inguinoscrotal conditions

1. INGUINO-SCROTAL
CONDITIONS
DR SAMWEL ROMAN,MD
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2. Learning objectives
• By the end of this session, students are expected
to be able to
• Describe surgical anatomy of the inguinal canal
and scrotum.
• Examine the patient with inguino-scrotal
conditions.
• Diagnose different scrotal conditions.
• Describe surgical and non-surgical management.
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3. Outline
• Overview of groin anatomy
• Overview of hernia and other inguino-
scrotal conditions
• History taking
• Physical examination
• Treatment
• References
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4. Surgical anatomy of inguinal region and
inguinal canal.
Inguinal Canal
• It is an oblique passage through the lower
part of the anterior abdominal wall
• Approx 4cm long in adults
• Formed in relation to descent of testis
during fetal development.
• It commences at the deep inguinal ring, ends
at the superficial inguinal ring.
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5. Inguinal Canal
• The inguinal canal is made up of:
• Anterior and posterior walls
• Superficial and deep rings (openings)
• Roof and floor (or superior and inferior
walls)
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6. Inguinal Canal…
• Lies parallel to and
immediately above the
inguinal ligament
• Transmits the spermatic
cord in male and round
ligament of the uterus in
females
• Transmits ilioinguinal
nerve in both sexes
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7. Diagram of inguinal canal
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8. Functions of Inguinal Canal
• It allows structures of spermatic cord to pass
to and from the testis to the abdomen in male
• Permits the passage of round ligament of
uterus from the uterus to the labium majus in
female
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9. WALLS (BOUNDARIES) OF THE INGUINAL
CANAL
Floor
Medial
Lateral
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10. Anterior Wall of the inguinal canal
Medial
Superficial inguinal ring
Lateral
External Oblique
Internal Oblique muscle
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11. Anterior wall..
• Is formed by the
external oblique
aponeurosis, reinforced
laterally by internal
oblique muscle.
• This wall is strongest
where it lies opposite
the weakest part of
posterior wall, that is
deep inguinal ring
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12. Posterior wall of the inguinal canal
Deep inguinal ring
Medial
The posterior wall is formed by the strong conjoint tendon medially
and the weak transversalis fascia throughout. Where the deep
inguinal ring is formed at its lateral part.
Lateral
Conjoint tendon
medially
Posterior wall
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13. Inferior wall (Floor) of the inguinal
canal
Floor
Medial
The floor is formed by inrolling lower edge of the inguinal
ligament, reinforced medially by the lacunar ligament.
Lateral
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14. Superior wall (Roof) of the
inguinal canal
• Formed by arching lowest fibers of the internal
oblique and transversus abdominis muscles
(Conjoint Tendon).
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15. INGUINAL RINGS
Floor
Medial
Deep inguinal
ring
Superficial inguinal
ring
Lateral
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16. Diagram of inguinal canal
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17. INGUINAL RINGS….
• Is an opening in the transversalis fascia.
• It lies about 1.25cm above the midpoint of the
inguinal ligament.
• The internal inguinal ring is demarcated
medially by inferior epigastric vessels.
Internal inguinal ring
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18. INGUINAL RINGS ….
EXTERNAL (SUPERFICIAL) INGUINAL RING:
• Is a triangular shape defect in the external
oblique aponeurosis.
• Split in the fibers forming the lateral crus
attaches to the pubic tubercle and the medial
crus to the pubic crest.
• It lies immediately above and medial to the
pubic tubercle.
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19. Inguinal rings
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20. Mechanics of inguinal canal
• The inguinal canal in the lower part of the anterior
abdominal wall, is a site of potential weakness in both
sexes
• In adults the canal is an oblique passage with the
weakest areas, namely, the superficial and deep rings
– The anterior wall of the canal is reinforced by the fibers of the
internal oblique muscle immediately in front of the deep ring.
– The posterior wall of the canal is reinforced by the strong
conjoint tendon immediately behind the superficial ring.
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21. Mechanics of inguinal canal….
• On coughing and straining, as in micturition,
defecation, and parturition, the arching lowest fibers
of the internal oblique and transversus abdominis
muscles contract, flattening out the arched roof so
that it is lowered toward the floor.
• When great straining efforts may be necessary, as in
defecation and parturition, the person naturally tends
to assume the squatting position; the hip joints are
flexed, and the anterior surfaces of the thighs are
brought up against the anterior abdominal wall.
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22. STRUCTURES THAT PASSES
THROUGH THE CANAL
• Male:
–Spermatic cord.
–Ilioinguinal nerve.
• Female:
Round ligament of the uterus.
Ilioinguinal nerve.
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23. Spermatic cord
• The spermatic cord is a collection of structures that
pass through the inguinal canal to and from the
testis and the fascial coverings contributed by the
layers of the abdominal wall.
• Function is to suspend the testis in the scrotum
and contain structures running to and from the
testis.
• It begins at the deep inguinal ring lateral to the
inferior epigastric artery and ends at the testis
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24. Covering of spermatic cord
• Internal spermatic fascia
– Derived from Transversalis fascia at deep inguinal
ring.
• Cremasteric fascia & cremaster muscle.
• External spermatic fascia:
– acquired from external oblique aponeurosis as the
cord passes between the crura of the superficial
ring.
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25. Content of spermatic cord
• 1-Vas deferens.
• 3-Arteries: Testicular artery, Artery to Vas,
Cremasteric artery.
• 1-Veins: Pampiniform plexus.
• 1- Lymphatic vessel.
• 3-Nerves: Genital branch of Genitofemoral
nerve, ilio-inguino nerve and autonomic
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26. Blood supply of testis
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27. Wall of inguinal canal
• Anterior wall
– aponeurosis of the external oblique
– internal oblique muscle laterally.
• Posterior wall.
– transversalis fascia.
• The roof
– transversalis fascia,
– internal oblique
– transversus abdominis.
• Floor-Inguinal ligament
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28. Hernia
• A hernia is the
protrusion of an organ
through its containing
wall.
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29. Composition of a hernia
1. The sac
2. Covering of the sac
3. The content of the sac
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30. Composition of a hernia
• The sac;
• It is a diverticulum
of peritoneum and
is made up of three
parts:
– The mouth
– The neck
– The body of the
sac
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31. Composition of a hernia
• The covering
– Are delivered from the
layers of the
abdominal wall
through which the sac
pass
• Contents;
• Omentum(omentocele)
• Intestine(enterocele)
• Portion of circumference
of intestine(Richter’s
hernia)
• Portion of bladder
• Ovary(with or without
oviduct)
• Meckel’s
diverticulum(Littre’s
hernia)
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32. Etiologies of hernia
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• Hernia occurs at site of weakness in the
wall.
• This weakness maybe due to
– Normal (physiological) weakness ,related to
anatomical causes
– Congenital abnormality
– Acquired
• Trauma
• Diseases

33. Sequel of hernia
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34. Classification of hernia
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• External hernia
– Inguinal
– Femoral
– Epigastric
– Umbilical
– Incisional
– Rarely
• Spigelian
• Gluteal
• Obturator
• Lumbar
• Internal hernia

35. Internal hernia
• Diaphragmatic
hernia
–Esophageal
hernia
–Paraesophageal
hernia
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36. Classification of groin hernias.
• Anatomical classification.
– Femoral hernias.
– Inguinal hernias
• According to extent:
– Bubonocele.come out of superficial ring
– Incomplete.
– Complete.
• According to its site of exit.
– Indirect hernia
– Direct hernia.
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37. Groin hernia cont..
• According to its content:
– Enterocele
– Omentocele or epiplocele
– Cystocele.
• Etiological classification:
– Congenital
– Acqeired.
• Clinical classification:
– Reducible
– Irreducible
– Obstructed or incarcerated
– Strangulated
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38. Direct and Indirect hernia
• Direct inguinal hernias
–occur medial to the inferior epigastric
vessels
• Indirect inguinal hernias
–occur when abdominal contents protrude
through the deep inguinal ring, lateral to the
inferior epigastric vessels;
–This may be caused by failure of embryonic
closure of the processus vaginalis.
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39. Direct and Indirect hernia
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40. Hesselbech triangle
• Medial border: Lateral margin of the
rectus sheath, also called linea
semilunaris
• Superolateral border: Inferior
epigastric vessels
• Inferior border: Inguinal ligament,
sometimes referred to as Poupart's
ligament
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41. Hesselbach Triangle
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42. Clinical Classification
• Reducible- This is the one which the contents of
the sac reduced spontaneously or can be pushed
back manually.
• A reducible hernia imparts an expansile on
coughing.
• Irreducible- This is the one whose contents can
not be returned to the peritoneal cavity because
there are;
Adhesions between the sac and the contents
Narrow neck of the sac 42

43. Clinical Classification
• Irreducible hernia can be;
• 1. Incarcerated; There are adhesions between the
sac and the contents but there is no obstruction of
interference with blood supply, the hernia simply will
not reduce
• 2. Obstructed; A hollow viscus is trapped within the
sac and obstruction occurs. The blood supply remains
intact. This is the common cause of small bowel
obstruction
• 3. Strangulated; The arterial blood supply to contents
of the sac is compromised , in such a hernia unless a
surgical relief is under taken th contents of the sac will
become gangrenous
43

44. Inguinal Hernia
• Epidemiology
• Male to female ration 9:1
• Young adults mostly have indirect inguinal
hernia
• As age patient increases the incidence of direct
hernia increases
• In men Indirect >direct >femoral
• In women indirect > femoral > direct
• 60% Right side
44

45. Inguinal-hernia Risk factors
(increase in intra-abdominal pressure)
• Chronic cough
• Constipation
• Pregnancy
• Straining at micturition
• Severe muscular effort (lifting heavy objects)
• Ascites- fluid may increase the size of an existing
sac
45

46. Symptoms and Signs
• A lump disappears, reappears and enlarges on
straining and discomfort
• A burning, gurgling or arching sensation at the
bilge
• Pain or discomfort in the groin, especially when
bending over, cough or lifting
• A heavy or dragging sensation in the groin
• Weakness or pressure in your groin
• Reducible or irreducible
• Cough impulse +ve
• Can not go above it
• Bowel sound and peristalisis
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47. Diagnosis.
• History
• Physical examination.
• Imaging (Rare required)
47

48. Differential diagnosis.
• Malignancy:
– lympoma,retroperitoneal
sarcoma,metastatic,testicular tumor.
• Primary testicular
– hydrocele,varicocele,epidydimitis,undesended testes,
ectopic testical, testicular torsion.
• Lymph node.
• Psoas abscess.
48

49. Management
• Operative repaired both to relieve
symptoms and eliminate complications
• Surgical technique;
– Endoscopic
– Open
• Herniotomy
• Herniorrhaphy
• Hernioplasty
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50. Complication of hernia repair
• Reccurence
• Chronic groip pain
• Nociceptive
• Neuropathic
• Cord and testicular
• Ischemic orchitis
• Testicular atrophy
• Injury to the vas deferens
• Hydrocele
• Bowel and bladder injury
50

51. Scrotum and its content.
• Part of external male genitalia located behind
and beneath the penis
• Two layers: skin and dartos fascia.
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52. Testis
• Coverings
– Visceral and Parietal layers of the tunica vaginalis
testis represent peritoneum that surrounded the
testicle during its descent into the scrotum.
– Internal spermatic fascia (transversalis fascia)
– Cremasteric muscle and its fascia (internal
oblique and transversus abdominis)
– External spermatic fascia (from the external
oblique)
– Dartos fascia
– Skin
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54. Main function is sperm and testosterone production

55. Scrotal masses
• Painful scrotal masses
– Testicular torsion
– Epididymitis
– Inguinal hernia
– Testicular
tumor(rapidly
growing)
– Trauma (testicular
rupture)
• Painless scrotal masses
– Testicular tumor
– Hydrocele
– Inguinal hernia
– Spermatocele
– Varicocele
– Paratesticular tumor
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56. Hydrocele
• Normally, the processus vaginalis is
obliterated from the internal inguinal ring to
the upper scrotum, leaving a small potential
space in the scrotum that partially surrounds
the testis
• Embryologic misadventures may occur and
results in (hydrocele, hydrocele of the cord,
and communicating hydrocele).
56

57. Communicating hydrocele
• Simple (scrotal) hydrocele is an accumulation
of fluid within the tunica vaginalis
• Results from persistence of or delayed
closure of the processus vaginalis
• Commonly seen at birth, frequently bilateral,
may be quite large. They transilluminate and
may seem quite tense but not painful
• Most resolve during the first 2 years of life
• If surgical repair is elected, an inguinal
approach should be used.
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58. Hydrocele of the cord
• Segmental closure of the processus, which leaves
a loculated hydrocele of the cord.
• Presents as a painless groin mass which is mobile
and transilluminates
• Inguinal exploration and high ligation is curative.
58

59. Surgical management of hydrocele
• Hydrocelectomy-
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60. Acute scrotum/ Testicular pain
Differential diagnoses.
• Torsion testis
• Torsion appendix testis
• Torsion appendix epididymis
• Epididymo-orchitis
• Hernia
• Trauma
• Vasculitis
• Dermatological
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61. Testicular Torsion
• True surgical/urological emergency of the
highest order.
• Irreversible ischemic injury may begin as
soon as 4 hours after occlusion of the cord
• Intravaginal torsion, result from lack of
normal fixation of the testis and epididymis to
the fascial and muscular coverings that
surround the cord
• This creates an abnormally mobile testis that
hangs freely within the tunical space (a "bell-
clapper deformity")
61

62. Testicular Torsion
• Occurs in any age but most commonly in
pre-pubertal males
• Presentation: Pain, NauseaV, Poor
appetite, previous episodes
• Examination: Swelling, Tenderness, High
riding, transverse orientation, Loss of
cremasteric reflex
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63. Testicular Torsion
• Doppler US may help in the diagnosis
• Manual detorsion may be attempted
• Scrotal exploration is mandatory
• Detorte the affected testis and pex the other side
while waiting for the testis to pink up
• If the testis is still alive pex it , if not do an
orchiectomy
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64. Varicocele
• Dilated and tortuous veins of the
pampiniform plexus.
• Found in approximately 15% of male
adolescents, with a marked left-sided
predominance.
• Etiology: increased venous pressure in the
left renal vein, incompetent valves of the
internal spermatic vein.
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65. Varicocele
• Unilateral varicocele may affect testicular
function bilaterally
• Toxic effect of varicocele may manifest as
testicular growth failure, semen abnormalities,
Leydig cell dysfunction, and histologic changes
• Possible mechanisms: hyperthermia, hypoxia,
local testicular hormonal imbalance, and
intratesticular hyperperfusion injury.
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66. Varicocele
• Presentation: asymptomatic,pain,scrotal
mass, infertility,atrophy
• Grading on physical examination
• Obtain scrotal US.
• Treatment options-ligation.
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67. Cryptorchidism/undescended testis.
• 3% of full-term male newborns and 30.3% incidence
in premature infants
• More prevalent among preterm, small-for-gestational-
age, low-birth-weight, and twin neonates
• Approximately 70% to 77% of cryptorchid testes will
spontaneously descend by 3 months of age
• By 1 year of age, the incidence of cryptorchidism
declines to about 1% and remains constant
throughout adulthood
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68. Cryptorchidism/undescended testis.
• 3% of full-term male newborns and 30.3% incidence
in premature infants
• More prevalent among preterm, small-for-gestational-
age, low-birth-weight, and twin neonates
• Approximately 70% to 77% of cryptorchid testes will
spontaneously descend by 3 months of age
• By 1 year of age, the incidence of cryptorchidism
declines to about 1% and remains constant
throughout adulthood
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70. Nonpalpable testis
• Intra-abdominal
• Vanishing
• Atrophic
• Missed on examination
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71. Surgical Intervention f cryptorchidsm
• Inguinal orchiopexy
• Laparoscopic orchiopexy
• Fowler-Stephens orchiopexy/Staged
orchiopexy
• Microvascular autotransplantation
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72. CONT
• Swelling-Groin/scrotal
– Duration
– Onset-How did it appear, where, size
– Progression-slowly, rapidly growing
– Aggravating vs relieving factors, standing or
on lying flat
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73. History taking
• Pain/painless
–Duration
–Nature of pain
–Onset-acute or gradual
–Radiating, non radiating
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74. History
• Ask about symptoms a/w other related
conditions
– Difficulty in passing urine- BPE, u/s, phimosis
– Chronic cough- COPD, TB
– Abdominal pain,abdominal sweeling,constipation
and vomiting.
• Enquire about h/o surgery-Abdominal or
pelvic; weakened the abdominal wall
• Family h/o of groin or scrotal swellings-
Congenital vitamin C deficiency a/w
weakened abdominal wall
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75. Physical examination
• General examination-General condition,
lymphadenopathy
• Systemic examination-P/E, DRE, external
genitalia
• Local examination: Mass- Site, size, surface,
shape, consistency, margin, reducible,
irreducible, peristalsis
– Cough impulse test
– Transillumination test
– Flactuant test
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76. Physical Examination
• Inflammatory conditions-Skin over the
swelling Redness and edema, warm
tender eg- Epididymorchitis, epididymitis
• Malignancy- Non tender, hard, nodulated,
irrregular margins, ?? Calcified orchitis
• Benign conditions- Smooth, non tender,
regular margin, firm eg. hydrocele
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77. Hernia vs Hydrocele
• Reducibility
• Margins
• Trans-illumination-test
• Testicles palpability
• Cough impulse test
• Peristalsis/bowel sounds
• Get above it
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78. Investigations
• Hormones
• US
• CT
• MRI
• Laparoscopy
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79. Summary
• External hernia are mostly diagnosed
clinically.
• It is important to understand clinical
differences between hernia and hydrocele.
• Irreducible hernia should be treated
promptly to avoid forthcoming
complications.
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80. References
• Das-Texbook of clinical surgery 9th edition
• Manipal-Clinical surgery 4th edition
• Beley and love-Textbook of surgery 27th
ed.
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