INGUINAL-SCROTAL

SWELLINGS
Definition

 Swelling of the groin area that extend from

inguinal region to the scrotum.
Anatomy
Processus vaginalis :

- Embryonic
developmental
outpouching of the
peritoneum.
- In males, it precedes the
testes in their descent
down within the
gubernaculum and closes.
- The remaining portion
around the testes becomes
the tunica vaginalis
• Failure of closure of processus vaginalis :

a) Peritoneal fluid can travel down a patent PV  hydrocele

b) Blood accumulation in patent PV  hematocele
c) Potential for an indirect inguinal hernia to develop
d) If it does not close in females  forms canal of Nuck (pouch of peritoneum
extending into labia majora  give rise to cyst/hydrocele in females.
Descent of testes

The testicle must migrate

from the site of formation
(at the level of the kidney)
through the belly and
groin, and into the
scrotum.
It can get stuck anywhere
along this path between
the kidney and the scrotum
(cryptorchidism)
Differential diagnosis of inguinal-
scrotal swelling
 Common causes :
1. Inguinal hernia
2. Femoral hernia
3. Inguinal lymphadenopathy

 Other causes :
1. Saphena varix
2. Femoral artery aneurysm
3. Groin abscess
4. Lipoma of the cord
5. Varicocele (‘bag of worms’ consistency)
6. Undescended testes (cryptorchidism)
7. Ectopic testis
8. Hydrocele of cord or the canal of Nuck
9. Hematocele
10. Testicular cancer
11. Testicular torsion
12. Epididymo-orchitis
History taking
 When the lump 1st noticed?
 What made the patient notice the lump? (pain/when
washing/someone else noticed)
 What are the symptoms related to the lump?
 Has the lump changed since it was first noticed?
(size/change in nature)
 Does the lump ever disappear? What makes the lump
disappear? (on lying down/while exercise)
 Has the patient had any other lumps?
 What does the patient think caused the lump ?
 Is there any discharge?
 What has been suggested and administered?
 • Ask about potential complications of hernia :
1. Irreducibility
2. Obstruction : abdominal pain, distension, constipation, vomiting
3. Strangulation : tender, painful, skin changes over the swelling

• Also ask about risk factors for hernia :

1. Chronic coughing
2. Chronic constipation
3. Straining with micturition
4. Strenous physical effort
5. Social hx : smoking, occupation, extreme bout of heavy lifting
 Case
 Chief complaint :
ZBJ, a 59 years old Malay man, day 1 post elective
hernioplasty was admitted to CTC Sg Buloh on 21st
January 2015 with chief complaint of left inguinal
swelling 5 months prior to admission.

 History of presenting illness :

-The swelling will appear upon standing and walking
but it was reduced spontaneously by sitting.
- The patient claimed that there was sense of
warmness and discomfort at the site of swelling. He
denied of having any pain at the swollen site.
-The swelling feels firm to touch and there was no skin changes over
it.
- Otherwise there was no other associated symptoms ; no fever, no
vomiting, no loss of appetite, no loss of weight, no haemorrhoid and
no constipation. But the swelling caused limitation in his daily
activities.
- In November, the patient noticed that the swelling got bigger and
had involved the left scrotum but it is still reducible with sense of
warmness and discomfort.
- Upon further asking, the patient denied of having other lump before.
- He was previously a body builder (routinely weight lifting) and also
worked in police rescue team. He was obese with BMI of 34.
- The patient made an appointment with CTC Sg Buloh in December
and was then admitted electively for hernioplasty 6 days ago.
 Systemic review :
- Gastrointestinal system : no altered bowel habit, no blood in stool,
no hematemesis
- Genitourinary system : no dysuria, no hematuria, no urinary
frequency or urgency
- Cardiovascular system : no sweating, no cyanosis, no dyspnea
- Respiratory system : no chronic coughing, no shortness of breath
- Musculoskeletal system : no joint pain, no muscle stiffness or
swelling
- Endocrine system : no heat or cold intolerance, no reduced or
increased in sweating, no polydipsia
- Skin : no rash, no bruising, no bleeding
 Past medical history :
-This is his second hospitalization
- His first hospitalisation was in 2010 at PPUM for stents insertion in
coronary artery.
- The patient has underlying diabetes mellitus, hypertension,
hypercholesterolemia and cardiac disease currently on medications.

 Allergic :
-Egg (burung puyuh) and mussels  nausea and vomiting
- Ponstan medication  swollen lips
- Sardine  gout (has to take painkiller and anti-gout)
 Family history :

-He is the 2nd out of 5 siblings. Two of his younger siblings passed
away due to heart failure.
- He has a strong family history of diabetes mellitus, hypertension,
hypercholesterolemia and cardiac disease.
- His mom had diabetes mellitus, hypertension and cardiac disease
(passed away due to heart failure)
- His dad has hypertension and gout.
- There is no family member having the same symptom as him.
- No malignancy running in the family.
- He has 3 children. All are healthy.
- His wife has hypertension.
 Social history :
- He had stopped smoking since 15 years ago. He is a non alcoholic and
does not take drugs for pleasure.
-He had retired for 3 years (police rescue team)
- He lives in Kg Melayu, Subang with his family.

 Summary :
In summary, ZBJ, a 59 year-old Malay man, day 1 post elective
hernioplasty was admitted with chief complaint of left inguinal swelling 5
months prior to admission. The swelling was reducible, painless with no
skin changes over it but it got bigger since last 2 months. It was not
associated with other symptoms. He was a body builder with routine weight
lifting and worked in police rescue team. He was also obese with BMI of
34. Otherwise no history of chronic coughing, no constipation and no
straining during micturition.
 Examination
a) Inspection :
i. Single/multiple
ii. Site/position
iii. Size
iv. Shape
v. Colour and texture overlying
vi. Surface
vii. Pulsation
viii. Expansile cough impulse (in hernia, swelling becomes larger and more tense in all directions
when coughing)

b) Palpation :
i. Confirm the inspection explanation
ii. Mobility
iii. Margin
iv. Consistency
v. Fluctuation
vi. Temperature of the skin overlying the hernia
vii. Transillumination
viii. Occlusion test
ix. Reducibility
- In males, palpate the testis and spermatic cord (decide whether the lump is a hernia or
a true scrotal lump)
1. If can get above it (feel its upper edge with normal spermatic cord) = true scrotal
swelling
2. If the lump has no upper edge because it passes into the inguinal canal = hernia

- Deep occlusion test :

1. The hernia must be reduced first
2. Press and occlude the deep ring with the tip of index finger
3. Ask patient to cough
4. It doesn’t bulge out on occluding deep ring : indirect inguinal hernia
5. It bulge out medial to the occluded ring : direct inguinal hernia
Midpoint of inguinal ligament : midway between anterior
superior iliac spine and pubic symphysis
Deep ring 1.5 cm above midpoint of
inguinal ligament
Superficial ring 1 cm above and medial to
pubic tubercle
c) Percussion :
-Ask the patient to cough to distend the swelling then percuss
gently :
i. Resonant : enterocele
ii. Dull : all other swellings

d) Auscultation :
- Bowel sound may be heard in hernia containing gut
- Peristalsis in enterocele
Midpoint of inguinal canal vs mid-
inguinal point
Midpoint of inguinal canal Mid-inguinal point
Midpoint between ASIS and pubic Midpoint between ASIS and pubic
tubercle symphysis

1.5 cm above it is a location of deep Location of femoral artery

inguinal ring
 Inguinal hernia
• Anatomy (layers of anterior abdominal wall)

a) Skin
b) Superficial fascia (fascia Camper and
Scarpa’s fascia)
c) Muscles :
i. External oblique ms
ii. Internal oblique ms
iii. Transversus abdominis
d) Transversalis fascia
e) Extraperitoneal fat
f) Peritoneum
g) Organs

- Deep inguinal ring : in transversalis fascia

(1.5 cm above midpoint of inguinal ligament)
- Sup inguinal ring : from external oblique
aponeurosis
 Indirect hernia
• Exit point : lateral to inferior epigastric artery
• Replicates the pathway by which the developing testis descends through the abdominal wall into
the scrotum
• The peritoneal membrane, s/t including part of intestine, descend along the same path.
• Herniating loop of intestine enters inguinal canal thru deep inguinal ring and would enter the
scrotum, after passed through superficial inguinal ring
• Patent processus vaginalis forming hernia sac
 Direct hernia
• Push through weak area of posterior wall medial to inferior epigastric artery.
• Bulge forward and doesn’t enter scrotum
• Usually found in older patients with deficient muscle and weak transversalis
fascia
• Not enter deep inguinal ring
• Peritoneum forming hernia sac
 Terms used
• Reducible : possible to return the contents of hernia to their
normal anatomical site – the abdomen
• Irreducible : contents of hernia sac can’t be replaced into
abdomen
- may be associated with :
i. Incarcerated : contents are literally imprisoned in the sac of
hernia (usually by adhesions) but are alive and functioning
normal. Non tender
ii. Obstructed : loop of bowel is trapped within the sac of hernia
(its lumen, not blood supply, is obstructed). Bowel is alive. Not
unduly tender. Sign and symptom of intestinal obstruction.
iii. Strangulated : compression/twisting has compromised the
blood supply to the contents of the sac. Ischemic/infarcted.
Acutely tender.
Thank you