The Case of the Mysterious

MassAndrew Williams

Ken KonciljaAravind Reddy

Meghan Kaumaya

Patient and Chief Complaint• 12 year old male with walnut size

enlargement left of pubic tubercle• Enlargement changes with body

position and activity level• Exacerbated by weight training, “barely

noticeable” in the morning• Physical exam revealed normal size

and position of external genitalia

Physical ExamVital Signs

• Pulse: 80• Rhythm: Regular• Temperature: 98.4 F• Respiratory Rate: 15• Height: 5’6”• Weight: 110 lbs.

Physical Examination• HEENT: Normal• Lungs: Normal• Cardiovascular: Normal• Abdomen: Small

palpable mass in groin, lateral to pubic tabercle

• Genitourinary: Normal• Musculoskeletal:

Normal• Neurological: Normal

Gross AnatomyInguinal Canal

•Oblique intermuscular passage through inferior anterior abdominal wall•Contains spermatic cord in males, round ligament in females•Extends from deep inguinal ring (lateral) to the superficial inguinal ring (medial), both rings are lateral to the pubic tubercle

Boundaries•Anterior: External abdominal oblique aponeurosis•Posterior: Transversalis fascia, conjoined tendon•Floor: Inguinal ligament•Roof: Internal abdominal oblique and transverse abdominal muscles

Spermatic Cord

Contains 3 layers

External spermatic fascia: from external oblique muscle

Cremasteric muscle: from internal oblique muscle

Internal spermatic fascia: from transversalis fascia

Possible Causes• Neoplasm: Unlikely• Fluid build up: Hydrocele (communicating

or non-communicating) of testis or cord, hematocele of testis, varicocele

• Inguinal Hernia: Direct or Indirect

Types of Inguinal HerniasIndirectLeaves abdominal cavity lateral

to inferior epigastric vessels Enters deep inguinal ring and

runs inside spermatic cord Sac formed from persistent

processus vaginalis

DirectLeaves abdominal cavity medial to inferior epigastric vessels, through inguinal triangleTravels through medial portion of inguinal canal, runs parallel to spermatic cordSac formed by peritoneum and transversalis fascia Less common

Congenital or Acquired?• Congenital

– Processus Vaginalis does not seal after the descent of the testes

– Fluid or intestines occupy the space in the inguinal canal left open by the patent processus

– The processus vaginalis remains patent in 25% of adults

– Indirect are far more common in younger males

• Acquired– Exercise or strain can

induce a direct hernia – Direct Hernias are more

common in males over 40– Problem lies in a weak falx

inguinalis (conjoint tendon) either by trauma or lack of exercise.

Diagnosis and Plan• Indirect or Direct hernia or Communicating

Hydrocele.• Determine with further testing, use illumination to

rule out hydrocele• Avoid sports and heavy lifting until repaired• Requires surgical treatment: be cautious of

ilioinguinal nerve and genitofemoral nerve

References• Deveney Karen E, "Chapter 32. Hernias & Other Lesions of the Abdominal

Wall" (Chapter). Doherty GM: CURRENT Diagnosis & Treatment: Surgery, 13e: http://www.accessmedicine.com/content.aspx?aID=5310246.

• Albanese Craig T, Sylvester Karl G, "Chapter 43. Pediatric Surgery" (Chapter). Doherty GM: CURRENT Diagnosis & Treatment: Surgery, 13e: http://www.accessmedicine.com/content.aspx?aID=531604.Albanese Craig T, Sylvester Karl G, "Chapter 43. Pediatric Surgery" (Chapter). Doherty GM: CURRENT Diagnosis & Treatment: Surgery, 13e: http://www.accessmedicine.com/content.aspx?aID=5316074.

• Moore, Keith L., Dalley, Arthur F., Agur, Anne M.  Clinically Oriented Anatomy.  6th ed.  Baltimore: Lippincott Williams & Wilkins; 2010. 

• Moore, Keith L., Persaud, T.V.N. The Developing Human: Clinically Oriented Embryology. 8th ed. Philadelphia: Saunders; 2008.

• Edelman D.S., Selesnick H.: “Sports” hernia: Treatment with biologic mesh (Surgisis). A preliminary study.  Surg Endosc  2006; 20(6):971-973

• Saad Samy, Duckett Olly, "Chapter 139. Urologic and Gynecologic Problems in Children" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: http://0-www.accessmedicine.com /content.aspx?aID=598506.