A single case report on management of Bilateral Epididymal Cyst - A...

[Full title: A single case report on management of Bilateral Epididymal Cyst - A successful Ayurvedic Surgical Approach]

CASE REPORT March 2022 Journal of Ayurveda and Integrated Medical Sciences | March 2022 | Vol. 7 | Issue 2 128 A single case report on management of Bilateral Epididymal Cyst - A successful Ayurvedic Surgical Approach Pallavi Viraktamath 1 , Siddayya Aradhyamath 2 , Aditya J. V. 3 1 First year PG Scholar, Department of PG Studies in Shalya Tantra, JSS Ayurveda Medical College, Mysore, Karnataka, India. 2 Professor and HOD, Department of PG Studies in Shalya Tantra, JSS Ayurveda Medical College, Mysore, Karnataka, India. 3 Assistant Professor, Department of PG Studies in Shalya Tantra, JSS Ayurveda Medical College, Mysore, Karnataka, India. I NTRODUCTION A soft fluctuant swelling containing fluid in a sac lined by epithelium or endothelium is called Cyst. The word Cyst derived from Greek word meaning bladder [1] In Ayurveda cyst can be compared with Granthi . It is the caused by aggravated Vatha , Pitta and Kapha vitiates the Mamsa, Rakta and Meda mixed with Kapha gives rise to round ( Vritta), elevated (Unnatha) and consolidated (Grathitha) swelling called Granthi (cyst) [2] Cyst of the epididymis, which are congenital and usually derived from an embryonic remnant around the epididymis and filled with crystal clear fluid. Though congenital, these cysts are usually found Address for correspondence: Dr. Pallavi Viraktamath First year PG Scholar, Department of PG Studies in Shalya Tantra, JSS Ayurveda Medical College, Mysore, Karnataka, India. E-mail: mvpallavi 1996@gmail.com Submission Date: 13/01/2022 Accepted Date: 21/02/2022 Access this article online Quick Response Code Website: www.jaims.in Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CC-by-NC-SA during middle life. When we go through incidence it is found in 20 to 40% of male population [3] If left untreated may cause abscess and even destroy the epididymis which can lead to infertility [4] The Epididymal cyst condition is often bilateral. These cysts are situated behind the body of testis. These cysts are due to cystic degeneration of; a Remnants of the Paramesonephric or Mullerian duct - the appendix of testis (sessile hydatid of Morgagni) b Remnant of mesonephric duct or Wolffian duct system. 1 The para epididymis or organ of Giraldes - this is the most cause 2 Appendix of the epididymis or Pedunculated of Morgagni 3 The Vas Aberrans of Haller [5] Clinical Features ▪ Swelling in the scrotum ▪ Non Tender ▪ Mobile ▪ Cystic A B S T R A C T Cysts are the fluid filled sacs. It can occur anywhere in the body. Epidydimal cyst occurs in male commonly in the middle age group. When it is small in size, there is no need of any treatment. If the size is large the ultimate treatment is the surgery that is excision of sac. If left untreated it may cause abscess and even destroy the epididymis which can lead to infertility. Here we report a case of bilateral Epididymal cyst in a 63 year old man who was admitted and underwent the Chedana Karma for the removal of the cyst/ Kaphaja Granthi . He was successfully managed with regular wound care and dressings and patient had complete relief from his complaints. Detailed case history is presented below. Key words: Epididymal Cyst, Kaphaja Granthi, Chedana, Excision, Case Report, Ayurveda.

Pallavi Viraktamath et al. A single case report on management of Bilateral Epididymal Cyst ISSN: 2456-3110 CASE REPORT March 2022 Journal of Ayurveda and Integrated Medical Sciences | March 2022 | Vol. 7 | Issue 2 129 ▪ Increasing in size over a period of time ▪ Heaviness These are the tense cysts. These consists of aggregation of number of small cysts which feel like bunch of tiny grapes [6] Fluctuation testes is difficult to elicit. These cysts are very common, usually multiple and vary in size at presentation [7] Trans - illumination Test: These are brilliantly translucent but are finely transilluminant due to presence of numerous septae giving all appearance of Chinese lantans. The content of the cysts is crystal clear fluid which will be evident on aspiration [5] C ASE R EPORT A 63 year old male patient (OP - 13507, IP - 36339) visited the OPD of Shalya Tantra with the complaints of increased size in bilateral scrotum associated with itching and discomfort since a year. History of Present Illness As per patient he was apparently normal a year back but he gradually noticed increasing size of his bilateral scrotum associated with discomfort for which he approached a nearby doctor but did not get any relief from his symptoms, so he approached JSS Ayurveda Medical Hospital, Mysore, for further management. History of Past Illness N/K/C/O T 2 DM/HTN/IHD/COPD/Thyroid dysfunction No history of previous surgery. Family History: Nothing significant Personal History He was vegetarian, Vyasana : Coffee Mutra : 4 -5 times /day Mala : once in a day. General Examination Built - Moderate Appearance - Normal Temperature - 98°F PR - 66 B/M RR - 18 cycles/ min BP - 130/80 mmHg Nourishment - Moderate No evidence of pallor / icterus / cyanosis / edema/ clubbing Systemic Examination CNS Higher mental function test : Conscious well oriented with time place person. Memory: Recent and remote : intact Intelligence : Intact Hallucination / delusion / speech disturbance : Absent Cranial nerve / sensory nerve / motor system : normal Gait : Normal CVS Inspection : No scar/pigmentation found Auscultation : S 1 and S 2 heard Percussion : Normal cardiac dullness RS Inspection : B/L symmetrical Palpation : Trachea is centrally placed, Non tender Auscultation : B/L NVBS heard Percussion : Normal resonant sound GIT Inspection : Umbilicus centrally placed , Not distended, No visible vein , No scar/pigmentation Palpation : Soft, non-tender, No organomegaly Auscultation : Normal peristaltic sound heard (4/m) Percussion : Normal resonant sound heard over abdomen

Pallavi Viraktamath et al. A single case report on management of Bilateral Epididymal Cyst ISSN: 2456-3110 CASE REPORT March 2022 Journal of Ayurveda and Integrated Medical Sciences | March 2022 | Vol. 7 | Issue 2 130 Local Examination / Examination of Cyst Site : Bilateral Scrotum Number : 2 cyst Size : Left (10 x 6 x 5), Right (8 x 4 x 3) Shape : spherical Surface : Smooth, regular and shinny Skin : Soft, smooth Edge : Regular, smooth Pigmentation : Absent Tran’s illumination Test : Positive Fluctuation Test : Positive Get above swelling : Positive Consistency : Soft Reducibility : Irreducible Traction Test : Negative Testis : Not separately palpable Epididymis : Not felt Lymph Node : Not palpable. Investigation Done Ultrasound Doppler study of testis : Bilateral large loculated Epididymal Cyst Diagnosis : Bilateral Epididymal cyst ( Kaphaja Granthi ) Treatment Planned : Chedhana Karma (Excision of cyst) Operative Procedure Pre-Operative ▪ Patient advised for NBM for 6 hours before surgery. ▪ Injection TT IM 0.5 mg stat and Injection XYLOCAINE 0.5 mg subcutaneous given. ▪ Proctoclysis enema given for emptying the bowel. ▪ IV fluids started one hour prior to surgery. Operative Procedure: 7/7/2021 Under all aseptic precautions patient was shifted to OT. ↓ Spinal Anesthesia given ↓ Part Prepared and draped ↓ Incision over Left Scrotum, 1-2 cm away from the median raphe parallel to it, was done ↓ Opened all layers one by one; Skin → Dortos muscle → External spermatic Fascia → Cremastric Fascia → Internal spermatic Fascia reached Tunica Vaginalis ↓ Opened the Tunica Vaginalis ↓ Identified the testis location by palpating Tunica Vaginalis (to avoid the Testis damage) ↓ Sac/Cyst was identified and separated ↓ A big sac was excised out ↓ Multiple sac’s were drained and excised ↓ Incision over Tunica Vaginalis layer was extended ↓ Testis was visible ↓ Taken Thunica Vaginalis to posterior aspect i.e., eversion of sac done ↓ Cut edges of Tunica Vaginalis was sutured with Vicryl 2.0 suture material

Pallavi Viraktamath et al. A single case report on management of Bilateral Epididymal Cyst ISSN: 2456-3110 CASE REPORT March 2022 Journal of Ayurveda and Integrated Medical Sciences | March 2022 | Vol. 7 | Issue 2 131 ↓ A corrugated rubber drain was kept for drainage purpose. ↓ Scrotum sutured in layers ↓ Same procedure was carried out on the right side ↓ Hemostasis achieved & whole procedure was uneventful Post OP ▪ Patient advised NBM for 6 hours after surgery ▪ Catheterization was done ▪ Advised for restricted head movement for 6 hours of surgery ▪ Foot end elevation for 6 hours of surgery Treatment given ▪ T. Triphala Guggulu 2/0/2 after food for 5 days ▪ T . Gandhaka Rasayna 2/0/2 after food for 5 days ▪ T. Shallaki Plus 2/2/2 after food for 5 days ▪ Syp Dashamoolorishta 40 ml/ 0/40 ml after food for 5 days ▪ Swamla compound ½ tsp /0/ ½ tsp ▪ IV Antibiotics and Analgesics for 3 days Advice on Discharge ▪ T. Pan D 1/0/1 before food for 5 days ▪ T. Mahacef 1/0/1 after food for 5 days ▪ T. Metrozyl 1/0/1 after food for 5 days ▪ T. Ultracet BD after food for 5 days ▪ T. Triphala Guggulu 2/0/2 after food for 5 days ▪ T. Gandhaka Rasayna 2/0/2 after food for 5 days ▪ Swamla compound ½ tsp /0/ ½ tsp ▪ Syrup. Amyron 20 ml/0/20 ml after food ▪ T. Shallaki Plus 2/2/2 after food for 5 days ▪ Regular Dressing and wound care did every alternate day. Follow up after Surgery ▪ Patient advised to for follow up for every week ▪ Suture was removed after 15 days of surgery. ▪ Wound was completely healed, patient was feeling better ▪ No evidence of complications found Image 1: Pre OP picture Image 2: Post OP picture

Pallavi Viraktamath et al. A single case report on management of Bilateral Epididymal Cyst ISSN: 2456-3110 CASE REPORT March 2022 Journal of Ayurveda and Integrated Medical Sciences | March 2022 | Vol. 7 | Issue 2 132 Image 3: After 15 days of surgery Image 4: One month after surgery Image 5: Incised and opened the left scrotum Image 6: veiw of left epidydimal cyst during surgery Image 7: Left epidydimalcyst during surgery Image 8: Right epidydimal cyst during surgery

Pallavi Viraktamath et al. A single case report on management of Bilateral Epididymal Cyst ISSN: 2456-3110 CASE REPORT March 2022 Journal of Ayurveda and Integrated Medical Sciences | March 2022 | Vol. 7 | Issue 2 133 Image 9: During Approxiamtion of 2 cut ends of left scrotum Image 10: After removal of left epidydimal cyst Image 11: Incised and opened the right srotum Image 12: View of right epidydimal cyst during surgery Image 13: View of right epidydimal cyst during surgery Image 14: View of right epidydimal cyst during surgery

Pallavi Viraktamath et al. A single case report on management of Bilateral Epididymal Cyst ISSN: 2456-3110 CASE REPORT March 2022 Journal of Ayurveda and Integrated Medical Sciences | March 2022 | Vol. 7 | Issue 2 134 Image 15: During suturing of right scrotal layers Image 16: after the complete procedure DISCUSSION Clinically differentiation of epididymal cyst from hydrocele always important, in present case was clinically diagnosed as hydrocele, because Trans illumination and fluctuation test were positive but by ultrasonography conformed it as an epidydimal cyst. If the cyst is small no treatment is required, if the cyst is large and causing discomfort, surgical treatment has to be done [5] As per Sushruta present case can be compared with Kaphaja Granthi . It will be having symptoms like swelling will be cold to touch ( Sheetha ), not discolored ( Avivarna ), has slight pain but severe itching ( Rujo Athikandu ), grown big like a stony appearance ( Pashanavath Samhanopanna ) [8] Kaphaja Granthi is Chedhana Sadhya Vyadhi by Acharya Sushrutha . The wise surgeon can apply the surgery of Mutravriddi in Kaphaja Vidradi told by Acharya Sushrutha in Muthra Vriddi Chikithsa Adhyaya . The procedure goes like this fomentation ( Swedana ) followed by a puncture should be made at the inferior surface of scrotal sac with a Vrihimukha Shastra on either side of Median raphe of Scrotum ( Sevani ). Then Dvimukha Nadi (Tube open at both ends) should be introduced and accumulated fluid should be tapped out [9] Then tube should be removed and bandaged. It is almost similar to surgery (Jaboulay’s method of eversion of sac) [10] which is currently practiced in modern science. As per intelligence of surgeon, same procedure can adopted in an Epididymal cyst excision followed by eversion of sac but only change made was use of Chedhana karma of Granthi as per the Yukthi of the Vaidya . CONCLUSION Epidydimal cyst often bilateral, contains clear fluid. They feel like bunch of tiny grapes situated behind the body of the testis. Cysts are compared as Granthi in Ayurveda surgical excision only the line of treatment if it is larger in size. In case of Epidydimal cyst, cyst will be present at behind the body of the testis. As per Yukti of surgeon adopt the surgery explained in Mutravriddi Acharya Sushrutha in his time period. As it is almost similar to Jaboulay’s method of eversion of sac nowadays. By this one can understand that before invention of modern surgical technique excision of sac, our Acharya ‘s were well versed in excision of Epidydimal cyst and aversion of sac. By this we can come to a conclusion that Acharya Sushrutha performed various surgical procedures not only Mutravriddi but various other surgical procedures for various surgical diseases was also told and saved numerous lives before modern system opened its eyes. That’s why Acharya Sushrutha till date is called as father of surgery and branch of surgery is ever green. REFERENCES 1 Das Somen (ed). A Concise text book of Surgery. Dr S Das, 13 Old Mayor’s Court, Kolkata. 2016;p 94

Pallavi Viraktamath et al. A single case report on management of Bilateral Epididymal Cyst ISSN: 2456-3110 CASE REPORT March 2022 Journal of Ayurveda and Integrated Medical Sciences | March 2022 | Vol. 7 | Issue 2 135 2 Patil V (ed). Sushrutha Samhitha of Maharshi Susrutha. New Delhi, Chaukambha Publications. 2018;p 71. 3 https://www.topdoctors.co.uk/medical-articles/is-anepididymal-cyst-serious# 4 https://denverurology.com/maleurology/epididymitis/ 5 Das S (ed). A Concise text book of Surgery. Dr S Das 13 Old Mayor’s Court, Kolkata 2016;p 1318-1319. 6 Bhat S (ed). SRBS Manual of Surgery. New Delhi: Jaypee Brothers Medical Publisher. 2019;p 1062-1063. 7 William N (ed). Bailey and Love's Short Practice of Surgery. Londo: Hodder Arnold, an imprint of Hodder Education, a Hachette UK company, 338 Euston road, London. 2008;p 1383. 8 Patil V (ed). Sushrutha Samhitha of Maharshi Susrutha. New Delhi: Chaukambha Publications. 2018;p 71-72. 9 Patil V (ed). Sushrutha Samhitha of Maharshi Susrutha. New Delhi: Chaukambha Publications. 2018;p 442. 10 Bhat S (ed). SRBS Manual of Surgery. New Delhi: Jaypee Brothers Medical Publisher. 2019;p 1059-1060. ******************************* How to cite this article: Pallavi Viraktamath, Siddayya Aradhyamath, Aditya J. V. A single case report on management of Bilateral Epididymal Cyst - A successful Ayurvedic Surgical Approach. J Ayurveda Integr Med Sci 2022;2:128-135. Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2022 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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Ayurveda, Kaphaja Granthi, Scrotum, Incision, Ayurvedic, Family history, Treatment, Excision, Surgical excision, Non-commercial purpose, Vrihimukha-shastra, Personal history, Infertility, Case report, Cyst, Local examination, Surgical Procedure, Wound care, Chedana karma, Surgical approach, Middle-age group, Acharya Sushrutha, History of present illness, TESTIS, Cystic degeneration, Past illness, Sushrutha, Sushrutha Samhitha, Incidence, Non-tender, Surgical, Mullerian duct, Mobile.