The injection therapy of hydrocele and spermatocele

THE INJECTION THERAPY OF HYDROCELE AND SPERMATOCELE* ARTHUR Adjunct

Attending

Urologist, Correction

H.

MILBERT,

M.D.

and Sydenham HospitaIs; Lecturer in Urology, New York PoIyclinic HospitaI and Medical School NEW

YORK

I

N medicine as in industry, simphcity, conservation, and economy represent the acme of attainment in any given procedure. To this end, injection therapy for varicosities, herniae and pathologic processes in endotheIiaI-Iined sacs has en joyed widespread apphcation in recent years. This brief exposition wiI1 concern itseIf with a new pharmacoIogic agent for injection treatment of hydroceIe of the tunica vaginaIis and spermatoceIe. MedicaI heaIers from time immemoria1 have wrestIed with the problem of hydroceIe. CeIsus, in ancient Rome, essayed eradication of the sac by injecting saItpeter and by surgica1 excision of a portion of the sac. Various surgica1 procedures from exteriorization to tota enucIeation of the cystic mass were subsequently tried with varying resuIts. Down the ages, various scIerosing soIutions have been used, a partia1 Iist incIuding tincture of iodine, phenol, sodium chIoride, quinine urea hydrochIoride, sodium morrhuate, quinine dihydrochIoride and a host of other combinations of drugs. Injection therapy feI1 into disrepute severa centuries ago due to the untoward painfu1 inhammatory processes set up by the extremely powerfu1 scIerosing agents used. True, results were attained, but at too great a price. ConsequentIy, the penduIum swung to surgica1 correction of the deformity to the excIusion of a11 other forms of therapy. Within the past decade, however, a more rationa approach to the use of scIerosing agents for injection has been made. The accumuIated data obtained from varicose vein therapy have been appIied to hydro* Read before the Section of Genito-Urinary

CITY

ceIe. This is a condition which cIaims 2 to 4 per cent of a11 uroIogic admissions to cIinics and hospitaIs, according to EweII, Marquardt and Sargent. l The Iate Dr. Norman J. KiIbourne and Dr. C. J. Murray2 expounded the foIIowing requirements for the idea1 injection soIution : I. It must not cause immediate pain at the time of injection. 2. It must not cause pain severa hours after injection. 3. It must not cause undue IocaI inffammatory reaction disabIing the patient. He must not be kept from his reguIar work or Iose time. 4. It must be bactericida1. If it is strongIy bactericida1, the possibility of infection is eIiminated. 3. It must not be dangerousIy toxic. 6. It must be efficient in destroying even Iarge hydroceIes with thickened waIIs, and yet it must not be so caustic as to bring on hemorrhage into the sac. This was reported in the oId days with strong phenol concentrations. After experimenting with eucupin, a quinine derivative, and quinine hydrochIoride with urethane, Kilbourne added diothane as an additiona anesthetic agent. It is this soIution of quinine hydrochIoride, urethane and diothane which forms the basis for our work. It was successfuIIy appIied in twenty-eight consecutive cases in the hands of KiIbourne,3 but further conIirmation was desired. At the suggestion of, and in coIIaboration with Dr. CIarence G. BandIer, who was one of the first to show the merits of diothane as an effective mucosa1 surface anesthetic agent in uroI-

Surgery, New York Academy 487

of Medicine,

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20,

1938.

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American Journal of Surgery

~gy,~ this work was fundamenta1 technique foIIowed.

MiIbert-Hydrocele

undertaken. of KiIbourne

The was

JUNE,1939

above mentioned proportions :

drugs

Diothane.............., NATURE

OF

NEW

PREPARATION*

Let us consider the constituents and rationaIe for the incIusion of the three drugs mentioned in the injection soIution under consideration. Quinine hydrochIoride is an irritant that has bactericida1 as we11 as anesthetic properties. This gives it preference over sodium morrhuate which is said to be non-bactericida1 and painfu1 on injection. The objection to quinine on a basis of idiosyncrasy or toxicity is avaIid one. Auditory and optic nerve impairment has been reported after as Iittle as 15 gr. of the drug had been taken. Since the content of quinine hydrochIoride in this soIution is only 5.5 per cent, a maximum of 10 C.C. wouId contain onIy 0.5 Gm. or 7.5 gr. The average dose used for injection in our hands was 6 c.c., representing 5 gr. No evidence of quinine sensitivity has been reported by any of the observers using this preparation. Urethane is anesthetic in itself and also enhances the action of quinine, promoting its soIubiIity, faciIitating its penetration into the endotheIia1 Iining of the hydroceIe sac, and most important, preventing a strong IocaI inff ammatory reaction. According to experimenta work of KiIbourne, this latter property is an apparent specific action of urethane with quinine. Diothane, a pheny1 urethane synthesized by Rider,5 has a powerfu1 proIonged IocaI anesthetic action and further enhances the effect of the soIution. A noteworthy finding has been the tota absence of pain from the injection per se. NaturaIIy, rough handling of the scrotum and testicIe wiI1 produce pain and striking the testis or cord structures with the needIe during aspiration or injection may give excruciating pain. We have noted no post-injection discomfort. Rider, of MerreII and Company, has provided a simpIe stabIe solution of the * The drug was supplied by the WiIliam S. MerreII Company

of Cincinnati.

in the

,.,

,....

Quinine HCI. Urethane.......................

foIIowing Per Cent 0.75

4 .s 3.0

The research product has been issued in IO C.C. ampuIes, represented as a cIear, coIorIess soIution. Any discoIoration in the soIution shouId be a contraindication to its use, The compIete eradication of pain represents an accompIishment which has Iong been sought. Even in recent contributions to the Iiterature we note references to this Ione disturbing factor. Mayers,6 in reporting on twenty-three successes using quinine hydrochIoride and urethane states “an aImost constant reaction at the time of the first injection is rather sharp pain.” Baretz’ reported twenty-nine, or 70 per cent cures in forty-two cases, with severa patients FompIaining of pain at the time of injection of the quinine and urethane soIution he used. WhiIe this pain never incapacitated, discomfort was experienced in some cases for one to two days. KiIbourne used quinine, urethane and diothane in twenty-eight cases without any pain and we have used it in twenty-six instances without such sequeIae. TECHNICAL

PROCEDURE

SeveraI points in the technique of aspiration and injection of hydroceIe or spermatoceIe are worthy of note. The patient is pIaced in a supine position, the scrota1 area prepared and surface antiseptic appIied. We favor shaving the patient, both to combat infection and to faciIitate appIication and remova of an adhesive suspensory. A smaI1 whea1 is raised at the site of injection, using I per cent procaine hydrochIoride. KiIbourne has emphasized the necessity for using a 3 inch 17 gauge needIe for aspiration. Various observers have advised specia1 trocars and taking particuIar care in reversing the direction of the needIe as it is pushed through the scrota1 waI1, thus

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preventing Ieakage after its withdrawa and aIso heIping to prevent it from slipping out of the sac. We foIIowed this Iatter step, as advised by Kilbourne, in order to dupIicate his technique exactIy so that resuIts could be evaIuated. In recent cases we have simpIy used a 2 inch Ig gauge needIe, inserting it aImost at a right angIe to the skin surface and directing it toward the upper recess of the sac-away from the testis and epididymis and paraIIe1 to the cord. We have noted no extravasation or Ieakage as a resuIt. Care must be taken to keep the needle in pIace and we insert it, where possibIe, to its hub. In one instance, about I C.C. of the scIerosing agent was pIaced in the scrota1 waI1 when the needIe did slip out, but there was very IittIe tissue reaction and no pain whatsoever. Of great importance is the thorough evacuation of the sac. Depending on the size of the sac, a IO, 20 or 50 C.C. syringe may be attached to the needle for aspiration. Another IO C.C. syringe fiIIed with the drug is held ready for attachment to the needIe. It is not sufEcient to consider the sac empty when no more fluid can be aspirated. Digital paIpation, “cornering” the fluid in the upper recess where the needIe point Iies, and manua1 expression without the syringe attached to the needIe, wiI1 often yieId IO to 20 C.C. more fluid. It is readily understandabIe how ineffectua1 this amount of hydroceIe fluid, if Ieft behind, wouId render the sclerosing material. Assistance makes the entire procedure easier, but we have carried it out singlehanded, in both the cIinic and the offIce. Depending on the amount of ffuid obtained, a proportionate volume of the drug is injected. Thus, 2 C.C. was injected into a sac from which 15 C.C. of fIuid was obtained; 300 C.C. of fluid was repIaced by IO C.C. of the drug. The dose is arbitrary-the aim being to inject enough to reach the entire endothelial Iining of the sac. This brings up another important step in technique-that of “kneading” the coIIapsed sac foIIowing injection, to faciIitate uniform distribution of the drug.

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FinaIIy, we favor a measure which has not been empIoyed or emphasized by others. We appIy a snug, adhesive suspensory immediateIy after the injection. This is kept on for three to five days without being disturbed. FolIowing its remova a bag suspensory is worn unti1 cure is effected. We beIieve the immediate compression of the coIIapsed sac enhances the action of the drug on the endotheIia1 surface. Further, after the first week, nightIy hot sitz-baths are advised to promote speedier resoIution of the Auid accumuIation. ANALYSIS

OF

CASES

Our particuIar study embodied a tota of nineteen hydroceles and seven spermatoceIes in twenty-three patients, whose ages ranged from 4 to 75 years. Thirteen, or 60 per cent, were over 50 years of age. Fifteen patients, representing thirteen hydroceIes and four spermatoceIes, have been foIIowed through to apparent cure and have been observed for foIIow-up periods varying from one to fourteen months. It is this group which forms the basis for our observations and concIusions. Some of our cases represented clinic materia1, and because of the migratory nature of the aduIt maIe patient, we have seven incompIete records. We wish to express our indebtedness to Dr. J. A. Hyams for making such materia1 avaiIabIe in the UroIogic Out-Patient Department of the Gouverneur HospitaI, and to Doctors D. A. Anderman and S. KIein for their clinica assistance. Private cases are aIs incIuded in the study. A brief anaIysis of the seventeen compIeteIy foIIowed apparent cures in fifteen patients yieIds some interesting data. In a11 except one case, definite etiology couId not be eIicited and they were therefore classified as idiopathic. One foIIowed partia1 phIebectomy for varicocele. The size of the hydroceIe or spermatocele as determined by fluid content varied from 4 to 300 C.C. and the amount of quinine hydrochloride, urethane and diothane injected ranged

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from ?d C.C. to IO C.C. The cases were consecutive and unseIected. Injections were made from one to four weeks apart. Th e number of injections necessary for fina eradication of the sac was : in nine cases, one injection ; in five instances, two; and three, four, and five injections, respectiveIy, were necessary in three remaining cases. In the earIy cases we were too anxious to effect a rapid cure. We have since Iearned to wait at Ieast three weeks between injections, for IittIe is gained by repeated rapid injection therapy. We feel certain that the next group of cases in this series wiI1 show far fewer injections per case. The aspirated ffuid is routinely examined microscopicaIIy. The hydroceIes yieIded cIear yeIIow Auid on initiaI aspiration and subsequent post-injection specimens were either cIear, hazy or deep orange in color. SpermatoceIes yieIded pathognomanic milky ffuid. FoIIowing injection and with diminution in the ffuid content of the sac, a characteristic crepitant sensationlis elicited, not unIike a pIeura1 friction rub. This finding is evidence of effectivity of the drug and bodes we11 for uItimate cure. No infection, IocaI or systemic reaction was noted in any of the cases folIowing injection therapy. SeveraI workers have cited this point as a contrast to operative figures pubIished by Campbe in reviewing 502 open operations for hydroceIe. He noted a 15 per cent incidence of superficial or deep infections. Six patients deveIoped uninfected and tweIve infected hematoceIes, eight of the Iatter resulting in orchidectomy. Despite a tota of thirty-one injections, we did not have a single case of hematoceIe. Of the seven cases Iisted as incompIete, three did not return to the cIinic and investigators couId not Iocate them. Two were more recentIy injected. Two represented communicating hydroceIes, ordinariIy a contraindication to injection therapy. Care was taken, by using pad compression over the inguina1 cana to prevent entry of the soIution into the peritonea1 cavity.

JUNE,1939

Injection in these cases was carried on from a pureIy academic standpoint, since operation was indicated and we were seeking histoIogic studies of the effect of the sclerosing drug on the endotheIia1 Iining of the tunica. Cures were not anticipated nor effected, but the patients have put off surgery-unfortunateIy. We have not cIassified these. cases as true faiIures since we couId not consider them suitabIe ones for injection therapy and wouId not have resorted to this course except with the hope of obtaining tissue studies. SPERMATOCELE

THERAPY

Of four spermatoceIes, three were cured by one injection. A characteristic induration remains, varying from pea to olivesize. It apparentIy represents a contracted sac, for attempts at aspiration of possibIe fluid content have been unsuccessfu1. In two instances, the sacs were IocuIated and as many as three individua1 cavities on one side have been aspirated and injected at one sitting. Others have reported indifferent resuIts in injection therapy of spermatoceIe. Our own few resuIts are gratifying since the tendency of the Iesion to recur even after surgica1 excision is we11 known unless the epididymis and rete testis are sacrificed. An interesting observation was made in studying the ffuid content of the spermatoceIe microscopicaIIy, before and after injection. Prior to treatment, the fluid contains swarms of activeIy motiIe spermatozoa. Subsequent examinations after injection show either very sIuggish motiIity or of activity and a compIete cessation diminution in numbers. The spermicida1 action of the drug may expIain this efficacy. A possibIe expIanation of the mechanism by which scIerosing soIutions act has been advanced by EweII, Marquardt and Sargent.1 A patient who had been injected three times with quinine hydrochIoride and urethane and cured, was prevaiIed upon to submit to operation one month Iater. GrossIy, a norma testis and epididymis were found, together with a smaI1 amount

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of dark amber Auid and severa Iong Ioose strands of attached and organized fibrin. MicroscopicaIIy, the endotheIia1 Iayer was intact, the bIood vesseIs appeared normal, but the subserous tissue of the tunica was distinctIy thickened and infiItrated with organizing fibrous tissue. These workers advanced the hypothesis that fibrosis of the tunica waI1 after injection so interferes with the blood and Iymph suppIy of the endotheIium that it aIters the process of fluid formation or absorption. Others fee1 that obliteration of the sac is accomplished by adherence of apposing waIIs folIowing a scIerosing infIammatory reaction. While this is apparently a IogicaI theory, the sparse work on the subject does not bear it out. Further study aIong such lines is essentia1. Without question, injection therapy is an ideal procedure for eradication of chronic hydrocele or spermatoceIe in the aged, the poor operative risk, in recurrent postoperative hydroceIe or spermatoceIe, in hydroceIe folIowing partial phIebectomy for varicoceIe, in those who refuse surgery but wiI1 submit to office injections, and for that Iarge group which, for economic reasons, cannot be hospitaIized. CONTRAINDICATIONS

Contraindications to injection therapy appIy to the acute hydroceIe which wiI1 usuaIIy subside with rest and immobiIization, and to communicating hydroceIes with or without hernia. It has been stated that without open operation, neopIasm or tubercuIosis may be overlooked. If carefu1 paIpation is made of the scrota1 contents when the sac is first emptied, such errors in diagnosis wouId not occur. Needless to say, a11 cases suspected of possibIe epididymal or testicuIar Iesions shouId be expIored. With the advent of a nontoxic, nonirritating, effective scIerosing agent, such as quinine hydrochIoride, urethane and diothane whose injection is free of pain, many of the previousIy reported compIications of injection therapy of hydroceIes may be obviated. LocaI and systemic reactions,

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sIough, infections, injury of testicIe, epididymis or cord structures, and hematoceIe must now be attributed to fauIty technique or to the drug. To avoid injury to a Iarge scrota1 vesse1 at the time of injection, we suggest the added precaution and relinement of pIacing a Iighted eIectric Iight under the sterile draping at the time of injection to transiIIuminate the mass. We have used a Cameron Iight which can be steriIized and brought in direct contact with the scrotum. The relative merits of aspiration and injection as opposed to open operation can onIy be determined by carefu1 statistica comparison. Sanford9 noted thirty, or 2.4 per cent reIapses, in I ,2 16 cases of open surgery for hydrocele. Of these, there had been Iate investigation of 412 cases with twenty-two reIapses, or 5.33 per cent. The same author revealed that 6 to 14 per cent faiIures had been reported folIowing injection therapy, aIthough conceding that with newer methods and drugs the percentage of faiIures is Iower. In evaIuating recurrences after injection therapy, one must distinguish between fluid re-accumuIation which may require one or more injections to eradicate, and true return of ffuid after a period of apparent obliteration of the sac. Nor shouId one caII a case a faiIure which does not respond to a singIe injection of the scIerosing soIution. CONCLUSIONS

We are presenting our data as a prewith fina evaIuation liminary report, deferred , pending wider application of the method in our own hands and those of others. No compIications, disabiIity, or recurrence to date has occurred-admittedly a promising beginning. The economic status of the patient is an important factor in the choice of therapy. InabiIity to face the expense and time Ioss invoIved in surgica1 treatment of hydroceIe may counterbaIance the inconvenience of a series of injection treatments over a period of time. In charity hospitaIs, where beds

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are at a premium, injection therapy is an invaIuabIe therapeutic aid in the outpatient department. The simphcity of the method may prove its worst enemy, for its indiscriminate use by those inexperienced in its technique or unabIe to recognize scrota1 pathoIogy wiII onIy bring discredit to a procedure which time and experience may prove to be a method of choice. The best test of any procedure Iies in whether one wouId subject himself to the same method if he had such a condition. For myseIf, I would certainIy have a hydroceIe injected before choosing open surgery. Sincere thanks are extended to Dr. Clarence G. Bandler for his sponsorship of this work and and the priviIege of making this report.

JUNE,1939

REFERENCES I.

EWELL, G. H., MARQUARDT, C. R., and SARGENT, M. D. Hydrocele, its treatment by the injection method. Wisconsin M. J., 34: 451 (JuIy) 1935. KILBOURNE, N. J., and MURRAY, C. J. Treatment of hydrocele. Calij. @ West. Med., 37: 3 (JuIy) x932. KILBOURNE, N. J. Persona1 communication and unpubIished work. BANDLER, C. G. Diothane: a new IocaI anesthetic. Am. J. Surg., Ig: 250 (Feb.) 1933. RIDER, T. H. Piperidinopropanediol di-phenyIurethane hydrochloride. A new IocaI anesthetic. J. Pbarmocol. CY Exper. Tberap., 47: 255 (Feb.)

1933. 6. MAYERS, M. M. Treatment of hydroceIe and simiIar scrota1 cysts by the injection method. J. Ural., 37: 308 (Feb.) 1937. 7. BARETZ, L. H. Cure of hydroceIe by injection. N. Y. State J. Med., 7: 489 (April I) 1938. 8. CAMPBELL, M. F. HydroceIe of the tunica vaginalis. Surg., Gyflec. 0 Obst., 14: 192 (Aug.) 1927. 9. SANFORD, H. L. In Cabot’s Modern UroIogy. PhiIa., 1936. Lea and Febiger.