Inguino scrotal swelling

1. Inguino-Scrotal Lumps
Marty Smith
Saturday 30th July 2010
Western Hospital

2. Inguino-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.

3. Pathologies
 Inguinal
 Sebaceous
Cysts/Lipoma’s
 Inguinal
Lymphadenopathy
 Saphenous Varix
 Femoral Artery aneurysm
 Psoas Abscess
 Undescended testes.
 Inguinal Hernia
 Femoral Hernia
 Scrotal
 Testicular tumor
 Epididymal cyst
 Spermatocoele
 Hydatid of Morgagni
 Varicocoele
 Hydrocoele
 Inguino-scrotal
Hernia

4. Assessment-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?

5. Assessment-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

6. Assessment-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

7. Assessment
 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

8. Assessment
 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

9. Anatomy
 Inguinal region
 Inguinal Canal
 Spermatic Cord
 Femoral Canal and Ring
 Scrotum/testes

10. Anatomy
 Inguinal region
 Includes
 Lower abdominal wall
 Femoral Triangle
 Sartorius/Add Longus/
Inguinal Lig
 Contains
 Femoral Pedicle
 Lymph Nodes
 Skin/fat/muscle

11. Anatomy
 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.

12. Anatomy
 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

13. Anatomy
 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.

14. Anatomy
 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
•Site of Femoral Herniae

15. Anatomy
 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.

16. Anatomy
 Spermatic cord
 Pedicle of the testes
 Made up of 12 things

17. Anatomy
 Spermatic cord
 Pedicle of the testes
 Made up of 12 things You’re not getting
away with that!

18. Anatomy
 3 Arteries
 3 Nerves
 3 Important structures
 3 Coverings

19. Anatomy
 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

20. Anatomy
 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.

21. Anatomy
 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

22. Pathologies
 Inguinal
 Sebaceous
Cysts/Lipoma’s
 Inguinal
Lymphadenopathy
 Saphenous Varix
 Femoral Artery aneurysm
 Psoas Abscess
 Undescended testes
 Inguinal Hernia
 Femoral Hernia
 Scrotal
 Testicular tumor
 Epididymal cyst
 Spermatocoele
 Hydatid of Morgagni
 Varicocoele
 Hydrocoele
 Inguino-scrotal
Hernia

23. Skin 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.

24. Skin stuff
 Lipomas
 Benign Fatty lumps
 Clinically
 fixed (skin and fat)
 soft lumps,
 usually longstanding and
asymptomatic.
 Management
 excise surgically

25. 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

26. Saphenous 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.

27. 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.

28. Psoas 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

29. Undescended 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.

30. Scrotal Lumps
 Assessment
 Hx/Ex as previous
 If not obvious Hernia/Varicocoele/ Hydrocoele and
normal testes Ultrasound
 Lump origin
 Solid vs cystic etc.
 If still in doubt-Call a Urologist.
 Surgical exploration

31. Scrotal 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

32. Testicular 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

33. Hydrocoele
 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.

34. Hydrocoele

35. Varicocoele
 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.

36. Other 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.

37. Hernias

38. Inguinal 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

39. Hernia types
 Inguinal
 Direct
 Indirect
 Pantaloon
 Femoral
 Also
 Sliding herniae

40. Sliding 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.
Sliding hernia
Non sliding hernia

41. Inguinal herniae
 Clinically
 Groin pain/discomfort
 Dragging, worse during the day
 Lump
 Asymmetry-inguino-scrotal swelling
 GI/GU obstruction
 Incarceration/Irreducibility

42. Hernia examination

43. Direct 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.

44. Femoral 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

45. Hernia 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.

46. Hernia Management
 Fix it!
 Eliminates pain
 Eliminates Lump
 Avoids hernia growth
 Avoids risk of strangulation
Esp in indirect hernia
 Straightforward surgery.

47. Inguinal Operations
 Previous
 Bassini, McVay, Shouldice
Forget them
 Now
 Lichtenstein tension free mesh repair.
 Laproscopic repair.

48. Hernia operations
 Lichtenstein tension free mesh repair.
Developed in NY at the Lichtenstein Hernia
clinic
Originally done as OP procedure under LA
 Involves
Dissecting Inguinal canal and mobilising cord
Inverting/removing hernia sac
Reinforcing posterior inguinal wall with prolene
mesh.

49. Open Hernia Repair

50. Hernia operations
 Lichtenstein tension free mesh repair.
 Results
All can be done under LA
Widely adopted
Recurrence rate 1-2%-Lichtenstein

51. Hernia Operations
 Laparoscopic
TAPP
 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.

52. Lap Hernia Repair

53. Hernia Operations
 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.

54. Hernia Operations
 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%

55. Femoral 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

56. Summary
 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