Table Of ContentHydrocele
in the
Temperate
and
Tropical Countries
Volume I
Author
Fortunato Fasana, M.D., Ph.D.
Associate Professor of Anatomy
University of Nairobi
Nairobi, Kenya
Illustrated by
A. H. Walji, M.D.
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INTRODUCTION
Hydrocele is a disease which occurs in the temperate countries in 0.22% of the total
population. In the tropics, hydrocele is a riddle and a challenge, and its prevalence
ranges from 1 to 39.3%, being the most frequent surgically treated condition. In standard
textbooks, this condition is often discussed only briefly, and although the literature is
extensive, no comprehensive account has yet been published except for a few short mon-
ographs in the past 2 centuries.
This monograph is intended to collate hundreds of studies found in the literature; part of
it consists of personal observations made and experience acquired in India, Uganda, and
Kenya over the past 30 years. This has been done in order to give to the practicing surgeons,
physicians, and pediatricians in the temperate and tropical countries, especially those working
in isolated places, all the necessary information about this condition.
The history, the pre- and postnatal development, anatomy, and surgical anatomy of
hydrocele have been described, with due consideration being given to geographical distri-
bution and incidence. Numerous etiological factors, some of which are still controversial,
are described, and a comprehensive classification, which takes into account the various types
of hydroceles, has been proposed.
The pathology and pathogenesis of hydrocele have been discussed in general and in relation
to the lesions found in the scrotal structures. Without a precise recognition of the range of
pathological manifestations and their assessment, improper and inadequate treatment may
result. In the chapters dealing with symptoms, signs, and differential diagnosis, a detailed
discussion of clinical and laboratory investigations and radiological procedures has been
included. Their significance and usefulness facilitate the differential diagnosis of hydrocele
from the numerous conditions which may also cause scrotal swellings.
Numerous medical and operative measures have been proposed for this condition. As
John Hunter in 1786 put it very precisely, “No disease affecting the human body and
requiring an operation for its cure has called forth the opinions and pens of surgeons as this
disease. Each finds that every mode of operating except his own has failed”. The various
surgical procedures are described, evaluating their successes and failures, and a personal
method has been proposed which in the tropics has shown to be radical and without re-
currence. Special emphasis has been given to the treatment of hydrocele associated with
hernia in children and adults.
In spite of the progress that has been made in the field of diagnosis and treatment of
hydrocele, our knowledge still remains incomplete in many etiological, epidemio-
logical, and pathological aspects, and there is still a wide field open for further investi-
gation. This is truer in the tropical countries where more than 200 million individuals suffer
from filarial infections, 10% of whom have genital involvement with signs and symptoms
of varying degree and severity.
The author hopes that this monograph will be useful to surgeons who are frequently called
upon to deal with hydrocele and that it will aid in a more effective assessment and treatment
of this disease.
Fortunato Fasana
THE AUTHOR
Fortunato Fasana, M.D., Ph.D., received his degree in medicine from the University
of Milan in 1943 and the Health Officer degree in 1947. In 1973 he earned his specialization
degree in surgery from the University of Pavia. His Ph.D. in Human Anatomy came in
1974 at the University of Nairobi, Kenya.
During World War II, Dr. Fasana served as House Surgeon at Clinica Villa Salus in
Bergamo, Italy before becoming a Provincial member of the Liberation National Committee.
Arrested by the Germans in 1944, he escaped from prison and joined the Partisan Brigade,
“24th May”, as a Commander and Medical Officer. He remained with them in the Orobic
Alps until May 1945.
In May 1945, Dr. Fasana returned to Bergamo where he again served as House Surgeon
for Clinica Villa Salus and as Senior Surgeon at Calcinate Hospital.
In 1947 Dr. Fasana left Italy to become Chief Medical Officer (C.M.O.) at St. Camillus
Hospital in Hweitseh, China. While there, he organized a leprosary (300 patients) and a
network of health centers in the district. He also undertook the vaccination of 40,000 against
smallpox. From 1949 to 1950, he served as a consultant physician and surgeon to the Eighth
Communist Army fighting for the occupation of Chinese Tibet.
Between 1952 and 1964, Dr. Fasana served as C.M.O. and Surgeon of Nirmala Hospital
in Marikunnu, India and as Consultant of Cherukunnu and Manantoddy Hospitals and of
the Leprosary of Calicut, India. He also trained and studied at St. Thomas’s Hospital in
London with Professor J. B. Kinmonth and at St. Michael Hospital in Paris with Professor
M. Servelle. In 1959, Dr. Fasana received the Pro Ecclesia Medal from Pope John XXIII.
From 1964 to the present, Dr. Fasana has spent most of his time in Africa. From 1964
to 1966, he was C.M.O. of St. Mary’s Hospital in Gulu, Uganda and Consultant Surgeon
of the hospitals in Aber, Angal, and Kitgum. From 1966 to 1968, he served as C.M.O. at
Consolata Hospital in Nyeri, Kenya. In 1968, he returned to Italy as Lecturer in Human
Anatomy at the University of Padua, but returned to Kenya as Assistant Lecturer in the
Department of Human Anatomy at the University of Nairobi under the program of Italian
Technical Assistance in Kenya. He is presently Associate Professor of Human Anatomy at
the University of Nairobi, where, in the past years, he has actively collaborated in the
organization of the work, studies, and curriculum for the Department of Anatomy and for
the Faculty of Medicine and has served for 2 years as the Chairman of the Department.
Dr. Fasana has been involved in research in comparative anatomy, primatology, tropical
surgery, and paleanthropology in collaboration with the National Museum of Nairobi and
has published several articles dealing with these topics.
To my patients in China, India, and East Africa from whom I learned
so much, in the hope that this contribution may help to relieve further
suffering.
ACKNOWLEDGMENTS
I am very grateful to Professor J. B. Kinmonth, Head of the Department of Surgery, St.
Thomas’s Medical School, London; Professor L. Gallone, former Head of the Department
of Surgery, University of Milan; Professor G. Riquier of the University of Milan; Dr. J.
M. R. Miller, F.R.C.S.O.B.E., Chief Surgeon Kenya Medical Services; Professor M. H.
Day, St. Thomas’s Medical School, London; Professor A. C. Templeton, St. Vincent
Hospital of Worchester; Dr. D. J. B. Wijers of the Medical Research Centre of Nairobi;
and Dr. A. Walker, Johns Hopkins School of Medicine, Baltimore, for their valuable
suggestions and criticism. I also wish to express my appreciation to Dr. A. H. Walji for
doing the illustrations and for his constant support and to Mr. D. Ngugi for his photographic
work.
TABLE OF CONTENTS
VOLUME I
Chapter 1
The History of Hydrocele.................................................................................................. 1
I. Definition................................................................................................................. 1
II. Historical Notes....................................................................................................... 1
References...............................................................................................................................5
Chapter 2
The Embryology of the Genital System..............................................................................9
I. Historical Notes.........................................................................................................9
II. The Development of the Male Genital System........................................................9
A. The Urogenital Ridge...................................................................................11
B. The Mesonephros, Mesonephric, and Paramesonephric Ducts..................12
C. The Development of the Gubemaculum Testis.........................................14
D. The Development of the Processus Vaginalis.............................................16
E. The Development of the External Genitalia................................................19
F. The Development of the Inguinal Canal and Rings...................................20
G. The Obliteration of the Processus Vaginalis..............................................24
H. The Descent of the Testis............................................................................25
I. The Testis at Birth and During Infancy......................................................27
1. Incidence of Cryptorchidism and Ectopia........................................28
2. Causes of Failure of Testicular Descent.........................................29
a. Mechanical Abnormalities..................................................29
b. Anatomical Abnormalities..................................................30
c. Endocrine and Genetic Deficiencies...................................31
References.............................................................................................................................31
Chapter 3
The Anatomy of the External Genitalia
I. The Anatomy of the Spermatic Cord......................................................................39
II. The Anatomy of the Scrotum.................................................................................39
A. Skin.............................................................................................................40
B. Dartos..........................................................................................................41
C. External Spermatic Fascia..........................................................................44
D. Cremasteric Fascia and Muscle..................................................................44
E. Internal Spermatic Fascia............................................................................44
F. Areolar Tissue.............................................................................................44
G. The Processus Vaginalis.............................................................................45
H. Tunica Vaginalis..........................................................................................45
III. The Blood Supply of the Testis and Epididymis..................................................47
A. Arterial Supply............................................................................................47
1. The Testicular Artery......................................................................47
2. The Deferential Artery....................................................................48
3. External Spermatic Artery................................................................48
B. Venous Drainage.........................................................................................49
IV. The Blood Supply of the Scrotum..........................................................................51
A. Arterial........................................................................................................51
B. Venous Drainage........................................................................................52
C. Clinical and Surgical Considerations..........................................................53
V. The Blood Supply of the Undescended Testis......................................................53
VI. The Innervation of the Testis, Epididymis, and Scrotum.......................................54
A. Ilioinguinal Nerve.......................................................................................54
B. Genitofemoral Nerve (External Spermatic or Inguinal Nerve).................56
C. Perineal Nerve.............................................................................................56
D. The Perineal Branches of the Posterior Femoral Cutaneous Nerve.........56
VII. The Lymphatic Drainage of the Testis,E pididymis,a nd Scrotum.........................57
References.............................................................................................................................60
Chapter 4
The Geographic Distribution and Prevalence of Hydrocele...........................................65
I. Introduction.............................................................................................................65
II. Temperate Countries...............................................................................................65
III. Tropical Countries..................................................................................................67
A. Central and South America........................................................................69
B. Africa............................................................................................................70
C. East Africa..................................................................................................70
1. Kenya...............................................................................................70
2. Uganda.............................................................................................73
3. Tanzania and Zanzibar....................................................................73
D. India, Pakistan, and Bangladesh.................................................................74
E. Southeast Asia and the Far East.................................................................75
1. Burma...............................................................................................75
2. Malaya.............................................................................................75
3. Thailand............................................................................................75
4. Vietnam................................. 75
5. Indonesia and New Guinea.............................................................75
6. Philippines.......................................................................................77
7. China...............................................................................................77
8. Japan................................................................................................77
F. Pacific Islands and Australia.......................................................................77
1. Micronesian Zone (Periodic W. barter ofti Transmitted by Culex
fatigans)............................................................................................77
2. Papuan Zone (Periodic W. bancrofti Transmitted by Many Species
of Mosquito)....................................................................................77
3. Polynesian Zone (Nonperiodic W. bancrofti var. pacifica, Trans-
mitted Mainly by Aedes polynesiensis)...........................................77
4. New Caledonian Zone (Nonperiodic W. bancrofti Transmitted by
Aedes vigilax)..................................................................................78
5. Australia..........................................................................................78
References.............................................................................................................................80
Chapter 5
The Etiology of Hydrocele in Temperate Climates........................................................89
I. Introduction.............................................................................................................89
II. Idiopathic Hydrocele...............................................................................................89
III. Congenital Hydrocele.............................................................................................91
IV. Secondary Hydrocele...............................................................................................93
A. Hydrocele Secondary to Trauma.................................................................93
1. Accidental..........................................................................................93
2.62. Torsion of the Spermatic Cord.......................................................95
3. Torsion of the Appendages of the Testis and Epididymis.............95
4. Cryptorchidism.................................................................................95
B. Postoperative Hydrocele..............................................................................96
1. Herniotomy......................................................................................96
2. Varicocelectomy.............................................................................96
3. Hydrocelectomy................................................................................97
4. Vasectomy.......................................................................................97
5. Kidney Transplantation....................................................................97
6. Ventriculoperitoneal Shunt..............................................................97
7. Glove-Starch Granuloma.................................................................97
8. Irradiation and RetroperitonealL ymphadenectomy.........................98
9. Testicular Prosthesis.......................................................................98
C. Hydrocele Secondary to Systemic Diseases.................................................98
1. Cardiopathic and Renal Diseases.....................................................98
2. Cardiac Infarction............................................................................98
3. Ascites.............................................................................................98
4. Cystic Fibrosis.................................................................................98
5. Meconium Peritonitis.....................................................................99
6. Myxedema.......................................................................................99
D. Hydrocele Secondary to Infection..............................................................99
1. Bacterial Diseases.............................................................................99
2. Viral Diseases.................................................................................102
E. Hydrocele Secondary to Diseases of Unknown Etiology..........................103
1. Schonlein-Henoch Syndrome.........................................................103
2. Idiopathic Retroperitoneal Fibrosis...............................................103
3. Sarcoidosis.....................................................................................103
F. Hydrocele Secondary to Neoplastic Processes of the Intrascrotal
Organs.........................................................................................................103
G. Congenital Defects....................................................................................104
1. Hypoplasia of the Iliac LymphN odes............................................104
2. Milroy’s Disease............................................................................104
3. Berry-Treacher Collins Syndrome.................................................104
References..........................................................................................................................105
Chapter 6
The Etiology of Hydrocele in Subtropical and Tropical Countries...........................115
I. Introduction..........................................................................................................115
II. Filariasis...............................................................................................................115
A. Wuchereria barterofti.................................................................................115
1. Historical Notes..............................................................................115
2. Geographic Distribution.................................................................115
3. Morphology....................................................................................116
4. Periodicity.....................................................................................118
5. Epidemiology.................................................................................118
6. Clinical Manifestations..................................................................119
7. Treatment.......................................................................................120
B. Brugia malayi............................................................................................120
1. Historical Notes..............................................................................120
