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Treatment of Hydrocele and Similar Scrotal Cysts by the Injection Method
TREATMENT OF HYDROCELE AND SIMILAR SCROTAL CYSTS BY THE INJECTION METHOD MORTON M. MAYERS From the Department of Urology, Ross-Loos Medical Group, Los Angeles, California
A therapeutic measure intended to supercede an accepted method should offer advantages; first, from the standpoint of decreased risk and lessened morbidity and, second, in the matter of economy. It is our opinion that the modern treatment of hydrocele by injection meets these requirements. The injection therapy of hydrocele is not new. On the contrary, the stigma attached to this treatment originates from older methods of injection antedating the present by more than half a century. An excellent historical summary is given by Baretz. Some of the preparations used in the past are listed by him chronologically. They are iodine, phenol, iodine and phenol, equal parts of phenol, glycerine and alcohol (Morestin's fluid), Mellenah's vaccine, equal parts of 40 per cent alcohol and water, alcohol and phenol, port wine, milk, and 25 per cent sodium chloride solution. Celsus, in the days of the Roman Empire, attempted to cure hydroceles by injection. The objections to most of the older methods, as shown by Baretz, are severe pain, unfavorable reaction, sloughing and uncertainty of results. Not discouraged, more recent investigators have turned to the solutions used so successfully in treating varicosities. Pybus, in England in 1922, injected 2 cases with quinine and urethane. In 1.929, Sharma of India used quinine. In 1931 Porrit of England and in 1934 Floyd and Pittman used 5 per cent sodium morrhuate (Baretz). In 1932, splendid work was done by Kilbourne and Murray in their search for the most ideal solution for the injection treatment of hydrocele. They concluded that a 13.33 per cent solution of quinine hydrochloride and 6.66 per cent urethane for the initial injection, most nearly met the requirements of (1) painlessness, (2) lack of disability, (3) permanency of cure and adaptability to all types of hydroceles, (4) non-toxicity, (5) bactericidal action, and (6) absence of hemorrhage after injection. For subsequent injections, they employed a similar solution of quinine dihydrochloride but without the urethane. In recent years reports have come from workers who have followed Kilbourne and Murray's procedure closely and successfully. In 1935, 308
TREATMENT OF HYDROCELE BY INJECTION METHOD
309
Baretz reported the treatment of 41 cases, of which, 24 were carefully followed, with successful results in 14. In the same year, Kemble reported the treatment of 5 cases with 4 cures and 1 failure. Blavier reported the apparent cure of 56 hydroceles treated with the double salt of quinine and urea chlorhydrolactate. In 1936, Keitzer treated 17 cases who were apparently cured at the time of their discharge, although not followed. In the same year Ewell, Marquardt and Sargent reported the injection treatment of 64 hydroceles in 58 patients, followed from a few months to 2 years, all apparently cured. The numerous types of operations suggested, as well as the incidence of recurrence, does not bear out the assumption of most physicians and surgeons that the surgical treatment of hydrocele is relatively simple and effective. Sanford estimated the recurrence of hydrocele after operation to be 5 per cent (Ewell et al.). The most complete resume of hydroceles treated by open surgery is that by Campbell. He summarized results of 502 hydroceles in 456 patients operated at Bellevue Hospital. The incidence of infection was 15 per cent. Hemorrhage was common. Six cases developed uninfected and 12 infected hematoceles, 8 of the latter resulting in orchidectomy. Any procedure involving anesthesia is a potential one for mortality (Baretz). The untoward results of injection therapy as done with the newer solutions contrast favorably with those of open surgery. In Kilbourne and Murray's series there were no complications of any kind, such as infection, violent tissue reaction, or hemorrhage. Baretz reports one case of epididymitis, one of epididymo-orchitis and one case of subcutaneous ecchymosis following injection. In the treatment of 17 cases, Keitzer reports a flare-up of chronic epididymitis in 3 cases associated with spermatocele, one of which required epididymectomy. He mentioned one case of pyocele resulting from injection treatment of a hydrocele elsewhere, which was cured by incision and drainage. Ewell and his co-workers report epididymo-orchitis following injection in 5 cases, with no apparent deleterious effects. The injection method has a distinct economic advantage. In Campbell's series of hydroceles treated surgically, the average hospitalization was 6.1 days for clean cases and 9.3 days for all cases. The experience of most surgeons is that the operated patient required 1 or 2 weeks' hospitalization and at least 2 weeks' convalescence. With rare exception, all cases treated by means of injection are ambulatory. Less tangible but just as real is the suffering spared patients when subjected to injection therapy rather than surgery. Except for a moment or two of
-----
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TABLE 1 GROUP I . All followed and cured cases
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i5 0
Ill
-
0
77 53
90
300 150 7 5 40 15
50
5
49
6 7
60 37
8
54
9 10
41 57
11
60
69 61
14 15
6 56
16 17
55
18
66
100
52 20 54
360 560
5
125§§
120 210 275 25
'"
cc. mos.
3 3 3 1
4 10 3 5 4 5
8 3 4
48 39 29 27
Cured Cured Cured Cured
2
3
25
Cured
3 3
4 8 4 10 3 8 4
24 24
Cured Cured
23
Cured
23 22
Cured Cured
1
5
3 3
6 6
6
5
6 14 10
22
Cured
2 1
4 3
19 15
Cured Incomplete
1 20 25 25 4
2 3
4
5 4
12 10
Cured Cured
2 3
4
8
4
9 6
Cured Cured
4 3 4 4 4 3
8
5
6
Cured
7 8
5 3
5
5
6 4 3 2 1
Cured Cured Cured Cured Cured
30
50
· son
12
3
35
60
~
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cc.
1 60 50 4
40 50
360
41
15
200 50 15 400:l:t 200 200 65§§ 100 150
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REMARKS
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FLUID
INJECTI0N
C)
125 12
35 12 12 4 10
55 23 60 15 40 40
1 3 3 3 1
4
Advanced Parkinsonism
Bean-sized epididymal cyst not treated Bilocular, recurrent from surgery for bilateral hydrocele 2 years previously Bilateral Surgery previously on On opposite side. check, slight recurrence of same Filbert-sized. Filberg-sized epididymal No cyst injected. larger after 22 months Associated left inguinal hernia, reducible* Hydrocele of right cord, pea-sized cyst remaining Bilocular. Pea-sized cyst of epididymis not treated Hydrocele with bottleneck constriction Bilateral
Group II. Cases not followed 24 25 26
56
25 300 205
285 60 15
1 3 3
2 4
Not followed 4 10 4 6 310
t Not followed
TABLE 1-Concluded Group III. Hydrocele failures, incomplete cases, and other conditions CASE NO.
AGE
REMARKS
-- -27 28 29 30 31
21 64 7 57
32
63
33
65
34
56
35 36
55
37 38
Original size, 180. Size 2nd injection, 100. Size 3rd injection, 70. Surgery performed elsewhere 2 weeks after 3rd injection Hernia mistaken for hydrocele. Tap attempted. No harmful result Epididymo-orchitis. 25 cc. fluid aspirated. No injection. Cured spontaneously Communicating hydrocele with associated hernia. No injection Surgery 2 months after 3rd injection. Somewhat suspicious of malignancy or tuberculosist Surgery. No injections because of doubt as to presence or absence of co-existing pathology§ 50 cc. clear fluid aspirated, November 16, 133. Stony induration and enlargement of epididyrnis. Retrovesical tumor** 5 cc. spermatocele. Hydrocele developed following same. Still in process of treatment. Spermatocele cured. Spermatocele. September 29, 1936 : Asymptomatic but about 15 cc. capacity Two epididymal cysts, 5 and 10 cc. Four injections given. Epididymitis following injection 1. One very small cyst remaining Hydrocele and hernia. Hydrocele injected once; no ill effect. Not completed yet. To have subsequent hernia injections Communicating hydrocele and herniatt
* Check-up September 25, 1936 : Large, easily reducible left inguinal hernia in scrotum. Testicular mass rather solid, twice that of right. Undoubtedly due to thick hydrocele sac. No transillumination. t Following second injection there was considerable swelling, not transilluminating. Hospitalized for a few days' observation. Subsided markedly within one week. At end of three weeks, very little evidence of hydrocele. Believed due to injection fluid extraneous to sac. t Surgery : Marked adhesions between tunica albugenia and t unica vaginalis . Sac contained approximately 1 ounce cloudy fluid and same amount of fibrinous material. The epididymis was enlarged and cystic, the testicle flabby. No microscopic study. § Because of patient's advanced age and good condition of opposite testicle, orchidectomy was performed August 9, 1934. "Specimen consists of a fairly large hydrocele sac, the wall of which is stiffened and irregularly thickened. At some points it is approximately 1 cm. thick. The inner surface is faintly trabeculated and partly covered by a film of loose fibrin. The testicle is essentially normal with slight thickening of the tunica albuginea. The epididymis is encased in the thickened tunica and is edematous." Microscopic : "Hydrocele sac wall is made up of a thick layer of irregularly arranged dense connective tissue which is diffusely and heavily infiltrated with small round cells, plasma cells and polynuclear oesinophiles and neutrophiles. No evidence of tuberculosis or neoplasm found ." ** Tumor resembling retrovesical sarcoma. Epididymitis gradually resolved. Tumor enlarged despite x-ray therapy. Expired as result of metastasis June 21, 1934. No autopsy. tt Considerable pain and swelling after first injection (aspirated 75 cc.). In upright position one week later 68 cc. removed. and second injection made, again causing severe pain. The following morning the scrotum was normal in size, but by evening was quite distended. One hundred and eight cubic centimeters was then withdrawn and third injection made with not as much pain, Three months later the hydrocele was much reduced in size, about 25 cc. capacity. Not s~fficient time to draw conclusions. HLeft. §§ Right. 311
312
MORTON M. MAYERS
pain at the time of the first injection, there is practically no discomfort throughout the treament. A common objection offered to the injection method is that some important co-existing pathology will be overlooked. In our opinion, this is not a valid argument. After emptying the sac, careful palpation of its contents will reveal deviations from the normal. If there is a suspicion of malignancy or of .a tuberculous epididymitis, one may then resort to surgery. If the aspirated :fl~id is bloody and definitely not due to needle trauma, surgery is indicated. The association of hydrocele and malignancy is rare. Campbell reports the occurrence of one malignancy in 502 hydroceles. It is not logical to operate every hydrocele to avoid the possibility of overlooking the rare case of malignancy. Another objection offered is the danger attendant upon the accidental injection of an irritant fluid outside the sac itself. With proper technique this should not occur. It happened in one of our cases, resulting in considerable swelling, which subsided within a week, without necrosis. Baretz is of the opinion that sloughing will not take place if the injection should, by accident, be made outside the tunica. The work of Kilbourne and Murray indicates that the quinine solutions used by them are far less likely to cause necrosis than other preparations employed for this purpose. f£]!ydrocele is to be differentiated from (1) hernia, (2) spermatocele, (3) hematocele, (4) chylocele, (5) gumma, (6) edema of chronic passive congestion, and (7) neoplasm (Campbell). It is not our purpose to discuss the differential diagnosis, but it is important to distinguish hernia from hydrocele, particularly as the two are often associated. The presence of hernia may be a definite contra-indication to the injection therapy of a co-existing hydrocele. Excellent results are being reported following the injection treatment of hernia. The advantage of injecting an accompanying hydrocele is very evident. In our series there are several cases cured by injection where there was a hernia associated. This is particularly applicable to the acquired type of hernia. Where a hydrocele is associated with a congenital hernia, there is most apt to be a communication between the hydrocele and the ·peritoneal cavity. This is variously called "congenital," "communicating" or "intermittent" hydrocele. It is generally found in infancy and childhood. Kilbourne and Murray found 2 of this type in 231 cases of hydrocele. In many cases the hernia may be a potential one rather than a true hernia. The hydrocele found in infancy and childhood is often cured by simple
TREATMENT OF HYDROCELE BY INJECTION METHOD
313
aspiration. In these, Baretz states that there are no ill effects from the injection fluid, but if communicating, the sac will not be obliterated. Kilbourne and Murray minimize the danger from such an injection. Nevertheless, it is most likely that if there is an associated hernia, both conditions will be best treated surgically. The rare abdomino-scrotal hydrocele, of which Tanzer recently reported 39, in which there is a direct communication of both components through the inguinal canal, could be cured by injection. Surgery, however, is preferable because, according to Tanzer, the sac acts as a tampon, and, when collapsed, a hernia may be permitted to descend. Contraindications to the injection treatment may therefore be listed as follows: (1) the presence of certain types of hernia, (2) the presence of co-existing pathology, such as tuberculous epididymitis and malignancy, (3) cases of abdomino-scrotal hydrocele, and (4) with certain reservations, acute or chronic inflammatory conditions of the scrotal contents. To these may be added a fifth contraindication, viz., where the injury to the testicle or epididymis at the time of tapping causes hemorrhage, or a hematoma results from a perforated vessel, a marked infection may follow. Treatment should therefore be delayed (Baretz). The presence of a very thick hydrocele wall may cause failure, but is no direct contraindication. Despite Rubin's assertion that the injection of irritants is definitely contraindicated in spermatocele and that the resection of the cyst is the only procedure for complete cure, accumulating evidence indicates to us that injection therapy may be applicable in such cases. True, a small cyst may remain after injection, but it is generally of no clinical significance, and subsequent aspiration may result in its almost complete disappearance. Keitzer does not hesitate to employ this method of treating spermatoceles. He believes injections are contraindicated when the spermatocele is associated with an acute or chronic epididymitis, having had 2 cases of chronic epididymitis flare up following the injection of spermatoceles. Kemble has successfully injected spermatoceles. Blavier treated 2 spermatic cysts in this manner. Both Porret and Baretz have suggested the method. Our results in 2 cases are not significant. Other cystic enlargements of the cord, epididymis or testes may be treated successfully by injection. We are indebted to Ewell and his associates for the histo-pathological study of the effects of quinine compounds on the hydrocele sac. One month after a final injection, resulting in apparent cure, they opened
MORTON
M.
MAYERS
the tunica vaginalis. There was a small amount of dark amber fluid in the sac, with several long, loose strands of attached and organized fibrin. The testicle and epididymis were grossly normal. Microscopic section of the tunica revealed an intact endothelium, normal blood vessels, with the subserous tissues distinctly thickened and infiltrated with organizing fibrous tissue. They suspected that this fibrosis altered the fluid forming or fluid re-absorbing mechanism. Similar histological changes were present in a second case in which there was clinical failure after 7 injections. In our early experience with this method, malignancy was suspected in one case at the time of the second injection and surgery was then resorted to. There were marked adhesions between the tunica albuginea and the tunica vaginalis. The sac contained approximately 1 ounce of cloudy fluid and the same amount of fibrinous material. Unfortunately, no microscopic study was made. In subsequent cases it was noted that after the first injection there was noticeable enlargement and increased firmness of the testicle. .This emphasized the necessity of carefully comparing the right and left testicle at the time of the first aspiration to avoid confusion later. Solley called attention to this condition. He stated that after the fluid ceased to re-accumulate there was thickening of the tunica vaginalis, probably an edema, which disappeared after 2 to 6 months. Most of our followed cases showed a return to normal in this respect. The technique employed by us is as follows: (1) Preparation. Shaving, tincture of green soap, 1: 10,000 mercury bichloride solution followed by 1: 1000 tincture of merthiolate, sterile towel drape. (2) Equipment. Several 19-gauge needles from 1½ to 3 inches in length. One 10 cc. Luer syringe and one 30 cc. Luer syringe. (3) Solutions. One per cent novocaine solution, two 2 cc. ampoules of quinine hydrochloride and urethane, 13.33 per cent for the first injection; for succeeding injections, ½ounce of freshly prepared quinine dihydrochloride solution, 13.33 per cent. (4) Procedure. A point in the scrotum is selected near the upper portion of the hydrocele in the least vascular area. Novocaine is injected intradermally and then under the skin, obliquely down to the sac. The 19-gauge needle is then placed through this point following the area of infiltration into the hydrocele sac, and is inserted as far as the sac will permit without striking the testicle, thus giving greater assurance that the point will not slip out of the sac. An Allis clamp is applied
TREATMENT OF HYDROCELE BY INJECTION METHOD
315
so as to grasp the needle and the anesthetized scrotal skin at the point of entrance (further assurance against slipping of the needle). The larger syringe is then used to aspirate all the fluid. By changing the direction of the needle, and by lifting or depressing the scrotum, complete emptying of the sac is often made easier. Inasmuch as 1 or 2 cc. of hydrocele fluid may considerably dilute the injection fluid, it is important that the sac be completely emptied. By injecting 5 to 10 cc. of air and aspirating, repeating this procedure several times, one can often withdraw even a very small amount of remaining hydrocele fluid. For our largest hydroceles we employed direct suction (by means of a tonsil suction apparatus) to empty the sac. From 1 to 4 cc. of quinine hydrochloride and urethane solution, depending on the size of the sac, are injected at the first sitting. From 4 to 10 cc. of quinine dihydrochloride are injected at succeeding treatments, the first one week after the first injection, and at 3-week intervals thereafter. A small piece of flamed adhesive is then placed over the needle wound. A scrotal support has not been found necessary. The patient is entirely ambulatory at all times. An almost constant reaction at the time of the first injection is pain, rather sharp, lasting 30 to 60 seconds, generally abdominal and along the same side as the injection. In our experience it has never been very severe. It has been the experience of those using sodium morrhuate that the pain is quite severe with that drug. Keitzer has given up sodium morrhuate because of this fact, using Kilbourne and Murray's solution at the present time. Solley, who uses 1 to 5 cc. of sodium morrhuate and benzyl alcohol, overcomes this objection by injecting one per cent novocaine into the empty sac and then aspirating the novocaine solution before proceeding with the injection therapy. At the time of the second injection, there is usually a re-accumulation of fluid, often more than the original amount, particularly so in the smaller size hydrocele or cyst. Ordinarily, subsequent injections result in decreasing amounts of fluid. From the results that others have obtained, one is led to believe that after one or two injections, simple aspiration will result in a cure. Future experience will decide this point. It is our impression that if the hydrocele is not cured in 4 injections, further injections will cause no improvement, although Kilbourne and Murray suggest repeated injections even beyond this figure. SUMMARY
Twenty-three cases involving 25 hydroceles have been classified as cured, with the exception of case 13. In the latter, a pea-sized cyst
316
MORTON M. MAYERS
following treatment of a hydrocele of the cord remained after 15 months. This was termed an incomplete cure. These cases were followed from 1 to 48 months with an average follow-up of 17 .3 months. In cases 4, 10 and 15 the cured hydroceles had been associated with small epididymal cysts, no attempt being made to inject the latter. There were 2 examples of multilocular hydroceles, cases 5 and 15, the smaller of which was the result of a recurrence of a hydrocele surgically treated several years previously. There were two examples of bilateral hydroceles, cases 7 and 18, with complete cure of both sides in each case. The smallest hydrocele was 5 cc. and the largest 1400 cc., the average size being 187 cc. for all the cured hydroceles, which should be an indication that size is no contraindication to this type of therapy. The youngest patient was 6 years of age and the oldest 77, the average age for those cases in which the age is given being 50.4 years. This fact should suggest that this procedure is particularly satisfactory for the treatment of hydroceles in old and debilitated individuals. From 1 to 4 injections were required, an average of 2.4 injections being employed in the cured cases. A small hydrocele in a child of 6 years (case 14) was cured by one injection, but cure might have been effected without any injection. Case 29 was apparently a so-called inflammatory hydrocele. After aspirating the hydrocele fluid, injection was decided against. This hydrocele cured spontaneously. Hernia was present in 5 of the cases. One of these, the largest of the series (1400 cc.), was cured by injection. Case 28 represents an error of diagnosis, no hydrocele being present in association with the hernia. One injection was made in case 37, but observation has not been completed. We have 2 examples, cases 30 and 38, of a communicating hydrocele associated with hernia. An attempted injection in the first was unsuccessful. Three injections were made in the latter. A check-up made 3 months after the third injection revealed a hydrocele very much reduced in size, about 25 cc. of fluid being present, but sufficient time has not elapsed to make any deductions. It was noteworthy that at the time of each injection the pain produced was of far greater severity than in all other cases. In 2 patients, 31 and 32, there was a suspicion of serious co-existing pathology, the ages being 57 and 63 years, respectively. Orchidectomy was decided upon in both. In the first of these, the testicle was found to be somewhat flabby, which may have been a preexisting condition or may have been the result of injection. The latter had a very thick hydrocele wall, as much as 1 cm. thick. The testicle in this patient, although more or less embedded in
TREATMENT OF HYDROCELE BY INJECTION METHOD
317
the wall, was found to be normal. Case 31 occurred early in our experience. The thickening of the tunica vaginalis, which subsequently was found to be a usual sequence in our other cases, was undoubtedly misleading. In case 33, despite the knowledge of a large retrovesical tumor, an attempt was first made to treat the hydrocele to study the effect, but this was not continued. The patient died over a year later as a result of metastasis from the retrovesical malignancy. Cases 34 and 35 were spermatoceles. Following the treatment and apparent cure of the spermatocele in case 34, a hydrocele developed, apparently on an inflammatory base, but it is too recent to determine the final result. In case 35, the spermatocele was apparently the cause of distress. After one treatment it became asymptomatic and was reduced in size, but not cured. Here again elapsed time is not sufficient to draw conclusions. Case 36 involved 2 small epididymal cysts. Treatment resulted in a cure of one, but incomplete cure of the second. Following the first injection an epididymitis resulted, which resolved in a short while. There is indication in this group of cases (nos. 34, 35 and 36) that injection treatment of cysts of the epididymis may result in an undesirable inflammatory reaction. Cases 24, 25 and 26 have not been followed. Case 26 is an illustration in point that no serious consequences develop from the extraneous injection of the solution. Case 27 is classed as a distinct failure. The recurrence of a hydrocele several weeks after the third injection was treated by surgery performed elsewhere. CONCLUSIONS
The injection of hydroceles with the newer types of solutions is a practical procedure, with definite advantages over the surgical treatment. The injection treatment may be employed in almost all cystic enlargements of the scrotum. The treatment of spermatoceles by this method shows promise of success, but there is more apt to be an undesirable inflammatory reaction from its use. Although hydroceles associated with hernias are best reserved for surgical treatment, satisfactory results are to be obtained in many cases by the injection treatment. This is particularly true where injection therapy is to be used for the treatment of the hernia as well. Communicating hydroceles may be injected, but results are indifferent. Hydroceles of infancy and childhood may be injected, but with the material so far available its recommendation cannot safely be made. THE JOURNAL OF UROLOGY, VOL.
37,
NO.
2
318
MORTON M. MAYERS
A properly performed injection is a safe and practically benign procedure. The technique is simple and accidents should therefore be rare. 1355 Wilshire Boulevard, Los Angeles, California. REFERENCES BARETZ, Louis H.: Injection treatment of hydrocele. Med. Times and Long Island Med. Jour., 63: 1, 1935. BLAVIER, L.: Treatment of hydrocele by injection of double chlorhydrolactate of quinine and urea. Jour. Amer. Med. Assoc., 103: 22, 1934. BLAVIER, L.: Abstract: The injection treatment of hydrocele (Bruxilles Med., June 2, 1935). Urol. and Cutan. Rev., 39: 656, 1935. CAMPBELL, M. F.: Hydrocele of the tunica vaginalis. Surg., Gynec. and Obstet., 14: 192, 1927. EWELL, G. H ., MARQUARDT, C. R., AND SARGENT, J . C.: Hydrocele: Its treatment by the injection method. Urol. and Cutan. Rev., 386-390, 1936 (June). FLOYD, E., AND PITTMAN, J. L.: Injection of hydroceles with newer sclerosing solutions; experimental study. Georgia Med. Assoc. Jour., 23: 41- 82, 1934. Jour. Amer. Med. Assoc., 102: 164, 1934. KEITZER, WALTER A.: The injection treatment of cystic enlargements of the scrotum: hydrocele and spermatocele. Jour. Mich. State Med. Soc., 36: 168- 169, 1936. KEMBLE, ADAM: The treatment of hydrocele and spermatocele by injection. Urol. and Cutan. Rev. 39: 862-863, 1935. KILBOURNE, N. J., AND MuRRAY, CHARLES J.: Treatment of hydrocele. Researches in new solutions for the injection treatment; results compared with operation. Calif. and West. Med., 37: 1, 1932. RUBIN, J. S. : Bilateral spermatoceles. Urol. and Cutan. Rev., 502, 1936 (July). SOLLEY, F . W.: The injection treatment of hydrocele of the tunica vaginalis. Surg. Clin. N . Amer., 16: 867-870, 1936. TANZER, R. C.: Abdominoscrotal hydrocele. Jour. Urol., 34: 447-452, 1935.
A therapeutic measure intended to supercede an accepted method should offer advantages; first, from the standpoint of decreased risk and lessened morbidity and, second, in the matter of economy. It is our opinion that the modern treatment of hydrocele by injection meets these requirements. The injection therapy of hydrocele is not new. On the contrary, the stigma attached to this treatment originates from older methods of injection antedating the present by more than half a century. An excellent historical summary is given by Baretz. Some of the preparations used in the past are listed by him chronologically. They are iodine, phenol, iodine and phenol, equal parts of phenol, glycerine and alcohol (Morestin's fluid), Mellenah's vaccine, equal parts of 40 per cent alcohol and water, alcohol and phenol, port wine, milk, and 25 per cent sodium chloride solution. Celsus, in the days of the Roman Empire, attempted to cure hydroceles by injection. The objections to most of the older methods, as shown by Baretz, are severe pain, unfavorable reaction, sloughing and uncertainty of results. Not discouraged, more recent investigators have turned to the solutions used so successfully in treating varicosities. Pybus, in England in 1922, injected 2 cases with quinine and urethane. In 1.929, Sharma of India used quinine. In 1931 Porrit of England and in 1934 Floyd and Pittman used 5 per cent sodium morrhuate (Baretz). In 1932, splendid work was done by Kilbourne and Murray in their search for the most ideal solution for the injection treatment of hydrocele. They concluded that a 13.33 per cent solution of quinine hydrochloride and 6.66 per cent urethane for the initial injection, most nearly met the requirements of (1) painlessness, (2) lack of disability, (3) permanency of cure and adaptability to all types of hydroceles, (4) non-toxicity, (5) bactericidal action, and (6) absence of hemorrhage after injection. For subsequent injections, they employed a similar solution of quinine dihydrochloride but without the urethane. In recent years reports have come from workers who have followed Kilbourne and Murray's procedure closely and successfully. In 1935, 308
TREATMENT OF HYDROCELE BY INJECTION METHOD
309
Baretz reported the treatment of 41 cases, of which, 24 were carefully followed, with successful results in 14. In the same year, Kemble reported the treatment of 5 cases with 4 cures and 1 failure. Blavier reported the apparent cure of 56 hydroceles treated with the double salt of quinine and urea chlorhydrolactate. In 1936, Keitzer treated 17 cases who were apparently cured at the time of their discharge, although not followed. In the same year Ewell, Marquardt and Sargent reported the injection treatment of 64 hydroceles in 58 patients, followed from a few months to 2 years, all apparently cured. The numerous types of operations suggested, as well as the incidence of recurrence, does not bear out the assumption of most physicians and surgeons that the surgical treatment of hydrocele is relatively simple and effective. Sanford estimated the recurrence of hydrocele after operation to be 5 per cent (Ewell et al.). The most complete resume of hydroceles treated by open surgery is that by Campbell. He summarized results of 502 hydroceles in 456 patients operated at Bellevue Hospital. The incidence of infection was 15 per cent. Hemorrhage was common. Six cases developed uninfected and 12 infected hematoceles, 8 of the latter resulting in orchidectomy. Any procedure involving anesthesia is a potential one for mortality (Baretz). The untoward results of injection therapy as done with the newer solutions contrast favorably with those of open surgery. In Kilbourne and Murray's series there were no complications of any kind, such as infection, violent tissue reaction, or hemorrhage. Baretz reports one case of epididymitis, one of epididymo-orchitis and one case of subcutaneous ecchymosis following injection. In the treatment of 17 cases, Keitzer reports a flare-up of chronic epididymitis in 3 cases associated with spermatocele, one of which required epididymectomy. He mentioned one case of pyocele resulting from injection treatment of a hydrocele elsewhere, which was cured by incision and drainage. Ewell and his co-workers report epididymo-orchitis following injection in 5 cases, with no apparent deleterious effects. The injection method has a distinct economic advantage. In Campbell's series of hydroceles treated surgically, the average hospitalization was 6.1 days for clean cases and 9.3 days for all cases. The experience of most surgeons is that the operated patient required 1 or 2 weeks' hospitalization and at least 2 weeks' convalescence. With rare exception, all cases treated by means of injection are ambulatory. Less tangible but just as real is the suffering spared patients when subjected to injection therapy rather than surgery. Except for a moment or two of
-----
~
TABLE 1 GROUP I . All followed and cured cases
"'z ~
.,
.,'"
. ~
~ z
"' <
. =- =-~ =-. ~ "' ... "''"
.... ~g
i5 0
Ill
-
0
77 53
90
300 150 7 5 40 15
50
5
49
6 7
60 37
8
54
9 10
41 57
11
60
69 61
14 15
6 56
16 17
55
18
66
100
52 20 54
360 560
5
125§§
120 210 275 25
'"
cc. mos.
3 3 3 1
4 10 3 5 4 5
8 3 4
48 39 29 27
Cured Cured Cured Cured
2
3
25
Cured
3 3
4 8 4 10 3 8 4
24 24
Cured Cured
23
Cured
23 22
Cured Cured
1
5
3 3
6 6
6
5
6 14 10
22
Cured
2 1
4 3
19 15
Cured Incomplete
1 20 25 25 4
2 3
4
5 4
12 10
Cured Cured
2 3
4
8
4
9 6
Cured Cured
4 3 4 4 4 3
8
5
6
Cured
7 8
5 3
5
5
6 4 3 2 1
Cured Cured Cured Cured Cured
30
50
· son
12
3
35
60
~
~
-
cc.
1 60 50 4
40 50
360
41
15
200 50 15 400:l:t 200 200 65§§ 100 150
1400
12 13
19 20 21 22 23
500 65
0
-
REMARKS
.. ... "~. z .:
cc.
cc.
1 2 3 4
"'M ;:iu z~u .,
f:l,
~;;; ~ 0 "'0 "'0 "' ~ ~ "'~ z z z z " -- - - - - - - - - - - - i:l ti
=-.
FLUID
INJECTI0N
C)
125 12
35 12 12 4 10
55 23 60 15 40 40
1 3 3 3 1
4
Advanced Parkinsonism
Bean-sized epididymal cyst not treated Bilocular, recurrent from surgery for bilateral hydrocele 2 years previously Bilateral Surgery previously on On opposite side. check, slight recurrence of same Filbert-sized. Filberg-sized epididymal No cyst injected. larger after 22 months Associated left inguinal hernia, reducible* Hydrocele of right cord, pea-sized cyst remaining Bilocular. Pea-sized cyst of epididymis not treated Hydrocele with bottleneck constriction Bilateral
Group II. Cases not followed 24 25 26
56
25 300 205
285 60 15
1 3 3
2 4
Not followed 4 10 4 6 310
t Not followed
TABLE 1-Concluded Group III. Hydrocele failures, incomplete cases, and other conditions CASE NO.
AGE
REMARKS
-- -27 28 29 30 31
21 64 7 57
32
63
33
65
34
56
35 36
55
37 38
Original size, 180. Size 2nd injection, 100. Size 3rd injection, 70. Surgery performed elsewhere 2 weeks after 3rd injection Hernia mistaken for hydrocele. Tap attempted. No harmful result Epididymo-orchitis. 25 cc. fluid aspirated. No injection. Cured spontaneously Communicating hydrocele with associated hernia. No injection Surgery 2 months after 3rd injection. Somewhat suspicious of malignancy or tuberculosist Surgery. No injections because of doubt as to presence or absence of co-existing pathology§ 50 cc. clear fluid aspirated, November 16, 133. Stony induration and enlargement of epididyrnis. Retrovesical tumor** 5 cc. spermatocele. Hydrocele developed following same. Still in process of treatment. Spermatocele cured. Spermatocele. September 29, 1936 : Asymptomatic but about 15 cc. capacity Two epididymal cysts, 5 and 10 cc. Four injections given. Epididymitis following injection 1. One very small cyst remaining Hydrocele and hernia. Hydrocele injected once; no ill effect. Not completed yet. To have subsequent hernia injections Communicating hydrocele and herniatt
* Check-up September 25, 1936 : Large, easily reducible left inguinal hernia in scrotum. Testicular mass rather solid, twice that of right. Undoubtedly due to thick hydrocele sac. No transillumination. t Following second injection there was considerable swelling, not transilluminating. Hospitalized for a few days' observation. Subsided markedly within one week. At end of three weeks, very little evidence of hydrocele. Believed due to injection fluid extraneous to sac. t Surgery : Marked adhesions between tunica albugenia and t unica vaginalis . Sac contained approximately 1 ounce cloudy fluid and same amount of fibrinous material. The epididymis was enlarged and cystic, the testicle flabby. No microscopic study. § Because of patient's advanced age and good condition of opposite testicle, orchidectomy was performed August 9, 1934. "Specimen consists of a fairly large hydrocele sac, the wall of which is stiffened and irregularly thickened. At some points it is approximately 1 cm. thick. The inner surface is faintly trabeculated and partly covered by a film of loose fibrin. The testicle is essentially normal with slight thickening of the tunica albuginea. The epididymis is encased in the thickened tunica and is edematous." Microscopic : "Hydrocele sac wall is made up of a thick layer of irregularly arranged dense connective tissue which is diffusely and heavily infiltrated with small round cells, plasma cells and polynuclear oesinophiles and neutrophiles. No evidence of tuberculosis or neoplasm found ." ** Tumor resembling retrovesical sarcoma. Epididymitis gradually resolved. Tumor enlarged despite x-ray therapy. Expired as result of metastasis June 21, 1934. No autopsy. tt Considerable pain and swelling after first injection (aspirated 75 cc.). In upright position one week later 68 cc. removed. and second injection made, again causing severe pain. The following morning the scrotum was normal in size, but by evening was quite distended. One hundred and eight cubic centimeters was then withdrawn and third injection made with not as much pain, Three months later the hydrocele was much reduced in size, about 25 cc. capacity. Not s~fficient time to draw conclusions. HLeft. §§ Right. 311
312
MORTON M. MAYERS
pain at the time of the first injection, there is practically no discomfort throughout the treament. A common objection offered to the injection method is that some important co-existing pathology will be overlooked. In our opinion, this is not a valid argument. After emptying the sac, careful palpation of its contents will reveal deviations from the normal. If there is a suspicion of malignancy or of .a tuberculous epididymitis, one may then resort to surgery. If the aspirated :fl~id is bloody and definitely not due to needle trauma, surgery is indicated. The association of hydrocele and malignancy is rare. Campbell reports the occurrence of one malignancy in 502 hydroceles. It is not logical to operate every hydrocele to avoid the possibility of overlooking the rare case of malignancy. Another objection offered is the danger attendant upon the accidental injection of an irritant fluid outside the sac itself. With proper technique this should not occur. It happened in one of our cases, resulting in considerable swelling, which subsided within a week, without necrosis. Baretz is of the opinion that sloughing will not take place if the injection should, by accident, be made outside the tunica. The work of Kilbourne and Murray indicates that the quinine solutions used by them are far less likely to cause necrosis than other preparations employed for this purpose. f£]!ydrocele is to be differentiated from (1) hernia, (2) spermatocele, (3) hematocele, (4) chylocele, (5) gumma, (6) edema of chronic passive congestion, and (7) neoplasm (Campbell). It is not our purpose to discuss the differential diagnosis, but it is important to distinguish hernia from hydrocele, particularly as the two are often associated. The presence of hernia may be a definite contra-indication to the injection therapy of a co-existing hydrocele. Excellent results are being reported following the injection treatment of hernia. The advantage of injecting an accompanying hydrocele is very evident. In our series there are several cases cured by injection where there was a hernia associated. This is particularly applicable to the acquired type of hernia. Where a hydrocele is associated with a congenital hernia, there is most apt to be a communication between the hydrocele and the ·peritoneal cavity. This is variously called "congenital," "communicating" or "intermittent" hydrocele. It is generally found in infancy and childhood. Kilbourne and Murray found 2 of this type in 231 cases of hydrocele. In many cases the hernia may be a potential one rather than a true hernia. The hydrocele found in infancy and childhood is often cured by simple
TREATMENT OF HYDROCELE BY INJECTION METHOD
313
aspiration. In these, Baretz states that there are no ill effects from the injection fluid, but if communicating, the sac will not be obliterated. Kilbourne and Murray minimize the danger from such an injection. Nevertheless, it is most likely that if there is an associated hernia, both conditions will be best treated surgically. The rare abdomino-scrotal hydrocele, of which Tanzer recently reported 39, in which there is a direct communication of both components through the inguinal canal, could be cured by injection. Surgery, however, is preferable because, according to Tanzer, the sac acts as a tampon, and, when collapsed, a hernia may be permitted to descend. Contraindications to the injection treatment may therefore be listed as follows: (1) the presence of certain types of hernia, (2) the presence of co-existing pathology, such as tuberculous epididymitis and malignancy, (3) cases of abdomino-scrotal hydrocele, and (4) with certain reservations, acute or chronic inflammatory conditions of the scrotal contents. To these may be added a fifth contraindication, viz., where the injury to the testicle or epididymis at the time of tapping causes hemorrhage, or a hematoma results from a perforated vessel, a marked infection may follow. Treatment should therefore be delayed (Baretz). The presence of a very thick hydrocele wall may cause failure, but is no direct contraindication. Despite Rubin's assertion that the injection of irritants is definitely contraindicated in spermatocele and that the resection of the cyst is the only procedure for complete cure, accumulating evidence indicates to us that injection therapy may be applicable in such cases. True, a small cyst may remain after injection, but it is generally of no clinical significance, and subsequent aspiration may result in its almost complete disappearance. Keitzer does not hesitate to employ this method of treating spermatoceles. He believes injections are contraindicated when the spermatocele is associated with an acute or chronic epididymitis, having had 2 cases of chronic epididymitis flare up following the injection of spermatoceles. Kemble has successfully injected spermatoceles. Blavier treated 2 spermatic cysts in this manner. Both Porret and Baretz have suggested the method. Our results in 2 cases are not significant. Other cystic enlargements of the cord, epididymis or testes may be treated successfully by injection. We are indebted to Ewell and his associates for the histo-pathological study of the effects of quinine compounds on the hydrocele sac. One month after a final injection, resulting in apparent cure, they opened
MORTON
M.
MAYERS
the tunica vaginalis. There was a small amount of dark amber fluid in the sac, with several long, loose strands of attached and organized fibrin. The testicle and epididymis were grossly normal. Microscopic section of the tunica revealed an intact endothelium, normal blood vessels, with the subserous tissues distinctly thickened and infiltrated with organizing fibrous tissue. They suspected that this fibrosis altered the fluid forming or fluid re-absorbing mechanism. Similar histological changes were present in a second case in which there was clinical failure after 7 injections. In our early experience with this method, malignancy was suspected in one case at the time of the second injection and surgery was then resorted to. There were marked adhesions between the tunica albuginea and the tunica vaginalis. The sac contained approximately 1 ounce of cloudy fluid and the same amount of fibrinous material. Unfortunately, no microscopic study was made. In subsequent cases it was noted that after the first injection there was noticeable enlargement and increased firmness of the testicle. .This emphasized the necessity of carefully comparing the right and left testicle at the time of the first aspiration to avoid confusion later. Solley called attention to this condition. He stated that after the fluid ceased to re-accumulate there was thickening of the tunica vaginalis, probably an edema, which disappeared after 2 to 6 months. Most of our followed cases showed a return to normal in this respect. The technique employed by us is as follows: (1) Preparation. Shaving, tincture of green soap, 1: 10,000 mercury bichloride solution followed by 1: 1000 tincture of merthiolate, sterile towel drape. (2) Equipment. Several 19-gauge needles from 1½ to 3 inches in length. One 10 cc. Luer syringe and one 30 cc. Luer syringe. (3) Solutions. One per cent novocaine solution, two 2 cc. ampoules of quinine hydrochloride and urethane, 13.33 per cent for the first injection; for succeeding injections, ½ounce of freshly prepared quinine dihydrochloride solution, 13.33 per cent. (4) Procedure. A point in the scrotum is selected near the upper portion of the hydrocele in the least vascular area. Novocaine is injected intradermally and then under the skin, obliquely down to the sac. The 19-gauge needle is then placed through this point following the area of infiltration into the hydrocele sac, and is inserted as far as the sac will permit without striking the testicle, thus giving greater assurance that the point will not slip out of the sac. An Allis clamp is applied
TREATMENT OF HYDROCELE BY INJECTION METHOD
315
so as to grasp the needle and the anesthetized scrotal skin at the point of entrance (further assurance against slipping of the needle). The larger syringe is then used to aspirate all the fluid. By changing the direction of the needle, and by lifting or depressing the scrotum, complete emptying of the sac is often made easier. Inasmuch as 1 or 2 cc. of hydrocele fluid may considerably dilute the injection fluid, it is important that the sac be completely emptied. By injecting 5 to 10 cc. of air and aspirating, repeating this procedure several times, one can often withdraw even a very small amount of remaining hydrocele fluid. For our largest hydroceles we employed direct suction (by means of a tonsil suction apparatus) to empty the sac. From 1 to 4 cc. of quinine hydrochloride and urethane solution, depending on the size of the sac, are injected at the first sitting. From 4 to 10 cc. of quinine dihydrochloride are injected at succeeding treatments, the first one week after the first injection, and at 3-week intervals thereafter. A small piece of flamed adhesive is then placed over the needle wound. A scrotal support has not been found necessary. The patient is entirely ambulatory at all times. An almost constant reaction at the time of the first injection is pain, rather sharp, lasting 30 to 60 seconds, generally abdominal and along the same side as the injection. In our experience it has never been very severe. It has been the experience of those using sodium morrhuate that the pain is quite severe with that drug. Keitzer has given up sodium morrhuate because of this fact, using Kilbourne and Murray's solution at the present time. Solley, who uses 1 to 5 cc. of sodium morrhuate and benzyl alcohol, overcomes this objection by injecting one per cent novocaine into the empty sac and then aspirating the novocaine solution before proceeding with the injection therapy. At the time of the second injection, there is usually a re-accumulation of fluid, often more than the original amount, particularly so in the smaller size hydrocele or cyst. Ordinarily, subsequent injections result in decreasing amounts of fluid. From the results that others have obtained, one is led to believe that after one or two injections, simple aspiration will result in a cure. Future experience will decide this point. It is our impression that if the hydrocele is not cured in 4 injections, further injections will cause no improvement, although Kilbourne and Murray suggest repeated injections even beyond this figure. SUMMARY
Twenty-three cases involving 25 hydroceles have been classified as cured, with the exception of case 13. In the latter, a pea-sized cyst
316
MORTON M. MAYERS
following treatment of a hydrocele of the cord remained after 15 months. This was termed an incomplete cure. These cases were followed from 1 to 48 months with an average follow-up of 17 .3 months. In cases 4, 10 and 15 the cured hydroceles had been associated with small epididymal cysts, no attempt being made to inject the latter. There were 2 examples of multilocular hydroceles, cases 5 and 15, the smaller of which was the result of a recurrence of a hydrocele surgically treated several years previously. There were two examples of bilateral hydroceles, cases 7 and 18, with complete cure of both sides in each case. The smallest hydrocele was 5 cc. and the largest 1400 cc., the average size being 187 cc. for all the cured hydroceles, which should be an indication that size is no contraindication to this type of therapy. The youngest patient was 6 years of age and the oldest 77, the average age for those cases in which the age is given being 50.4 years. This fact should suggest that this procedure is particularly satisfactory for the treatment of hydroceles in old and debilitated individuals. From 1 to 4 injections were required, an average of 2.4 injections being employed in the cured cases. A small hydrocele in a child of 6 years (case 14) was cured by one injection, but cure might have been effected without any injection. Case 29 was apparently a so-called inflammatory hydrocele. After aspirating the hydrocele fluid, injection was decided against. This hydrocele cured spontaneously. Hernia was present in 5 of the cases. One of these, the largest of the series (1400 cc.), was cured by injection. Case 28 represents an error of diagnosis, no hydrocele being present in association with the hernia. One injection was made in case 37, but observation has not been completed. We have 2 examples, cases 30 and 38, of a communicating hydrocele associated with hernia. An attempted injection in the first was unsuccessful. Three injections were made in the latter. A check-up made 3 months after the third injection revealed a hydrocele very much reduced in size, about 25 cc. of fluid being present, but sufficient time has not elapsed to make any deductions. It was noteworthy that at the time of each injection the pain produced was of far greater severity than in all other cases. In 2 patients, 31 and 32, there was a suspicion of serious co-existing pathology, the ages being 57 and 63 years, respectively. Orchidectomy was decided upon in both. In the first of these, the testicle was found to be somewhat flabby, which may have been a preexisting condition or may have been the result of injection. The latter had a very thick hydrocele wall, as much as 1 cm. thick. The testicle in this patient, although more or less embedded in
TREATMENT OF HYDROCELE BY INJECTION METHOD
317
the wall, was found to be normal. Case 31 occurred early in our experience. The thickening of the tunica vaginalis, which subsequently was found to be a usual sequence in our other cases, was undoubtedly misleading. In case 33, despite the knowledge of a large retrovesical tumor, an attempt was first made to treat the hydrocele to study the effect, but this was not continued. The patient died over a year later as a result of metastasis from the retrovesical malignancy. Cases 34 and 35 were spermatoceles. Following the treatment and apparent cure of the spermatocele in case 34, a hydrocele developed, apparently on an inflammatory base, but it is too recent to determine the final result. In case 35, the spermatocele was apparently the cause of distress. After one treatment it became asymptomatic and was reduced in size, but not cured. Here again elapsed time is not sufficient to draw conclusions. Case 36 involved 2 small epididymal cysts. Treatment resulted in a cure of one, but incomplete cure of the second. Following the first injection an epididymitis resulted, which resolved in a short while. There is indication in this group of cases (nos. 34, 35 and 36) that injection treatment of cysts of the epididymis may result in an undesirable inflammatory reaction. Cases 24, 25 and 26 have not been followed. Case 26 is an illustration in point that no serious consequences develop from the extraneous injection of the solution. Case 27 is classed as a distinct failure. The recurrence of a hydrocele several weeks after the third injection was treated by surgery performed elsewhere. CONCLUSIONS
The injection of hydroceles with the newer types of solutions is a practical procedure, with definite advantages over the surgical treatment. The injection treatment may be employed in almost all cystic enlargements of the scrotum. The treatment of spermatoceles by this method shows promise of success, but there is more apt to be an undesirable inflammatory reaction from its use. Although hydroceles associated with hernias are best reserved for surgical treatment, satisfactory results are to be obtained in many cases by the injection treatment. This is particularly true where injection therapy is to be used for the treatment of the hernia as well. Communicating hydroceles may be injected, but results are indifferent. Hydroceles of infancy and childhood may be injected, but with the material so far available its recommendation cannot safely be made. THE JOURNAL OF UROLOGY, VOL.
37,
NO.
2
318
MORTON M. MAYERS
A properly performed injection is a safe and practically benign procedure. The technique is simple and accidents should therefore be rare. 1355 Wilshire Boulevard, Los Angeles, California. REFERENCES BARETZ, Louis H.: Injection treatment of hydrocele. Med. Times and Long Island Med. Jour., 63: 1, 1935. BLAVIER, L.: Treatment of hydrocele by injection of double chlorhydrolactate of quinine and urea. Jour. Amer. Med. Assoc., 103: 22, 1934. BLAVIER, L.: Abstract: The injection treatment of hydrocele (Bruxilles Med., June 2, 1935). Urol. and Cutan. Rev., 39: 656, 1935. CAMPBELL, M. F.: Hydrocele of the tunica vaginalis. Surg., Gynec. and Obstet., 14: 192, 1927. EWELL, G. H ., MARQUARDT, C. R., AND SARGENT, J . C.: Hydrocele: Its treatment by the injection method. Urol. and Cutan. Rev., 386-390, 1936 (June). FLOYD, E., AND PITTMAN, J. L.: Injection of hydroceles with newer sclerosing solutions; experimental study. Georgia Med. Assoc. Jour., 23: 41- 82, 1934. Jour. Amer. Med. Assoc., 102: 164, 1934. KEITZER, WALTER A.: The injection treatment of cystic enlargements of the scrotum: hydrocele and spermatocele. Jour. Mich. State Med. Soc., 36: 168- 169, 1936. KEMBLE, ADAM: The treatment of hydrocele and spermatocele by injection. Urol. and Cutan. Rev. 39: 862-863, 1935. KILBOURNE, N. J., AND MuRRAY, CHARLES J.: Treatment of hydrocele. Researches in new solutions for the injection treatment; results compared with operation. Calif. and West. Med., 37: 1, 1932. RUBIN, J. S. : Bilateral spermatoceles. Urol. and Cutan. Rev., 502, 1936 (July). SOLLEY, F . W.: The injection treatment of hydrocele of the tunica vaginalis. Surg. Clin. N . Amer., 16: 867-870, 1936. TANZER, R. C.: Abdominoscrotal hydrocele. Jour. Urol., 34: 447-452, 1935.