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Objectives

Objectives. To 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 Data. General Data Gabaldon , Luis Arnel Beltran 16 years old Male

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Objectives

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  1. Objectives • To 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

  2. Identifying Data • General Data • Gabaldon, Luis Arnel Beltran • 16 years old • Male • Student • Roman Catholic • Pasay City • Chief complaint • Bilateral inguinal mass

  3. History of Present Illness 2 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

  4. History of Present Illness 1 year PTC • Persistence of left inguinal mass • Progression of mass to scrotal area • Reducible • Right inguinoscrotalmass • ~ 2-3cm in diameter • More prominent on exertion, straining, defecation • Occasional pain, relieved by wearing supporters • Reducible

  5. History of Present Illness 1 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

  6. Past Medical History • Childhood: febrile convulsions • Multiple hospitalizations • Grade 2: chickenpox • (-) measles, mumps, primary complex • Claims to have complete childhood vaccinations • Claims to have no sexual contact • (-) surgeries • (-) allergies to food or medications

  7. Family History • Hypertension- father • DM, inguinal mass???- mother • (-) Cancer, lung diseases

  8. Personal-Social History • Non- smoker • Occasional alcohol drinker • No illicit drug use • 1st year college student • Dance and sports

  9. Review of Systems • General: (+) fatigue, (-) fever, weight loss or gain, weakness • Musculoskeletal/dermatologic: (-) lumps, itching, muscle or joint pains, joint swelling, changes in hair or nails

  10. Review of Systems • HEENT: (-) dizziness, deafness, blurring of vision, tinnitus, nosebleeds, hoarseness, frequent colds, dry mouth, gum bleeding, enlarged LNs • Respiratory: (+) cough, (-) dyspnea, hemoptysis, wheezing

  11. Review of Systems • Cardiovascular: (-) palpitations, chest pains, syncope, orthopnea • GI: (-) nausea, vomiting, changes in bowel habits, dysphagia, jaundice, rectal bleeding • GU: (-) nocturia, frequency

  12. Review of Systems • Endocrine: (-) excess sweat or thirst, heat or cold intolerance • Neuro: (-) seizures, loss of sensation

  13. Physical Examination • General 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

  14. 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.

  15. 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.

  16. Pulmonary • Normal shape. (-) lesions in anterior and posterior thorax. (-) Areas of tenderness. Resonant. Clear breath sounds, no crackles, rales, wheeze.

  17. 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.

  18. Gastrointestinal • Flat. (-) Lesions. Normoactive bowel sounds. (-) Tenderness. (-) Organomegaly. Tympanitic in all quadrants. Traube’s space empty. (-) CVA tenderness.

  19. 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

  20. 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; (+) transilluminationtest

  21. 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.

  22. Salient Features Subjective • 2 year history of L and R inguinoscrotal mass • Reducible • (+) Pain relieved by wearing supporters • (+) Activity hindrance

  23. Salient Features Objective • Bilaterally descended testes • 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; (+) transilluminationtest

  24. Salient Features Objective • L: no palpable mass; L external ring ~ 1 cm in diameter; (-) transillumination test • Normal DRE

  25. Impression • R hydrocoele, communicating • L indirect inguinal hernia, complete

  26. Differentials

  27. Management • Bilateral 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

  28. Procedure Done/ Intra-op findings • Bilateral 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 • Tramadol50mg/ mL q 8o 50 mg/tab q 8o • Mefenamic acid 500mg/ tab

  29. Inguinal hernia • Protrusion 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.

  30. Indirect inguinal hernia • Patent processusvaginalis • Reducible • 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

  31. Risk factors • Male • Family history • Chronic cough, constipation • Obesity • Pregnancy • Prematurity • Previous history of hernia

  32. Treatment • Supporters, bindings • Surgery • Herniotomy, herniorrhaphy • Laparoscopy

  33. Prognosis • Treatable • Risk of strangulation (7%) • Recurrence, urinary retention, wound infection, hydrocoele, scrotal hematoma

  34. Hydrocoele • Buildup of fluid between the two layers of the tunica vaginalis • Can lead to either a communicating hydroceleor an indirect inguinal hernia • Inguinal/ scrotal mass • (+) Transillumination • Risk factors similar to indirect inguinal hernia

  35. Treatment • Wait and see • Herniotomy • Contralateral exploration

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