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A 40-year-old man presents with a painless, gradually enlarging left scrotal swelling over 6 months. On examination, the swelling is soft, fluctuant, and transilluminates brightly. The examiner can palpate above the upper margin. There is no cough impulse. The testis is not separately palpable.
Questions
a) What is the clinical diagnosis and which three signs confirm it? (3 marks)
Diagnosis: Vaginal hydrocele. Three confirming signs: (1) can get above the swelling (scrotal, not inguinal), (2) transillumination positive (serous fluid), (3) cough impulse absent (closed sac).
b) List three differential diagnoses with one distinguishing feature for each. (3 marks)
- Inguinal hernia — cannot get above; cough impulse positive; reducible.
- Testicular tumour — does not transilluminate; heavy, hard testis.
- Varicocele — bag of worms feel; left side; prominent standing, disappears lying down.
c) What investigation is essential before surgery and why? (2 marks)
Ultrasound scrotum — to evaluate the underlying testis and exclude a testicular tumour (which may present with a reactive hydrocele). Also confirms the fluid collection and assesses testicular blood flow.
d) Describe two surgical options for definitive treatment. (2 marks)
- Jabouley procedure — eversion of the tunica vaginalis, sutured behind the cord; secreted fluid absorbed by subcutaneous tissue.
- Lord plication — pleating the tunica to the testis border without excision; less dissection, lower haematoma risk.
Both have recurrence rates under 5%.