and the canal of the vaginal process of the peritoneum with a communicating funiculocele and excision of the cyst.
Prognosis and prevention
The prognosis for life with funiculocele is favorable. Timely surgical treatment allows you to avoid complications. Reliable preventive measures to prevent the congenital condition have not been developed, but adherence to a healthy lifestyle, examination by a couple before a planned pregnancy can reduce the likelihood of a child with malformations of organs and systems, including abnormalities of the genitourinary system.
Men should avoid any damage to the genitals, use protection when doing traumatic sports. Refusal of casual sexual relations without a condom, prevention of congestions (regular ejaculation, normalization of stool, restriction of weight lifting) allow to preserve men’s health. In the presence of palpable education, symptoms of distress, you should immediately consult a doctor. As a preventive measure for early detection of pathology, each man should conduct regular self-examination of the genitals.