Hernia and Approach to Testicular Pain

1. Hernia and Approach to
Testicular Pain/Swelling
Ivan Hedson

2. HERNIA

3. Hernia
• Definition - a protrusion of a structure through a weakness or
opening in the wall of a surrounding cavity.

4. Hernia

5. Inguinal Hernia
• Most common irrespective of gender, with umbilical, hiatal and
femoral hernias ranking next.
• (~75% of all hernia cases) Males > Females
• Two Types:
• Direct
• Indirect

6. Direct Inguinal Hernia
• Acquired Condition
• Weakening of the transversalis
fascia
• Conditions causing increased
intraabdominal pressure (e.g.
COPD w/ Chronic Cough,
Constipation, BPH, Ascites)
• Chronic use of steroids
• Anatomy – within Hesselbach
Triangle protruding through
superficial ring. Only surrounded
by external spermatic fascia

7. Indirect Inguinal Hernia
• Congenital Condition
(Male>Female)
• Incomplete obliteration of the
processus vaginalis during
development
• Associated with communicating
hydrocele
• Anatomy – Through deep
inguinal ring through inguinal
canal to the superficial ring. (in
men, along with spermatic cord)

8. Clinical Features/Diagnosis
• Clinical Diagnosis – History and Examination
• History
• Reducible when lying down.
• Not reducing when lying down.
• Strangulated Symptoms (Inflamed with Bowel Obstruction features)
• Underlying Causes
• Examination
• Palpation of the inguinal canal
• Signs of underlying causes
• Imaging
• Ultrasound

9. Clinical Features: Uncomplicated vs Complicated
• Uncomplicated
• History
• Painless groin swelling
• Increase in size when
coughing/straining
• Reduced when lying supine
• Physical Examination
• Palpate over inguinal ligament and
ask to cough or perform Valsalva
maneuver
• Palpable bulge confirms inguinal
hernia

10. Clinical Features: Uncomplicated vs Complicated
• Complicated
• Irreducible (Incarcerated) – Contents cannot be pushed back. Skin overlying
hernia is normal
• Obstructed – Symptoms of mechanical bowel obstruction (pain, N&V,
distention, constipation or obstipation)
• Strangulated – Severe groin pain caused by constriction and ischemia (or
necrosis). Skin overlying hernia is inflamed(warm, red, tender-may exfoliate
or blister)

11. Management
• Uncomplicated Inguinal Hernia
• Watchful waiting, treat underlying causes, suggest elective surgery
• Complicated Inguinal Hernia
• Incarcerated/Irreducible without Strangulation: Consider manual reduction of
the hernia
• If successful, close monitor, discuss the situation with specialist for admission to consider
hernia repair surgery
• If unsuccessful, urgent surgery indicated for high risk of strangulation>Ischemia
• Incarcerated/Irreducible with Strangulation: Immediate referral for
emergency surgery
• To reduce the likelihood of hernial contents becoming gangrenous > bowel resection

12. Treatment
• SURGERY – only definitive treatment
• Herniaplasty (Mesh Repair)
• Open vs Closed (Laparascopy)

13. TESTICULAR SWELLING/PAIN

14. Testicular Pain/Swelling
• Pain
• Testicular Torsion
• Epididymitis
• Superficial (Skin Related)
• Swelling
• Testicular Tumour
• Hydrocele
• Varicocele
• Spermatocele
• Hernia

15. Testicular Pain
Condition History Examination Investigation Treatment
Testicular
Torsion
Sudden Pain (<24h)
Unilateral
N&V
Inflamed
Abnormal Position
Negative Prehn
Negative Cremesteric
Non tender Spermatic Cord
*Not routinely done
Lab: Urinalysis
Imagine: Ultrasound of
the Scrotum
Emergency should be
treated within 6 hours qof
symptoms for the best
chance of testicular
salvage.
Manual Detorsion may be
attempted prior to
surgery to relief but
should not delay transfer.
Epididymitis Gradual
- Acute (<6 weeks)
- Chronic(>6 weeks)
Painful Swelling with
induration
Associated with Urethral
Discharge
Fever, dysuria, urinary
frequency
Very Tender
Positive Prehn Sign
Cremesteric Reflex
Tender Spermatic Cord
Clinical Diagnosis
Lab: Urinalysis with
Culture – Pyuria or
Bacteriuria
NAAT and Gram Stain(not
in Fiji)
USS: R/O Torsion or
Scrotal Abscess
Suspected UTI – treat
accordingly
Suspected STI – treat
accordingly

16. Testicular Swelling
Condition History Examination Investigation Treatment
Tumour Slow Progression
- Weeks to
Months
Sometimes
painless, +/-
unilateral swelling
Mass Felt
Possible limb swelling of the
same side
Negative Illumination Test
Lab: Tumour Markers
(AFP/HCG/LDH)
Image: USS - Solid mass with
variable echogenicity.
Vessels appearance.
Surgery with Adjuvant
Radiotherapy.
Hydrocele Fluctuant painless
swelling
Elastic swelling on palpation
Positive Illumination Test
Image: USS (confirmatory)
Hypoechoic mass around
testes.
Conservative
Surgery indicated if no
resolution
Varicocele Dull aching
swelling
Typically left side
Reduced when lying supine
Visible or palpable “Bag of
Worms”
Negative Illumination Test
Dilated hypoechoic
Pampiniform vessels
Conservative
w/management of cause
Spermatocele Painless swelling Fluctuant swelling over the head
of the testes
Positive illumination Test
Hypoechoic dilation of the
epididymal ducts
Conservative