MANAGEMENT OF

INGUINOSCROTAL
PATHOLOGIES IN
Department of Surgery
ADULTS
Connaught Hospital
University of Sierra Leone
Teaching Hospitals Complex
THOMAS ASHLEY
MBCHB, WACS PART 1, MRCS
EDINBURGH
FORMAT
Introduction

Differentials

Important anatomical considerations

History

Physical examination

Investigations

Treatment

Complications
INTRODUCTION
Hernia and hydrocoele are amongst the commonest inguino-scrotal pathologies

Inguino-scrotal pathologies go far beyond these two

It should be a ‘must do’ for all clinical year medical students to be competent and fliud in the following

Understanding of the anatomical/embryological bases of these pathologies

History taking and physical examination

Know most of the pathologies and their management

DIFFERENTIALS OF INGUINOSCROTAL PATHOLOGIES
Groin Sebaceous cyst

Coming from above the inguinal ligament Cyst of the spermatic cord

Inguinal hernia – direct, indirect, pantaloon, Lipoma of the spermatic cord

recurrent,
Malgaigne’s buldge
Psoas abscess

Psoas bursa

Undescended testis

Ectopic testis
DIFFERENTIALS OF INGUINOSCROTAL PATHOLOGIES
Groin Cyst of the cord

Coming from below the inguinal ligament Lipoma of the cord

Femoral hernia

Psoas abscess

Saphena varix

Femoral aneurysm

Undescended testis

Ectopic testis
DIFFERENTIALS OF INGUINOSCROTAL PATHOLOGIES
Scrotum - Can’t get above lump

Indirect inguinoscrotal hernia

Congenital/Infantile hydrocoele
DIFFERENTIALS OF INGUINOSCROTAL PATHOLOGIES
Scrotum - Can get above
the swelling

Palpable with the

Testis

Haematocoele

Hydrocoele

Orchitis

Testicular torsion

Tumour
DIFFERENTIALS OF INGUINOSCROTAL PATHOLOGIES
Scrotum - Can get above
the swelling

Palpable separately
to Testis

Epididymal cyst

Epididymitis

Spermatocoele

Varicocoele
TYPES OF GROIN HERNIA
Femoral hernia – primary vs recurrent

Inguinal hernia – primary vs Recurrent hernia

Litre’s hernia – sac contains Meckel’s Diverticulum

Amyan’s hernia – sac contains appendix

Maydl’s hernia – contains a W-shape loop of bowel such that the middle of the W is strangulated

Ritcher’s hernia – contains only one side of the bowel wall which may become strangulated

Sliding hernia (hernia ‘en glissade’ – the bowel wall forms part of the hernia sac
IMPORTANT ANATOMICAL CONSIDERATIONS
ANATOMY OF THE INGUINAL
REGION
The inguinal ligament is a reflection of the external oblique aponeurosis and has attachments to the anterior superior iliac
spine (ASIS) laterally and the pubic tubercle medially

The Deep(internal) Ring of the Inguinal Canal is a U-shaped aperture which lies 1.25cm just above and medial to the
midpoint of the inguinal ligament .

It is formed by an aperture through the transversalis fascia.

It is 12-20mm high and 6-10mm wide

ANATOMY OF THE INGUINAL
REGION
The Superficial (external) Ring of the Inguinal Canal lies just above and lateral to the pubic tubercle.

It is formed by an aperture through the external oblique aponeurosis

It is triangular shaped with its apex directed upwards and base above the pubic tubercle

Measures 2.5cm x 1.25cm

ANATOMY OF THE INGUINAL
REGION
The inguinal canal is an oblique passage directed muscular fibres of internal oblique laterally as it takes its
downwards, medially and forwards origin from the inguinal ligament

It measures about 4cm in adults Inferior wall (floor) – inguinal Ligament

Boundaries Posterior wall – Transversalis fascia re-inforced

superficially by the aponeurosis of transversus
Lateral end – the Deep Ring
abdominis laterally and conjoint tendon medially
Medial end – the superficial ring

Superior wall (Roof) – arching fibres of transversus

Remember mnemonics - MALT
abdominis and internal oblique (Muscles)

Anterior wall – External oblique Aponeurosis + arching

ANATOMY OF THE INGUINAL
REGION
Hasselberg’s Triangle

Location – medial aspect of posterior wall of the

inguinal region

Medially – lateral margin of rectus abdominis

Laterally – inferior epigastric vessels

Inferiorly - inguinal ligament

THE FEMORAL TRIANGLE
Boundaries

Laterally – medial border of satorius

Medially – medial border of adductor lungus

Superiorly – inguinal ligament

Floor – iliacus, psoas major and pectineus muscles

Roof – skin, subcutaneous tissue and fascia lata

THE FEMORAL TRIANGLE
Contents – lateral to medial

Femoral nerve and its branches

Femoral artery and several of its branches

Femoral vein and its tributaries

Femoral canal and lymph nodes

THE FEMORAL TRIANGLE
The femoral sheath It contains – fat, lymphatics and nodes of Cloquet

A shaped fascial sheath which is a 3-4cm extension of Nodes of cloquet drain lymph from lower limb,
the extraperitoneal connective tissue from the abdomen perineum and anterior abdominal wall inferior to the
umbilicus
Has 3 compartments

Laterally – surrounding the femoral nerve

Intermediate – surrounding the femoral vessels

Medially - forming the femoral canal

The femoral canal is the site for femoral hernia

THE FEMORAL TRIANGLE
The femoral ring

Is the superior opening of the femoral canal

Boundaries

Anteriorly - inguinal ligament

Posteriorly – pectineal ligament

Medially – lacuna ligament

Laterally – femoral vein

HISTORY
• 40yr old man presenting with painful left groin swelling over past 2 months.
• What questions would you want to ask ?
• What are your differential diagnoses?
HISTORY
• Biodata
• Age
• Sex – inguinal hernia commoner in males
• Occupation
HISTORY
• Duration • What symptoms does it cause? Eg weight loss
• When was the lump first noticed? • Does it interfere with movement, respiration or
swallowing?
• First symptom
• Pulsatility, ischemic - coldness, neurologic - numbness
• What made the patient to notice the lump?
• Describe the history of each symptom
• Felt when washing, or found by friend, or felt pain
on the area • Progression
• Note presence of pain which is usually due to • Has the swelling changed in size – smaller, larger or
inflammation and not tumour fluctuating size

• Take detailed history of the pain • Other changes – pain, discolouration, ulcer,
discharge,
• Other symptoms
HISTORY
• Persistence
• Has the lump ever disappeared- lying down, during exercise
• Multiplicity
• Any previous lump
• Swelling in the contralateral groin?
HISTORY
• Predisposing factors
• Chronic cough
• Chronic constipation
• Chronic obstructive urinary symptoms
• Occupation – manual jobs
• Previous lower limb trauma predisposing to lymphadenopathy
• Slim body stature
• Pregnancy
HISTORY OF PAIN
SOCRATES
HISTORY - PMHX
• Previous hernia
• Previous treatment for other conditions eg TB
• Previous surgery eg appendicectomy
HISTORY – FHX & SHX
• Family Hx of hernia or any other groin lump
• Smoking
• Number of sticks per day (N)
• Number of years Y
• One packet contains 20 cigarettes
• Number of pack years = Y x (N/20)
• Physical activity
• Diet
HISTORY
• Allergies
• Current regular medications
• Ilicit drug injections to groin
PHYSICAL EXAMINATION
INSPECTION
6 S’s - site, size, shape, symmetry, skin, scar

Cough impulse
PALPATION - SCROTUM
Characterise the swelling – T - SEC FFP TR Lyphadenopathy

Get above the lump? Contralateral side

Palpate the testicles

Palpate the Epididymus

Palpate the vas deferens

If you can not get above the swelling proceed hernia

examination

If you can go above the swelling continue as scrotal lump

PALPATION – HERNIA
Step 1 – T SEC FFP TR

Step 2 – determine whether it is inguinal or femoral

Step 3 – determine whether it is direct vs indirect hernia at the superficial ring

Step 4 - determine whether it is direct vs indirect at the deep ring

AUSCULTATION AND COMPLETION
Bowel sounds

Lymphadenopathy

Contralateral side

Scrotum

Abdominal examination
INVESTIGATIONS
Hb

FBC, CRP, Urea, creatinine, electrolyte, urinalysis, VDRL, AFP, beta HCG, HDL

Microbiology – C&S of swab/MSU; 3x early morning urine samples for ZN staining and mocroscopy

Radiologic

USS – linear probe for scrotum, curved probe for the scrotum –

shows defect, solid vs cystic

AXR ,CXR

CT Scan
TREATMENT
TREATMENT - HERNIA
Treatment options

1. Conservative
2. Medical
3. Surgical
TREATMENT - HERNIA
Conservative

Watch and wait

Use of Truss – used for reducible hernia. It is not

curative and rarely needed

Medical – uptimise COPD, treat pneumonia

TREATMENT - HERNIA
Surgical treatment – Herniotomy + Herniorrhaphy Gold standard

Can be done OPEN or LAPAROSCOPICALLY

Herniotomy – ligation of sac at its neck and resecting

Herniorrhaphy – strengthening of posterior wall

TREATMENT – INGUINAL HERNIA
Open Darn method

Herniotomy + Herniorrhaphy Shouldice

Methods of herniorrhaphy

Mesh repair (Lichtenstein) - using polypropylene

mesh

Non-Mesh(Suture) repair

Bassini - interrupted tension suture repair

Bassini with Tanner Slide

TREATMENT – INGUINAL HERNIA
Operative steps

Exposure of spermatic cord

Dissection of the hernial sac free of spermatic cord elements

Tightening of the internal ring

Strengthening of the posterior wall

Closure of the wound

TREATMENT – INGUINAL HERNIA
Laparoscopic

Transabdominal pre-peritoneal repair (TAPP) – the peritoneal cavity is entered

Total Extraperitoneal repair – the peritoneal cavity is not entered

 OPEN VS LAPAROSCOPIC INGUINAL HERNIA REPAIR

Open Laparoscopic

Cost Less expensive Expensive

Indications Can be used in all types Can also be used in all types but first choice in Recurrent
and Bilateral hernia
Operation time Shorter Longer

Learning curve Shorter Has long learning curve

Complication Associated with more general complications such as pain Associated with lesser general complications but higher
but lesser severe complications such as vascular, bowel or rare and more serious complications
bladder injuries
Recurrence Lower higher

Activity Earlier return to normal life

Anaesthesia Can be done under Local, Spinal or General anaesthesia Can only be done under General anaesthesia
TREATMENT - FEMORAL HERNIA
Principles III.Low - Lockwood
Exposure

Excision of sac

Closure of femoral ring

Closure of wound

Approach

I. High - McEvedy – preferred in strangulated cases

II. Trans-inguinal – Lotheissen
HYDROCOELE
Classification

Primary - due to persistent processus vaginalis

Secondary - due to underlying disease

Infection

Torsion

Tumour
HYDROCOELE - PRIMARY
Vaginal hydrocoele – commonest type. Accumulation of fluid in the tunica
vaginalis. No communication with vas deferens or peritoneal cavity

Congenital hydrocoele – accumulation of fluid in the tunica vaginalis and

extends to the vas deferens and communicates with the peritoneal cavity

Infantile hydrocoele – accumulation of fluid around testis and extending to the

vas deferens but the processus vaginalis is obliterated at the deep inguinal ring.
No communication with the peritoneal cavity

Hydrocoele of the cord – Rare. Accumulation of fluid around the vas deferens
only
TREAMENT - HYDROCOELE
Infantile hydrocoele may be manages conservatively until 1yr when surgery is indicated

Secondary hydrocoele usually resolve with treatment of underlying cause

Primary hydrocoele

Conservative – reassurance, scrotal support, aspiration, sclerotherapy – inject phenol

Surgical - Lord’s plication, Jaboulay’s procedure

TESTICULAR TORSION
Definition – twisting of the testis around the
axis of the spermatic cord

Common in age 12-19yrs boys

On examination
Clinical features
• Cord shorter and thicker
Acutely hot painful testicular swelling
• Very tender
Abdominal pain
• The testis may be in the Bell Clapper
Nausea position – the tunica does not anchor the
testis, hence allowing free movement of
Vomiting
the testis
TREATMENT – TESTICULAR
TORSION
This is a surgical emergency. Intervene within 4-6hrs to salvage the testis

Analgesics

Keep nil by mouth

IV fluids

FBC, U &E, Group and save

Consent for scrotal exploration +/- Bilateral orchidopexy +/-Orchidectomy

Courtesy of Dr Constance Cummings-John

EPIDIDYMITIS AND ORCHITIS
Causes

Viral – mumps, Coxsackie B, Infectious mononucleosis

Bacterial – ascending UTI, STI

Can be Acute or Chronic (e.g., due to TB)

TREATMENT – EPIDIDYMO-
ORCHITIS
It is important to rule out testicular torsion

Conservative – bed rest and scrotal support

Medical - analgesia, antibiotics

Surgical – Incision and Drainage of abscess. Orchidectomy if severe

PSOAS ABSCESS
Primary - direct spread from distance site through blood vessels and lymphatics

Secondary - direct spread from adjacent structures

Vertebrae

GIT

Aorta

Genitourinary tract

Pancreas
TESTICULAR MALDESCENT
A. Retractile testis – Common in children. The testis appear to be incompletely descended but goes back to scrotum with
warm bath. It is due to overactivity of the cremaster muscle. It usually improves as the child get older

B. Ectopic testis – the testis migrates to an abnormal position after exiting the superficial inguinal ring.

• Common sites – superficial inguinal pouch, perineum, root of penis, femoral canal

C. Undescended testis – the testis prematurely stops to descend anywhere along its normal path of descent as guided by the
gubernaculum
TREATMENT – UNDESCENDED
TESTIS
Undescended testis require intervention in order to prevent complications

Complications include : Trauma, Torsion, Tumour, Infertility, Psychological distress

Risk of developing testicular tumour is 30X, commonly seminomas

Treatment - orchidopexy before 1yr.

Give HCG or GnRH in older patients – helps in 15% of cases

TESTICULAR TUMOURS
Benign - Leydig cell tumours, Sertoli cell tumours

Malignant

Seminomatous

Non-Seminomatous

Mixed
TESTICULAR TUMOUR – CLINICAL FEATURES
Clinical features –

Painless hard testicular lump

Dragging sensation

Secondary hydrocoele

Back pain – para-aortic metastasis

Respiratory features – lung metastasis

TESTICULAR TUMOUR -
INVESTIGATIONS
Investigations

Blood –

Alpha Feto-protein – raised in teratomas and yolk sac tumours

Beta HCG – raised in seminomas

LDH

Radiologic –

USS to assess tumour; CXR for lung metastasis, CT scan for staging
TREATMENT – TESTICULAR
TUMOUR
Surgery – orchidectomy via inguinal approach after clamping the cord. Scrotal incision is avoided to prevent seeding to
scrotal skin

Chemotherapy – seminomas and teratomas

Radiotherapy - seminoma
COMPLICATIONS
Hernia

Obstruction

Strangulation

fistula
QUESTION
• 40yr old man presenting with painful left groin swelling over past 2 months.
• What questions would you want to ask ?
• What are your differential diagnoses?
• How would you examine this patient?
• How would you investigate this patient?
• What treatment will you give?
QUESTION
A 15-yr old boy presents with severe left scrotal pain.

what are your differential diagnoses?

Outline specific questions that will help you with the different diagnoses

Choose one of your differentials and discuss the treatment options of this.
QUESTION
• What is a Hernia?
• Protrusion of a viscus or part of a viscus through an abnormal opening in its covering
• Hernia has
• Neck, body, fundus
• How does hernia occur?
• Defect caused by
• Congenital
• Muscle weakness and tearing on straining