objectives to determine the proper approach to a patient presenting with inguinal mass to determine...

ObjectivesTo determine the proper

approach to a patient presenting with inguinal mass

To determine possible differentials for inguinal mass

To determine the appropriate management of an inguinal mass

Identifying DataGeneral Data

◦Gabaldon, Luis Arnel Beltran◦16 years old◦Male ◦Student◦Roman Catholic◦Pasay City

Chief complaint◦Bilateral inguinal mass

History of Present Illness2 years PTC Left inguinal mass

• Soft, smooth, “balloon-like” • Well-circumscribed • ~ 1-2cm in diameter• Spontaneously appears and disappears• (-) pain or tenderness• (-) fever, dysuria, hematuria

No consult

History of Present Illness1 year PTC Persistence of left inguinal

mass• Progression of mass to scrotal area• Reducible

Right inguinoscrotal mass• ~ 2-3cm in diameter• More prominent on exertion, straining, defecation• Occasional pain, relieved by wearing supporters• Reducible

History of Present Illness1 month PTC Progressive enlargement of

mass • R: 4-5cm in diameter• L: 2-3cm in diameter

Increase pain severity, VAS 5-6

Activity hindrance

Consult• Advised surgery

Admission

Past Medical HistoryChildhood: febrile convulsions

◦Multiple hospitalizationsGrade 2: chickenpox(-) measles, mumps, primary complexClaims to have complete childhood

vaccinations

Claims to have no sexual contact

(-) surgeries(-) allergies to food or medications

Family HistoryHypertension- fatherDM, inguinal mass???- mother(-) Cancer, lung diseases

Personal-Social HistoryNon- smokerOccasional alcohol drinkerNo illicit drug use1st year college studentDance and sports

Review of SystemsGeneral: (+) fatigue, (-) fever,

weight loss or gain, weakness

Musculoskeletal/dermatologic: (-) lumps, itching, muscle or joint pains, joint swelling, changes in hair or nails

Review of SystemsHEENT: (-) dizziness, deafness,

blurring of vision, tinnitus, nosebleeds, hoarseness, frequent colds, dry mouth, gum bleeding, enlarged LNs

Respiratory: (+) cough, (-) dyspnea, hemoptysis, wheezing

Review of SystemsCardiovascular: (-) palpitations,

chest pains, syncope, orthopnea

GI: (-) nausea, vomiting, changes in bowel habits, dysphagia, jaundice, rectal bleeding

GU: (-) nocturia, frequency

Review of SystemsEndocrine: (-) excess sweat or

thirst, heat or cold intolerance

Neuro: (-) seizures, loss of sensation

Physical ExaminationGeneral Survey

◦Alert, awake, coherent, ambulating◦Not in cardio-respiratory distress◦Height 170 cm, Weight 65 kg, BMI 22.5◦BP 100/70 mmHg; HR 90 bpm; RR 14 bpm;

T 36.4 °C◦Pain scale 0/10

Integumentary◦Nails clean and properly trimmed; with good

color, reddish pink nail beds. No cyanosis or clubbing noted

HEENT◦Head- No palpable and visible

masses or wounds.◦Eyes- eyelids normal. Visual fields

full. Pink conjunctiva. EOMs full and equal. (+) corneal light reflex. (+) Direct and consensual papillary reflex.

◦Ears- No visible wounds, lumps or deformities.

HEENT◦Nose- Nasal septum midline. Pink

mucosa, no exudate and swelling. No sinus tenderness.

◦Throat- Oral pale pink mucosa, no signs of ulcerations and swelling. Tongue midline. Symmetric elevation of soft palate; pink in appearance

◦Neck- (-) Lymphadenopathies over cervical, post and pre auricular, and submental areas. Trachea midline. Thyroid not palpable. No goiter and nodules.

Pulmonary◦Normal shape. (-) lesions in anterior

and posterior thorax. (-) Areas of tenderness. Resonant. Clear breath sounds, no crackles, rales, wheeze.

Cardiovascular◦(-) Pallor, cyanosis. A dynamic

precordium. No palpable masses. PMI, 5th left ICS MCL. Heart sounds normal rate and regular rhythm; S1>S2 on the apex, S2>S1 on the base, S3 and S4 not heard. Absence of bruits, thrills and murmurs.

Gastrointestinal◦Flat. (-) Lesions. Normoactive bowel

sounds. (-) Tenderness. (-) Organomegaly. Tympanitic in all quadrants. Traube’s space empty. (-) CVA tenderness.

Inguinal/ Genitalia◦Tanner stage 5◦Bilaterally descended testes◦(-) phimosis, hypospadia◦Skin normal looking◦L: no palpable mass; L external ring

~ 1 cm in diameter; (-) transillumination test

Inguinal/ Genitalia◦R: palpable mass ~ 4cm over

inguinal to upper scrotal area; soft, smooth, non-tender, well demarcated; mass pressing against the tip of the examining finger in the R inguinal canal; mass irreducible with taxis; R external ring ~ 2cm in diameter; (+) transillumination test

DRE◦(-) lesions, masses in the perianal; (-)

masses, fissures, hemorrhoids, pararectal tenderness; intact external anal sphincter; (-) blood on examining finger

Extremities ◦(-) cyanosis and edema. Pulses full

and equal. Good turgor.

Salient Features

Subjective2 year history of L and R

inguinoscrotal massReducible(+) Pain relieved by wearing

supporters(+) Activity hindrance

Salient Features

ObjectiveBilaterally descended testesR: palpable mass ~ 4cm over inguinal

to upper scrotal area; soft, smooth, non-tender, well demarcated; mass pressing against the tip of the examining finger in the R inguinal canal; mass irreducible with taxis; R external ring ~ 2cm in diameter; (+) transillumination test

Salient Features

ObjectiveL: no palpable mass; L external ring

~ 1 cm in diameter; (-) transillumination test

Normal DRE

Impression R hydrocoele, communicating L indirect inguinal hernia,

complete

DifferentialsRule in Rule out

Inguinal hernia (+) inguinoscrotal mass more prominent with straining

Hydrocoele (+) transillumination test

Varicocoele (+) scrotal mass (-) veins palpated(-) feeling of heaviness in the testicle(-) atrophy of testicle

Lymphadenopathy (+) inguinal mass (-) history of trauma, infection, malignancyChronic case

Epididymitis (+) scrotal pain (-) acute scrotal pain(-) fever(-) warm/ red scrotum

Testicular torsion (+) inguinoscrotal mass (-) acute testicular pain

Undescended testes (+) inguinal mass (+) testes palpated in the scrotum

ManagementBilateral herniotomy Pre op

◦CBC: unremarkable Hbg 141, Hct 0.43, WBC 6.6, Plt 266

◦CT: 2-4 mins.◦BT: 2-4 mins.◦UA: unremarkable ◦CXR: unremarkable

Procedure Done/ Intra-op findingsBilateral herniotomy

◦R: internal ring measures 1 cm in diameter, floor not attenuated

◦L: internal ring measures 0.5cm in diameter, floor not attenuated

Post op◦Tramadol 50mg/ mL q 8o 50 mg/tab

q 8o ◦Mefenamic acid 500mg/ tab

Inguinal herniaProtrusion of abdominal-cavity

contents through the inguinal canal

75% of all abdominal wall hernias occur in the groin

Indirect hernias vs. direct hernias- 2:1,

Right > L Male vs. female- 7:1.

Indirect inguinal herniaPatent processus vaginalisReducible

◦Inguinal mass that increases in size with straining, coughing; non-tender

Irreducible◦Occasional pain; incarcerated

Strangulated◦Pain; fever, skin changes, s/sx of

bowel obstruction

Risk factorsMaleFamily historyChronic cough, constipationObesityPregnancy PrematurityPrevious history of hernia

TreatmentSupporters, bindingsSurgery

◦Herniotomy, herniorrhaphy◦Laparoscopy

PrognosisTreatableRisk of strangulation (7%)

◦Recurrence, urinary retention, wound infection, hydrocoele, scrotal hematoma

HydrocoeleBuildup of fluid between the two

layers of the tunica vaginalis◦Can lead to either a communicating

hydrocele or an indirect inguinal hernia

Inguinal/ scrotal mass(+) Transillumination Risk factors similar to indirect

inguinal hernia

TreatmentWait and seeHerniotomyContralateral exploration