Urology JC080: Inguinal And Scrotal Swelling: Different Types Of Hernia, Testicular Mass

Question 1

***DDx of Groin swelling

Answer 1

Painful lumps:
1. **LN
2. Strangulated **inguinal hernia
3. Strangulated ***femoral hernia

Painless lumps:
1. **Skin swelling (e.g. sebaceous cyst, lipoma)
2. Non-tender LN
3. Inguinal hernia (not strangulated)
4. Femoral hernia (not strangulated)
5. **Undescended testes
6. ***Vascular problems
- Femoral artery aneurysm
- Saphenous varice

Question 2

***DDx of Scrotal swelling

Answer 2

Painful lumps
1. **Torsion of testes
2. Torsion of a testicular / epididymal appendage
3. **Epididymo-orchitis / Orchitis
4. Strangulated ***inguinal hernia
5. Hematocele / Hematoma

Painless lumps
1. Inguinal hernia
2. **Hydrocele
3. **Epididymal cyst
4. **Spermatocele
5. **Varicocele
6. ***Testicular tumour
7. Skin swelling (sebaceous cysts, abscess)

Question 3

***Other classification of Groin / Scrotal swelling

Answer 3

記: Hernia (Inguinal / Femoral), LN, Varice, Testes, Spermatic cord, Tunica vaginalis, Epididymis

Inguinal:
1. **Inguinal hernia
2. **LN
3. Encysted hydrocele of cord
4. **Undescended testes
5. **Round ligament varicoses (females / pregnant women)

Inguinoscrotal:
1. Inguinal hernia
2. Hydrocele
3. **Spermatic cord (e.g. varicocele)
4. Testes (*undescended / ectopic)

Femoral:
1. **Femoral hernia
2. **LN
3. ***Saphenous varices
4. Ectopic testes

Inguinofemoral:
1. Inguinal LN
2. Distended psoas bursa
3. Effusion in hip joint

Scrotal:
1. Skin (boils sebaceous cyst, papilloma, warts)
2. SC tissue (lymph scrotum, filariasis)
3. **Tunica vaginalis (hydrocele, hematocele)
4. **Testes (orchitis, neoplasms)
5. **Epididymis (cysts, infections)
6. **Spermatic cord (varicocele)

Question 4

Anatomy of groin

Answer 4

1. Inguinal ligament
   - ASIS to Pubic tubercle
   - **Femoral hernia: Lateral + Below
   - **Inguinal hernia: Medial + Above
2. Inferior epigastric vessels
   - separate Direct / Indirect inguinal hernia
   —> **Medial: Direct (pass through superficial ring only)
   —> **Lateral: Indirect (pass though superficial + deep ring)
3. Deep ring
   - 0.5 inch above midpoint of inguinal ligament
4. Superficial ring
   - 1cm above + superolateral to pubic tubercle (wiki)

**Cross-section of Inguinal canal:
- Anterior wall: External oblique aponeurosis
- Posterior wall: **Transversalis fascia + Conjoint tendon
- Inferior wall (Floor): Inguinal ligament
- Superior wall (Roof): Internal oblique + Transversus abdominis

Contents of Inguinal canal:
1. **Spermatic cord, Vas deferens (male) / **Round ligament (female)
2. Artery to the vas
3. **Gonadal artery + vein (pampiniform plexus)
4. Cermasteric artery + vein
5. **Genital branch of Genitofemoral nerve
6. ***Ilioinguinal nerve
7. Sympathetic nerves
8. Lymphatics
9. Internal spermatic fascia
10. Cremasteric fascia + muscle
11. External spermatic fascia

Question 5

Important nerves

Answer 5

1. Iliohypogastric nerve (injured in TEPP (self notes))
2. Ilioinguinal nerve (injured in open approach (self notes))
3. Genitofemoral nerve (injured in open approach (self notes))
4. Lateral femoral cutaneous nerve (injured in TAP (self notes))

Question 6

Internal ring

Answer 6

***Lateral to Inferior epigastric vessels

Male:
- Opening in transversalis fascia (posterior wall) through which Vas deferens enters on its course from pelvis

Female:
- Transmit Round ligament which suspends uterus anteriorly + Genital branch of Genitofemoral nerve

Question 7

***Inguinal hernia

Answer 7

1. Indirect:
   - protrude from Internal ring (**lateral to inferior epigastric vessels)
   - pass through Internal + Superficial ring
   - ∵ **Recannulation of obliterated vaginal process
2. Direct:
   - protrude from **medial to inferior epigastric vessels
   - pass through Superficial ring
   - ∵ **Insufficient transversalis fascia (weakened posterior wall)
3. Pantaloon hernia:
   - Presence of both direct + indirect hernia (look like pair of trousers with legs sticking out)
4. Sliding hernia:
   - Internal organ forming part of hernia wall protruding out (usually sigmoid colon) (其他bowel都走出黎)

Other types:
- Richter’s (only 1 side of bowel wall —> can cause strangulated hernia but ***no intestinal obstruction —> strangulated portion will necrosis —> perforation)
- Amyand (appendix protrude out)
- Littre (Meckel’s diverticulum protrude out)
- Maydl

Question 8

Femoral hernia

Answer 8

• Less common than Inguinal hernia (2-8% of all groin hernias)
• More common in females
• Higher chance of strangulation (∵ tight opening)

Anatomy:
- Roof: ***Inguinal ligament (above femoral canal)
- Lateral wall: Femoral vein
- Medial wall: Lacunar ligament
- Floor: Pectineus muscle

Question 9

***Myopectineal orifice (MPO)

Answer 9

包曬Femoral + Inguinal hernia
- area of weakness in pelvic region
- normal congenital / anatomical gaps occur in this area (∵ lack of muscle)
- not reinforced by muscle layers like rest of abdominal wall —> hernia
- more prone to repetitive increases in intra-abdominal pressure —> progressive bulging, weakness, hernia formation

Anatomy:
- Roof: Arching fibres of Internal oblique + Transversus abdominis
- Inferior: Coopers (Pectineal) ligament
- Medial: **Rectus abdominis + its fascial rectus sheath
- Lateral: **Iliopsoas muscle

During surgery:
1. Reduce peritoneum
2. Avoid Triangle of Doom (major blood vessels + spermatic cord)
3. Avoid Triangle of Pain (nerve, Cutaneous branch of Genitofemoral nerve —> chronic pain)

Question 10

***History taking

Answer 10

1. Reducible groin mass: Henia
2. Painful scrotal swelling: Epididymo-orchitis / Torsion
3. Painless scrotal enlargement: Hydrocele / Testicular tumour
4. Fullness / Bag of worms: Varicocele

Question 11

Risk factors for Inguinal hernia

Answer 11

Intrinsic
1. Family history
2. ***Previous contralateral hernia
3. Gender (more common in male)
4. Age
5. Abnormal collagen metabolism

Acquired
1. **Prostatectomy (MPO damaged before)
2. **Obesity
3. **Chronic constipation
4. **Pulmonary disease

Question 12

Diagnosis of Inguinal hernia

Answer 12

1. ***P/E
2. ***USG
3. CT (but not dynamic, can only look at hernias that are stuck / protruded)
4. MRI (less common)
5. Herniography (rare, inject contrast into abdominal cavity to look at lining of peritoneum)

Question 13

***P/E of hernia

Answer 13

Exposure: Entire abdomen to Mid-thigh
If sit —> stand up first
If lying —> supine first

Standing:
Inspect
1. Describe mass
2. ***Visible cough impulse (unilateral / bilateral)
3. Scars (recurrent?)

Palpate
1. Describe mass
2. ***Get above? (Scrotal mass vs Groin mass extending to scrotum)
3. Palpable cough impulse (unilateral / bilateral)

Supine:
Inspect
Palpate
1. Identify Pubic tubercle (PT) + ASIS —> to identify **Inguinal ligament (above: Inguinal hernia, below: Femoral hernia)
2. Relationship with PT
3. **Reducible
4. **Deep ring occlusion test (thumb on **0.5 inch above midpoint of inguinal ligament NOT mid-inguinal point)
- Direct inguinal hernia: can still feel after occlusion (accuracy 35%)
- Indirect inguinal hernia: cannot feel after occlusion (accuracy 86%)
5. Abdominal mass
6. Scrotum (for both testes, undescended testes)

(Pubic tubercle: most **superior + **lateral protrusion of pubic bone)

Question 14

Midpoint of Inguinal ligament vs Mid-inguinal point

Answer 14

Midpoint of Inguinal ligament:
- midpoint between ASIS and PT —> Deep inguinal ring

Mid-inguinal point:
- midpoint between ASIS and PS —> Femoral pulse

Question 15

Treatment of Inguinal hernia

Answer 15

Symptomatic: Surgery only
Asymptomatic: Watchful waiting (70% within 5 years will progress to symptomatic)

Question 16

***Hernia repair

Answer 16

1. Herniotomy
   - excision of hernia sac after reduction of contents
2. Herniorrhaphy
   - Herniotomy + strengthening of posterior wall without mesh
   - **Tissue repair
   —> Bassini repair
   —> **Shouldice repair
3. Hernioplasty (used nowadays)
   - Herniotomy + strengthening of posterior wall with mesh
   - **Mesh repair
   —> Open
   ——> Anterior approach: **Lichtenstein repair
   ——> Posterior approach: Stoppa repair (mesh behind rectus muscle))

—> Laparoscopic (always Posterior)
——> **TEP (total extraperitoneal)
——> **TAPP (transabdominal pre-peritoneal)
——> eTEP (extended TEP)

Question 17

Choice of approach

Answer 17

1. Patient characteristics
2. Surgical expertise
3. Local / National resources
4. Logistics

Pre-operative risk factors for recurrence
1. Poor surgical technique
2. Low surgical volume (unfamiliar operation)
3. Surgical inexperience

Best operative technique
1. Low risk of complications (pain + recurrence)
2. Easy to learn
3. Fast recovery
4. Reproducible result
5. Cost effective

Question 18

Lichtenstein repair

Answer 18

***Gold standard (most common type of repair worldwide)
- easy to learn, perform, teach, effective
- recurrence rate <1%

***Open Tensionless Mesh repair
1. Suprainguinal incision
2. Avoid spermatic cord, ilioinguinal nerve

Advantage (SpC Revision):
- Simple, quick
- Can be done under LA / SA

Question 19

Shouldice repair

Answer 19

• Best tissue, non-mesh technique
• Difficult to learn

Question 20

Endo/Laparoscopic repair

Answer 20

• Well accepted alternative to open repair
• Advantages: **less early post-op pain, **less chronic pain
• European Hernia Society Guideline: Endoscopic repair suitable for both unilateral + ***bilateral hernias
• Preferred approach when dealing with ***recurrent hernia after open repair (∵ already have scar in anterior wall, need to find a fresh plane i.e. posterior plane via laparoscopic approach —> vice versa)

Technique:
- Reduce content into abdominal cavity
—> place a mesh in pre-peritoneal plane behind muscle to strengthen hernia site

1. Total Extraperitoneal Repair (TEP)
   - directly dissect into pre-peritoneal plane without perforating peritoneum
2. Transabdominal Preperitoneal Repair (TAPP)
   - entering peritoneal cavity first (diagnostic laparoscopy) —> incising peritoneum to enter pre-peritoneal plane

TEP vs TAPP:
- Comparable outcomes (efficacy, complications etc.)
- Choice depends on surgeon’s skills, education, experience
- TEP has **longer learning curve than TAPP (∵ smaller working space with TEP)
- TEP more **vascular injuries
- TAPP more ***visceral injuries

Advantage over Open (SpC Revision):
- ***Decrease wound pain

Disadvantage over Open:
- ***GA required

Question 21

Consideration for Females

Answer 21

• ***Laparo-endoscopic recommended
• ↓ risk of chronic pain
• Avoid missing an ***occult femoral hernia (more prevalent in female)

Pregnant women:
- Watchful waiting —> ∵ can be self-limiting ***round ligament varicosities —> regress after giving birth

Question 22

Complications of surgery for hernia repair (SpC Revision)

Answer 22

1. Bleeding (haematoma)
2. Wound infection
3. Seroma
4. Nerve injury (chronic pain)
5. Injury to vas / testicular blood supply
6. Recurrence

Question 23

Classification of Hernias

Answer 23

**Nyhus classification:
Classification designed for **posterior approach based on size of internal ring + integrity of posterior wall

Type 1: Indirect inguinal hernia + normal deep ring
Type 2: Indirect inguinal hernia + enlarged deep ring
Type 3a: Direct inguinal hernia
Type 3b: Indirect inguinal hernia causing posterior wall weakness
Type 3c: Femoral hernia
Type 4: Recurrent hernia

European Hernia Society:
- Primary (P) vs Recurrent (R)
- Indirect (Lateral) vs Direct (Medial) vs Femoral
- 1 (<=1 finger breadth) vs 2 (1-2 finger breadth) vs 3 (>=3 finger breadth)

Question 24

Chronic groin pain (Inguinodynia)

Answer 24

A Surgical complication
Primary groin pain: groin pain not related to prior surgery
Secondary groin pain: groin pain that began after surgical procedure (including hernia repairs / orthopaedic surgery)

Chronic post-op inguinal pain (CPIP):
- 10-12% of all IH repair
- Bothersome moderate pain impacting daily activities lasting >=3 months post-op
- Risk factors:
—> young age
—> female
—> high pre-op pain
—> early high post-op pain
—> recurrent hernia
—> ***open repair

2 types of pain:
1. Nociceptive pain
- activation of nociceptors by nociceptive molecules due to ***tissue injury / inflammatory reaction
—> signals transmitted to brain via A-delta + C-fibres

2. Neuropathic pain
   - **direct nerve injury due to direct contact of nerves with mesh / nerve entrapment by sutures, staples, tacks, folded mesh, meshoma (mesh become a lump)
   - Pain / Numbness mapping
   —> Anterior thigh: **Genitofemoral nerve
   —> Medial thigh / Scrotal: ***Ilioinguinal nerve

Question 25

Treatment of Femoral hernia

Answer 25

Depends on whether there is suspicion of bowel injury

1. ***McEvedy’s high approach
   - if suspect bowel strangulation
   - high approach can enter peritoneum and examine bowel
2. Lotheissen’s transinguinal approach
3. ***Lockwood’s infrainguinal approach
   - if no suspicions of bowel strangulation
   - may accidentally reduce hernia content also

Question 26

Hydrocele

Answer 26

• Fluid in Tunica vaginalis
• Primary vs Secondary hydrocele

S/S:
- **Can get above it
- **Transillumination test: transillumination of light through hydrocele
- ***Fluctuant +
- Testes not palpable
- USG to examine testes

Types:
1. Vaginal hydrocele (hydrocele only in scrotum)
2. Congenital hydrocele (hydrocele communicates up to inguinal canal to deep ring)
3. Infantile hydrocele
4. Hydrocele of the cord

Management:
1. **Needle aspiration (tend to recur)
2. **Jaboulay procedure (invert cysts wall)

Question 27

Testicular tumour

Answer 27

Risk factors:
- 20-45 yo
- **Undescended testes
- Family + Personal history of testicular tumour
- White
- **HIV positive

S/S:
- Enlarged, Firm, ***Non-tender testes

Investigations:
- ***↑ AFP, hCG, LDH-1

Classification (according to cell type):
1. Germ cell tumour
- Spermatocytic seminoma
- Embryonal carcinoma + Teratoma (Teratocarcinoma)
- Teratoma (mature, immature, with malignancy transformation)
- Choriocarcinoma
- Yolk sac tumour

2. Sex cord stomal tumour
   - Leydig cell tumour
   - Sertoli cell tumour
   - Granulosa cell tumour
   - Mixed form

Treatment:
- **Inguinal radical orchidectomy +/- **RPLND (retroperitoneal LN dissection)
- Systemic chemotherapy
—> BEP (bleomycin, etoposide, cisplatin)
—> Carboplatin (for stage 1 pure seminoma only)
—> EP (etoposide, cisplatin)
—> TIP (paclitaxel, ifosfamide, cisplatin)
—> VeIP (vinblastine, ifosfamide, cisplatin)
—> VIP (etoposide, ifosfamide, cisplatin)
—> High-dose carboplatin + etoposide

Question 28

Varicocele

Answer 28

• ***Pampiniform venous plexus —> drains blood from testes
• Abnormal enlargement of pampiniform venous plexus in scrotum
• ~15% of men
• Left side more common than right
• May lead to ***fertility issues
• Important to ***rule out renal mass causing venous congestion

Pathology (SpC Revision):
- Physiological / Hormonal effect
- Rule out secondary causes (e.g. renal mass)

S/S:
- **Bag of worms felt on standing
- **Nutcracker syndrome (SMA + Aorta compress on Left renal vein)
- Scrotal swelling, soft lumps
- Pain (occasionally)
- ***Heaviness in scrotum
- Infertility in adult

Investigation:
- Doppler USG: confirm diagnosis + exclude renal mass

Treatment:
- Laparoscopic ligation of testicular vein
- Ligation of spermatic vein via Inguinal incision
- Embolisation

Indications for surgery:
1. Testicular atrophy
2. Symptom
3. ?Subfertility