inguino scrotal swelling neo

Inguino-Scrotal LumpsInguino-Scrotal Lumps

Marty Smith Saturday 30th July 2010

Western Hospital

Marty Smith Saturday 30th July 2010

Western Hospital

Inguino-Scrotal LumpsInguino-Scrotal Lumps

Why? Because they’re common. Because they’re really common. Because the anatomy is fun to quiz

people on. Because they’re common.

Account for up to 20% of General surgical referrals.

Why? Because they’re common. Because they’re really common. Because the anatomy is fun to quiz

people on. Because they’re common.

Account for up to 20% of General surgical referrals.

PathologiesPathologies

Inguinal Sebaceous

Cysts/Lipoma’s Inguinal

Lymphadenopathy Saphenous Varix Femoral Artery

aneurysm Psoas Abscess Undescended testes. Inguinal Hernia Femoral Hernia

Inguinal Sebaceous



aneurysm Psoas Abscess Undescended testes. Inguinal Hernia Femoral Hernia

Scrotal Testicular tumor Epididymal cyst Spermatocoele Hydatid of

Morgagni Varicocoele Hydrocoele Inguino-scrotal

Hernia



Hernia

Assessment-HistoryAssessment-History

Lump When was it first noticed?

How was it noticed? Precipitant activity Recent illnesses

What symptoms are present? ?pain, functional impairment GI/GU disturbance. Systemic symptoms-fevers, night sweats etc.

Is the lump changing? Does the lump come and go

How or when?

Lump When was it first noticed?

How was it noticed? Precipitant activity Recent illnesses

What symptoms are present? ?pain, functional impairment GI/GU disturbance. Systemic symptoms-fevers, night sweats etc.

Is the lump changing? Does the lump come and go

How or when?

Assessment-ExamAssessment-Exam

Lump Position, Shape and size Surface

Skin Mass surface

Temperature Tenderness Composition-Solid/Fluid/Gas

Consistency Fluctuation/Fluid thrills/Resonance Translucency Pulsatility

Reducibility/Cough impulse Relations to surrounding structures Regional Lymph nodes

Lump Position, Shape and size Surface

Skin Mass surface

Temperature Tenderness Composition-Solid/Fluid/Gas

Consistency Fluctuation/Fluid thrills/Resonance Translucency Pulsatility

Reducibility/Cough impulse Relations to surrounding structures Regional Lymph nodes

Assessment-ExamAssessment-Exam

Both sides Hernia Tests

Standing and lying ?Get above it Cough Impulse Reducibility and control

Associated structures Pulses, testes, Lymph nodes.

Special tests Transillumination

Both sides Hernia Tests

Standing and lying ?Get above it Cough Impulse Reducibility and control

Associated structures Pulses, testes, Lymph nodes.

Special tests Transillumination

AssessmentAssessment

Investigation Occasional use only

Ultrasound/duplex For early hernia’s-not so reliable. Useful for testes/vascular assessment

CT More for assessing deeper anatomy

Herniagram Laparoscopy

Investigation Occasional use only

Ultrasound/duplex For early hernia’s-not so reliable. Useful for testes/vascular assessment

CT More for assessing deeper anatomy

Herniagram Laparoscopy

AssessmentAssessment

How Not to Kill people, Don’t miss tumors

Exclude Malignancy Lymphadenopathy-Generalized, unexplained or

persistent BIOPSY!

Discrete Scrotal Lumps or unexaminable testes Ultrasound and/or Refer

No Part time Vascular Surgery

How Not to Kill people, Don’t miss tumors

Exclude Malignancy Lymphadenopathy-Generalized, unexplained or

persistent BIOPSY!

Discrete Scrotal Lumps or unexaminable testes Ultrasound and/or Refer

No Part time Vascular Surgery

AnatomyAnatomy

Inguinal region

Inguinal Canal Spermatic Cord Femoral Canal and

Ring

Scrotum/testes

Inguinal region

Inguinal Canal Spermatic Cord Femoral Canal and

Ring

Scrotum/testes

AnatomyAnatomy

Inguinal region Includes

Lower abdominal wall

Femoral Triangle Sartorius/Add

Longus/ Inguinal Lig

Contains Femoral Pedicle Lymph Nodes Skin/fat/muscle

Inguinal region Includes

Lower abdominal wall

Femoral Triangle Sartorius/Add

Longus/ Inguinal Lig

Contains Femoral Pedicle Lymph Nodes Skin/fat/muscle

AnatomyAnatomy

Inguinal Canal An oblique series of

defects in the layers of the abdominal wall.

Site of Inguinal Herniae

Transmits the Spermatic cord/Round ligament.

Round ligament Runs from Uterine

fundus via canal to Labia.

Inguinal Canal An oblique series of

defects in the layers of the abdominal wall.

Site of Inguinal Herniae

Transmits the Spermatic cord/Round ligament.

Round ligament Runs from Uterine

fundus via canal to Labia.

AnatomyAnatomy

Inguinal Canal Floor

Inguinal Ligament and Lacunar ligament

Roof Arching fibres of Int

Obl & Trans abdominis and Conjoint tendon

Anterior Wall External Oblique

aponeurosis Superficial Ring

Post Wall Conjoint tendon

medially, Transversalis fascia laterally

Deep ring

Inguinal Canal Floor

Inguinal Ligament and Lacunar ligament

Roof Arching fibres of Int

Obl & Trans abdominis and Conjoint tendon

Anterior Wall External Oblique

aponeurosis Superficial Ring

Post Wall Conjoint tendon

medially, Transversalis fascia laterally

Deep ring

AnatomyAnatomy

Femoral Canal Beneath the inguinal

ligament Iliacus muscle Femoral Nerve Femoral Sheath

containing… Femoral vessels Femoral Canal

Femoral Canal Space for venous

expansion Lymphatics. Upper end defined by

femoral ring.






femoral ring.

AnatomyAnatomy






femoral ring.






femoral ring.•Femoral Ring

•Site of Femoral Herniae

AnatomyAnatomy

Eponyms Hesselbachs Triangle

Lateral border of rectus muscle

Inguinal Ligament Inferior epigastric

vessels (med border of deep ring)

Fruchauds Myopectineal Orofice

Hesselbachs triangle Deep ring Femoral sheath/canal.

Eponyms Hesselbachs Triangle

Lateral border of rectus muscle

Inguinal Ligament Inferior epigastric

vessels (med border of deep ring)

Fruchauds Myopectineal Orofice

Hesselbachs triangle Deep ring Femoral sheath/canal.

AnatomyAnatomy

Spermatic cord Pedicle of the

testes

Made up of 12 things


testes


AnatomyAnatomy


testes



testes


You’re not getting

away with that!

AnatomyAnatomy

3 Arteries

3 Nerves

3 Arteries

3 Nerves

3 Important structures

3 Coverings

3 Important structures

3 Coverings

AnatomyAnatomy

3 Arteries Testicular Artery to the Vas

Deferens Cremasteric

3 Nerves Sympathetic branches Ilio-inguinal (on cord) Genital Br of Genito-

femoral nerve.

3 Arteries Testicular Artery to the Vas

Deferens Cremasteric

3 Nerves Sympathetic branches Ilio-inguinal (on cord) Genital Br of Genito-

femoral nerve.

3 Important structures Vas Deferens Pampiniform Plexus Processus Vaginalis

3 Coverings External Spermatic Fascia Cremasteric Muscle Internal Spermatic Fascia

3 Important structures Vas Deferens Pampiniform Plexus Processus Vaginalis

3 Coverings External Spermatic Fascia Cremasteric Muscle Internal Spermatic Fascia

AnatomyAnatomy

Spermatic cord Only truly forms at

the superficial ring. Passes through the

superficial ring above and medial to

the pubic tubercle. Descends through

S/C fat into the scrotum.

Spermatic cord Only truly forms at

the superficial ring. Passes through the

superficial ring above and medial to

the pubic tubercle. Descends through

S/C fat into the scrotum.

AnatomyAnatomy

Testes Suspended on spermatic cord, Enveloped within Tunica

vaginalis Drain via epididymis to Vas

Deferens

Made up of Germinal elements-

Seminiferous tubules Non-Germinal elements-

Stroma, Leydig cells

Testes Suspended on spermatic cord, Enveloped within Tunica

vaginalis Drain via epididymis to Vas

Deferens

Made up of Germinal elements-

Seminiferous tubules Non-Germinal elements-

Stroma, Leydig cells

PathologiesPathologies

Inguinal Sebaceous



aneurysm Psoas Abscess Undescended testes Inguinal Hernia Femoral Hernia

Inguinal Sebaceous



aneurysm Psoas Abscess Undescended testes Inguinal Hernia Femoral Hernia



Hernia



Hernia

Skin stuffSkin stuff

Sebaceous cysts Retention cysts of sebaceous

glands

Fixed to skin-dimple if squeezed

Can become infected-abscess. Incise and drain

Management excise when non-inflammed.

Sebaceous cysts Retention cysts of sebaceous

glands

Fixed to skin-dimple if squeezed

Can become infected-abscess. Incise and drain

Management excise when non-inflammed.

Skin stuffSkin stuff

Lipomas Benign Fatty lumps

Clinically fixed (skin and fat) soft lumps, usually longstanding and

asymptomatic.

Management excise surgically

Lipomas Benign Fatty lumps

Clinically fixed (skin and fat) soft lumps, usually longstanding and

asymptomatic.

Management excise surgically

Inguinal Lymphadenopathy

Inguinal Lymphadenopathy

Causes Primary Lymphatic disease-

Lymphoma Secondary Lymphadenopathy

Malignant disease Benign

Physiological reaction to inflammatory state

Management Exclude Inflammatory causes

Examine, Observe, Antibiotics etc. Exclude obvious malignancy Biopsy-FNA/Open

Causes Primary Lymphatic disease-

Lymphoma Secondary Lymphadenopathy

Malignant disease Benign

Physiological reaction to inflammatory state

Management Exclude Inflammatory causes

Examine, Observe, Antibiotics etc. Exclude obvious malignancy Biopsy-FNA/Open

Saphenous VarixSaphenous Varix

Prominent Varicosity of Upper Long Saphenous Vein. Typical Patient

Middle aged and older F>M

Usual Risk Factors Pregnancy, Pelvic Mass

Clinically Dragging lump over upper thigh, disappears when lying Cough impulse + Thrill down vein when percussing.

Management-surgical ligation.

Prominent Varicosity of Upper Long Saphenous Vein. Typical Patient

Middle aged and older F>M

Usual Risk Factors Pregnancy, Pelvic Mass

Clinically Dragging lump over upper thigh, disappears when lying Cough impulse + Thrill down vein when percussing.

Management-surgical ligation.

Femoral Artery Aneurysm.Femoral Artery Aneurysm.

True aneurysms Pulsatile lump in groin Associated with other aneurysmal

disease Mx-Vascular surgical repair if >2-

3cm

False aneurysm Secondary to puncture

Dx on duplex Mx-Call a vascular surgeon-

thrombose or repair.

True aneurysms Pulsatile lump in groin Associated with other aneurysmal

disease Mx-Vascular surgical repair if >2-

3cm

False aneurysm Secondary to puncture

Dx on duplex Mx-Call a vascular surgeon-

thrombose or repair.

Psoas AbscessPsoas Abscess

Abscess within Psoas fascia that tracks to groin and presents as a lump.

Associated with Retroperitoneal infection/inflammation

Post Surgical eg. Nephrectomy Colonic Pancreatitis Spinal TB

Management Drain and treat underlying cause

Abscess within Psoas fascia that tracks to groin and presents as a lump.

Associated with Retroperitoneal infection/inflammation

Post Surgical eg. Nephrectomy Colonic Pancreatitis Spinal TB

Management Drain and treat underlying cause

Undescended TestesUndescended Testes

Rare in adults Usually Dx and treated as children

In adults usually present as infertility Alt painless lump in Inguinal canal

Prone to infertility and testicular cancer.

Managemant Refer to Urologist.

Rare in adults Usually Dx and treated as children

In adults usually present as infertility Alt painless lump in Inguinal canal

Prone to infertility and testicular cancer.

Managemant Refer to Urologist.

Scrotal LumpsScrotal Lumps

Assessment Hx/Ex as previous

If not obvious Hernia/Varicocoele/ Hydrocoele and normal testesUltrasound Lump origin Solid vs cystic etc.

If still in doubt-Call a Urologist. Surgical exploration

Assessment Hx/Ex as previous

If not obvious Hernia/Varicocoele/ Hydrocoele and normal testesUltrasound Lump origin Solid vs cystic etc.

If still in doubt-Call a Urologist. Surgical exploration

Scrotal LumpsScrotal Lumps

Solid lumps. Testicular origin

mostly malignant

Paratesticular origin mostly benign

Cystadenoma, Adenomatoid tumor (epididymis) Inflammatory pseudotumor

Cystic lumps Usually benign

Epididymal cyst, Spermatocoele, Hydatid of Morgagni

Solid lumps. Testicular origin

mostly malignant

Paratesticular origin mostly benign

Cystadenoma, Adenomatoid tumor (epididymis) Inflammatory pseudotumor

Cystic lumps Usually benign

Epididymal cyst, Spermatocoele, Hydatid of Morgagni

Testicular LumpsTesticular Lumps

Testicular tumors Usually painless lumps in 2nd to 4th decades Germinal-95%

Seminoma/Embryonal Cell/ChorioCa/Teratoma

Non-Germinal Stromal-Leydig Cell Tumor; Gonadoblastoma

Management Call a Urologist Usually multimodal Therapy

Testicular tumors Usually painless lumps in 2nd to 4th decades Germinal-95%

Seminoma/Embryonal Cell/ChorioCa/Teratoma

Non-Germinal Stromal-Leydig Cell Tumor; Gonadoblastoma

Management Call a Urologist Usually multimodal Therapy

HydrocoeleHydrocoele Collections of fluid in Tunica Vaginalis

Typically >40yrs except infantile. Classes

Congenital-communicating Reactive-tumor/trauma/infection Idiopathic.

Clinically Usually dragging scrotal mass, Can get above them, fluctuant, transilluminate well Must exclude malignancy

Clinically normal testes or ultrasound

Treatment Aspirate-tend to recur Surgery-Jaboulet procedure.

Collections of fluid in Tunica Vaginalis Typically >40yrs except infantile. Classes

Congenital-communicating Reactive-tumor/trauma/infection Idiopathic.

Clinically Usually dragging scrotal mass, Can get above them, fluctuant, transilluminate well Must exclude malignancy

Clinically normal testes or ultrasound

Treatment Aspirate-tend to recur Surgery-Jaboulet procedure.

HydrocoeleHydrocoele

VaricocoeleVaricocoele

Dilatation of the Pampiniform Plexus Usually affects 20 to 50 yo’s L>R

due to venous anatomy. Acute varicocoele-exclude RP infiltration

May cause infertility Painless lump

Bag of worms Cough impulse +ve May reduce on lying down

Treatment Ligation at deep ring or excision.

Dilatation of the Pampiniform Plexus Usually affects 20 to 50 yo’s L>R

due to venous anatomy. Acute varicocoele-exclude RP infiltration

May cause infertility Painless lump

Bag of worms Cough impulse +ve May reduce on lying down

Treatment Ligation at deep ring or excision.

Other Scrotal LumpsOther Scrotal Lumps

Epididymal cyst Cyst arising from epididymis

Spermatocoele Sperm filled cyst arising from the testes.

Hydatid of Morgagni Small mobile cyst from top of testes

Embryological remnant of Mullerian duct. Subject to torsion

Management Exclude testicular Mass-Ultrasound Surgery if large/symptomatic.

Epididymal cyst Cyst arising from epididymis

Spermatocoele Sperm filled cyst arising from the testes.

Hydatid of Morgagni Small mobile cyst from top of testes

Embryological remnant of Mullerian duct. Subject to torsion

Management Exclude testicular Mass-Ultrasound Surgery if large/symptomatic.

HerniasHernias

Inguinal herniaeInguinal herniae Hernia Numbers

25% of males (2% F) will develop a groin hernia 65% Indirect Inguinal herniae

55% on the right

31% Direct Inguinal Herniae Although represent 80% of bilateral herniae

4% Femoral Herniae More common in women 20 % of all groin herniae c/w 2%

male.

Causes Congenital Chronic Stress to area Metabolic-Collagen-vasc Ds, Smoking

Hernia Numbers 25% of males (2% F) will develop a groin hernia 65% Indirect Inguinal herniae

55% on the right

31% Direct Inguinal Herniae Although represent 80% of bilateral herniae

4% Femoral Herniae More common in women 20 % of all groin herniae c/w 2%

male.

Causes Congenital Chronic Stress to area Metabolic-Collagen-vasc Ds, Smoking

Hernia typesHernia types

Inguinal Direct Indirect Pantaloon

Femoral

Also Sliding herniae

Inguinal Direct Indirect Pantaloon

Femoral

Also Sliding herniae

Sliding HerniaSliding Hernia

A Hernia in which the peritoneal wall that forms part of the sac has an organ naturally adherent to it. Eg. If an extraperitoneal organ (usually

Bladder or colon) slides out with its adherent peritoneum through the hernia defect the organ itself becomes part of the wall of the sac.

Must look out for this at the time of surgery because the organ is easily injured upon opening the sac.

Can be direct or indirect.

A Hernia in which the peritoneal wall that forms part of the sac has an organ naturally adherent to it. Eg. If an extraperitoneal organ (usually

Bladder or colon) slides out with its adherent peritoneum through the hernia defect the organ itself becomes part of the wall of the sac.

Must look out for this at the time of surgery because the organ is easily injured upon opening the sac.

Can be direct or indirect.

Sliding hernia

Non sliding hernia

Inguinal herniaeInguinal herniae

Clinically Groin pain/discomfort

Dragging, worse during the day Lump

Asymmetry-inguino-scrotal swelling GI/GU obstruction Incarceration/Irreducibility

Clinically Groin pain/discomfort

Dragging, worse during the day Lump

Asymmetry-inguino-scrotal swelling GI/GU obstruction Incarceration/Irreducibility

Hernia examinationHernia examination

Direct vs indirectDirect vs indirect

Direct Diffuse bulge Rarely into scrotum Controlled only at superficial ring

Indirect Usually more defined May extend into scrotum Herniation/reduction more prominent Controlled at deep ring.

Direct Diffuse bulge Rarely into scrotum Controlled only at superficial ring

Indirect Usually more defined May extend into scrotum Herniation/reduction more prominent Controlled at deep ring.

Femoral vs inguinalFemoral vs inguinal

Inguinal Lie in/above groin crease Appear above and medial to pubic tubercle. Extend into scrotum

Femoral Lie below crease Appear below and lateral to tubercle Extend into thigh

Inguinal Lie in/above groin crease Appear above and medial to pubic tubercle. Extend into scrotum

Femoral Lie below crease Appear below and lateral to tubercle Extend into thigh

Hernia ComplicationsHernia Complications

Incarceration Strangulation

Risk-Indirect and Femoral>>>Direct Surgical emergency

Call the surgeon-don’t try and reduce. Herniated Viscera is entrapped and infarcted.

Acute, tender, painful lump +/- SBO Richters Hernia Reduction en-masse

Progressive growth=Natural Hx of herniae.

Incarceration Strangulation

Risk-Indirect and Femoral>>>Direct Surgical emergency

Call the surgeon-don’t try and reduce. Herniated Viscera is entrapped and infarcted.

Acute, tender, painful lump +/- SBO Richters Hernia Reduction en-masse

Progressive growth=Natural Hx of herniae.

Hernia ManagementHernia Management

Fix it! Eliminates pain Eliminates Lump Avoids hernia growth Avoids risk of strangulation

Esp in indirect hernia

Straightforward surgery.

Fix it! Eliminates pain Eliminates Lump Avoids hernia growth Avoids risk of strangulation

Esp in indirect hernia

Straightforward surgery.

Inguinal OperationsInguinal Operations

Previous Bassini, McVay, Shouldice

Forget them

Now Lichtenstein tension free mesh repair. Laproscopic repair.

Previous Bassini, McVay, Shouldice

Forget them

Now Lichtenstein tension free mesh repair. Laproscopic repair.

Hernia operationsHernia operations

Lichtenstein tension free mesh repair.Developed in NY at the Lichtenstein Hernia

clinicOriginally done as OP procedure under LA

Involves Dissecting Inguinal canal and mobilising cord Inverting/removing hernia sac Reinforcing posterior inguinal wall with

prolene mesh.

Lichtenstein tension free mesh repair.Developed in NY at the Lichtenstein Hernia

clinicOriginally done as OP procedure under LA

Involves Dissecting Inguinal canal and mobilising cord Inverting/removing hernia sac Reinforcing posterior inguinal wall with

prolene mesh.

Open Hernia RepairOpen Hernia Repair

Hernia operationsHernia operations

Lichtenstein tension free mesh repair. Results

All can be done under LAWidely adoptedRecurrence rate 1-2%-Lichtenstein

Lichtenstein tension free mesh repair. Results

All can be done under LAWidely adoptedRecurrence rate 1-2%-Lichtenstein

Hernia OperationsHernia Operations

LaparoscopicTAPP

Trans abdominal Pre-peritoneal Patch

TEPP Totally Extraperitoneal Pre-peritoneal Patch

Both place a Mesh patch over the hernial defect inside the abdominal muscle layer, outside the peritoneum.

LaparoscopicTAPP

Trans abdominal Pre-peritoneal Patch

TEPP Totally Extraperitoneal Pre-peritoneal Patch

Both place a Mesh patch over the hernial defect inside the abdominal muscle layer, outside the peritoneum.

Lap Hernia RepairLap Hernia Repair


Lap repairs Multiple RCT’s C/W open repair.

Results equivalent for Recurrence rate (? Better) LoS

Better for Post -op pain Return to work ?Chronic Groin pain

Worse for OP time Cost

Tend to be reserved for Recurrent or Bilateral repairs.

Lap repairs Multiple RCT’s C/W open repair.

Results equivalent for Recurrence rate (? Better) LoS

Better for Post -op pain Return to work ?Chronic Groin pain

Worse for OP time Cost

Tend to be reserved for Recurrent or Bilateral repairs.


Complications Infection ~1.5%

Incl Mesh infection

Bleeding~1% Hernia recurrence

Varies with technique, should be <2%

Nerve injury/Chronic groin discomfort 5-10% Ischaemic orchitis/atrophy ~1-2% Urinary retention 1-10%

Complications Infection ~1.5%

Incl Mesh infection

Bleeding~1% Hernia recurrence

Varies with technique, should be <2%

Nerve injury/Chronic groin discomfort 5-10% Ischaemic orchitis/atrophy ~1-2% Urinary retention 1-10%

Femoral HerniaeFemoral Herniae

3 ways High Approach

McEvedy-via the abdomen Best for difficult or strangulated Herniae

Middle Lothieson-via the Inguinal canal Used occasionally for indeterminate herniae.

Low Lockwood-via the upper thigh/groin Best for small hernia and elective repairs

3 ways High Approach

McEvedy-via the abdomen Best for difficult or strangulated Herniae

Middle Lothieson-via the Inguinal canal Used occasionally for indeterminate herniae.

Low Lockwood-via the upper thigh/groin Best for small hernia and elective repairs

SummarySummary

Remember the anatomy Lumps can arise from any tissue. Understand the Hernia anatomy and

the clinical management is easy Don’t kill anyone

Don’t miss Malignancy-Ing LN and scrotal lumps.

Fix the hernias

Remember the anatomy Lumps can arise from any tissue. Understand the Hernia anatomy and

the clinical management is easy Don’t kill anyone

Don’t miss Malignancy-Ing LN and scrotal lumps.

Fix the hernias

inguino scrotal swelling neo

Health & Medicine

anatomy femoral canal

anatomy testes

anatomy spermatic cord

site of inguinal herniae

ring scrotumtestes

spermatic cordround

discrete scrotal lumps

assessmenthistory lump