Scrotal surgery

A hydrocele is a collection of fluid in the sac surrounding the testicle, within the scrotum. Usually, the testicle produces a small amount of fluid for lubrication which is then reabsorbed by the tissues lining the sac. If too much fluid is produced or more commonly if scarring and inflammation of the sac lining prevent the fluid from being reabsorbed then it will accumulate and form a swelling. Hydroceles can occur on one (unilateral) or both (bilateral) sides of the scrotum.

Hydroceles are often painless but can cause symptoms from the dragging feeling produced by the weight or discomfort from it “getting in the way”. When large they can also cause embarrassment from the size of the bulge.

Hydroceles are fairly common and will develop in around 1% of men however any lump in the scrotum should be examined by a medical practitioner as it may not necessarily be due to a hydrocele. Often an ultrasound scan can help identify the cause of the mass.

Hydrocelectomy is surgery that removes the hydrocele. Under general anaesthetic, a short incision is made in the scrotum. The inner lining of the sac is opened, the fluid is removed and the tissue is then trimmed and folded back behind the testicle where it is sewn in place. This is done to reduce the chances that the hydrocele returns. You may be able to feel this tissue when self-examining afterwards. The skin is stitched back together using sutures that dissolve later so that they don’t need to be removed. Strapping is applied with the dressing as it reduces the chances of post-operative bleeding. The operation takes less than an hour to do and men are able to return home the same day (although cannot drive or operate machinery for the next 24 hours because of the general anaesthetic).

Although hydrocelectomy is considered minor surgery there are some risks. These include bleeding and bruising, infection, swelling, discomfort and scarring. Rare complications include the wound opening or injury to the testicle. Hydroceles recur in about 20% of men and occasionally further surgery may be necessary.

After surgery you will be given a script for painkillers, usually, a combination of paracetamol and an anti-inflammatory (NSAID) is sufficient. The strapping will ideally remain on for 48 hours when you can remove it, although it does not matter if it falls off earlier.

You may shower 24 hours after surgery but do not take a bath for the first week. Avoid soap or other chemicals on the wound as they may cause tissue irritation. Pat the wound dry.

Ice packs or a bag of frozen peas may be useful to help with swelling and discomfort (don’t apply ice directly to the skin as it will stick and cause damage to the tissues).

After your surgery, you may feel more tired than usual and have some mild groin pain for several days. Your groin and scrotum may be swollen or bruised. This usually gets better in 2 to 3 weeks.

You will probably be able to go back to work or school 5 to 7 days after surgery. However, you will need to avoid strenuous exercise (cycling, jogging, aerobic exercise, contact sports), sexual activity and heavy lifting for 2 to 4 weeks. Heavy lifting means anything heavier than 5kg (such as heavy grocery bags, briefcases, backpacks and children) If you have a physically demanding job, you may need up to two weeks to recover before returning to work.

Each person recovers at a different pace so rest when you feel tired. Getting enough sleep will help you recover. Try to walk each day and gradually increase the distance each time. Walking boosts blood flow and helps prevent pneumonia and constipation.

If you have had a large hydrocele, the skin in your scrotum may have stretched, and you may have loose skin after a hydrocelectomy. Your scrotum should shrink back (recoil) to its typical size 2 - 4 weeks after surgery.

An epididymal cyst is a benign (not cancerous) fluid-filled sac that develops like a water balloon off the side of the epididymis. The epididymis is a coiled tube where sperm travel down from the testicle on the way to the vas. Sometimes called spermatoceles (although these are actually different as they have sperm as well as fluid), epididymal cysts are common especially with age and after vasectomy.

Epididymal cysts are often painless but can cause symptoms from the dragging feeling produced by the weight or discomfort from it “getting in the way”. When large they can also cause embarrassment from the size of the bulge.

Any lump in the scrotum should be examined by a medical practitioner as it may not necessarily be due to an epididymal cyst. Often an ultrasound scan can help identify the cause of the mass.

Epididymal cyst removal is surgery that is usually done under general anaesthetic when a short incision is made in the scrotum. The structures are mobilised, and the lining of the cyst is removed with the fluid inside it. The skin is stitched back together using sutures that dissolve later so that they don’t need to be removed. Strapping is applied with the dressing as it reduces the chances of post-operative bleeding. The operation takes less than an hour to do and men are able to return home the same day (although cannot drive or operate machinery for the next 24 hours because of the general anaesthetic).

Although epididymal cyst removal is considered minor surgery there are some risks. These include bleeding and bruising, infection, swelling, discomfort and scarring. Rare complications include the wound opening or injury to the testicle. New epididymal cysts often develop in other parts of the epididymis and occasionally further surgery may be necessary.

After surgery you will be given a script for painkillers, usually, a combination of paracetamol and an anti-inflammatory (NSAID) is sufficient. The strapping will ideally remain on for 48 hours when you can remove it, although it does not matter if it falls off earlier.

You may shower 24 hours after surgery but do not take a bath for the first week. Avoid soap or other chemicals on the wound as they may cause tissue irritation. Pat the wound dry.

Ice packs or a bag of frozen peas may be useful to help with swelling and discomfort (don’t apply ice directly to the skin as it will stick and cause damage to the tissues).

After your surgery, you may feel more tired than usual and have some mild groin pain for several days. Your groin and scrotum may be swollen or bruised. This usually gets better in 2 to 3 weeks.

You will probably be able to go back to work or school 5 to 7 days after surgery. However, you will need to avoid strenuous exercise (cycling, jogging, aerobic exercise, contact sports), sexual activity and heavy lifting for 2 to 4 weeks. Heavy lifting means anything heavier than 5kg (such as heavy grocery bags, briefcases, backpacks and children) If you have a physically demanding job, you may need up to two weeks to recover before returning to work.

Each person recovers at a different pace so rest when you feel tired. Getting enough sleep will help you recover. Try to walk each day and gradually increase the distance each time. Walking boosts blood flow and helps prevent pneumonia and constipation.

If you have had a large epididymal cyst, the skin in your scrotum may have stretched, and you may have loose skin after the surgery. Your scrotum should shrink back (recoil) to its typical size a few weeks to a month after cyst removal.

A varicocele is a collection of dilated testicular veins.

Development of the testicle begins inside the abdomen near the lower end of the kidney. Before birth, it migrates down the abdomen, through the inguinal canal (just above the fold where the leg joins the abdomen) and into the scrotum. As it migrates the testicle takes its blood supply with it which therefore follows a long and twisting course in the male.

Dilation of the veins that drain the testicle may occur as the one-way valves that help return blood to the heart stop functioning effectively. This may happen because the vein represents a long, standing column of fluid under the influence of gravity. The varicocele that develops is comparable to varicose veins commonly seen in the legs. It may cause a low-grade dragging discomfort or impair fertility to some degree (thought to be due to the effect of temperature changes from the inefficiently drained blood on sperm formation). If neither of these issues is the case then doing nothing may be the most appropriate course of action.

Varicoceles are common and affect about 15% of adult men. The left side is more commonly involved than the right because the vein is longer and more pressure develops in it due to gravity. The dilated veins typically feel like a “bag of worms”. When lying flat this should disappear (because gravity is not causing the pooling of blood in the same way). If that does not happen then you need to be examined by a medical professional to look for other causes.

Varicocelectomy is an operation designed to reduce the size of the dilated veins in the scrotum and therefore improve the symptoms it is causing. It can be done as either an open or laparoscopic procedure. Laparoscopy is usually reserved for varicoceles affecting both sides of the body.

An open varicocelectomy can be done in a number of different ways but involves a short incision in the groin under general anaesthetic. This is similar to the approach used for the open repair of an inguinal hernia. The veins are dissected out then tied off and divided. The tissue layers of the groin are then closed with sutures all of which are internal and will dissolve without needing to be removed. The operation takes less than an hour to do and men are able to return home the same day (although cannot drive or operate machinery for the next 24 hours because of the general anaesthetic).

Although varicocelectomy is considered minor surgery there are risks which include bleeding and bruising, infection, swelling, discomfort and scarring. Rare complications include the wound opening or injury to the testicle. Hydroceles (a collection of fluid around the testicle) can develop. In up to 10% of cases, varicoceles can reoccur because small veins that exist in atypical locations can open up to contribute blood to the dilated vessels and occasionally further surgery may be necessary.

After surgery you will be given a script for painkillers, usually, a combination of paracetamol and an anti-inflammatory (NSAID) is sufficient.

You may shower 24 hours after surgery but do not take a bath for the first week. Avoid soap or other chemicals on the wound as they may cause tissue irritation. Pat the wound dry.

Ice packs or a bag of frozen peas may be useful to help with swelling and discomfort (don’t apply ice directly to the skin as it will stick and cause damage to the tissues).

After your surgery, you may feel more tired than usual and have some mild groin pain for several days. Your groin and scrotum may be swollen or bruised. This usually gets better in 2 to 3 weeks.

You will probably be able to go back to work or school 5 to 7 days after surgery. But you will need to avoid strenuous exercise (cycling, jogging, aerobic exercise, contact sports), sexual activity and heavy lifting for 2 to 4 weeks. Heavy lifting means anything heavier than 5kg (such as heavy grocery bags, briefcases, backpacks and children) If you have a physically demanding job, you may need up to two weeks to recover before returning to work.

Each person recovers at a different pace so rest when you feel tired. Getting enough sleep will help you recover. Try to walk each day and gradually increase the distance each time. Walking boosts blood flow and helps prevent pneumonia and constipation.

Occasionally the most appropriate way to treat a varicocele, especially if it has recurred, is with embolization. This is done by an Interventional Radiologist who uses imaging to help direct a small catheter along the veins internally and then place a coil in the varicocele. This works by blocking the blood from getting into the abnormal veins.

Vasectomy is a minor surgical day-stay procedure performed for male contraception. It interrupts the tubes (vasa deferens) that carry the sperm from the testicles to the prostate and urethra (outflow tube).

The procedure involves the instillation of local anaesthetic, skin puncture and division of the vas on each side. Each end is tied back on itself to reduce the risk of failure (recanalisation or re-forming of the tube).

Vasectomy has a higher success rate than other common forms of contraception such as the oral contraceptive pill and tubal ligation. As with all surgical procedures, complications are possible (but not common) and include infection, contraception failure due to recanalisation of the vasa, bleeding, formation of sperm granuloma (a tender lump at the division point of the vas) and post-vasectomy pain syndrome.

After the operation, rest is advised for the first few days and vigorous exercise is avoided for the first week. Supportive underwear and an ice pack may help in addition to analgesic medications.

Follow-up is important because sperm must be cleared out downstream of the point that the tubes are tied off. Semen samples (usually three over several weeks) are required to ensure that no viable sperm remain. Alternative contraception is required until the "all clear" is given.

Orchidectomy involves the surgical removal of the testicle. This procedure is performed in a hospital under general anaesthetic. An incision is made into the groin, where the blood vessels leading to the testicle are divided before the testicle is removed. This is similar to the approach used for the open repair of an inguinal hernia. The operation is often performed as day surgery and takes less than an hour to complete.

Most side effects from this surgery tend to be temporary. Typically pain and discomfort around the operation site are the most common side effects, but this pain can be managed with painkillers and should subside over time. Bleeding and infection are possible but uncommon side effects of orchidectomy.

If you have had an orchidectomy, a prosthetic testicle can be made and inserted into the scrotum at a later date for cosmetic reasons if you wish. Sexuality and fertility should not be affected by the removal of one testicle presuming that the other is present and normal. A single testicle will usually be able to make sufficient testosterone without requiring replacement therapy.

Removing both testicles leads to infertility. Hormone therapy may be needed to replace the lack of testosterone production which has many effects on the body. These include preserving muscle mass and bone density, preventing fat formation as well as helping to maintain mood and energy levels. Taking hormones will help relieve symptoms of reduced testosterone levels. Sexual activity can continue as erections and ejaculation will still be possible – although no sperm will be produced. Removal of both testicles is sometimes done to treat prostate cancer that has spread to other parts of the body as reducing testosterone will slow the growth of cancer.