TITLE OF CASE
A 6 month old male who presented with a scrotal mass
AUTHORS OF CASE
Ayesha Younas, MD,FAAP*
Pediatrician, Avera St. Luke’s Hospital
Aberdeen, SD, USA, 57401
Dr.Suleman Younas, MD
Medical Registrar,
Department of Medicine,
Waitakere Hospital,
Lincoln Road, Henderson, Auckland, NZ
SUMMARY
Case of a 6 month old male infant who presented to the clinic for an upper respiratory infection.
During the examination a large scrotal mass was seen predominantly on the left side that was
previously known to be bilateral congenital hydroceles. However on this day’s exam, a solid
mass was felt and bowel sounds were heard over it. On further physical exam and investigations
an inguinal hernia was discovered. The infant was admitted to the ward and surgery was
performed with left inguinal hernia reduction and bilateral mesh repair.
An inguinal hernia is more common in male infants. It may be reducible, irreducible or
incarcerated. Gangrene or necrosis may develop in an inguinal hernia where the intestinal blood
supply is impaired. It almost always requires surgical repair.
BACKGROUND
This is an important case that emphasizes the importance of careful examination of scrotal
masses in infants. Even though this is not an unusual presentation of inguinal hernia in infants, it
is an important diagnosis. If missed, it can lead to significant morbidity. This case report
reminds one not to miss the common but important condition of scrotal mass due to an inguinal
hernia.
Primary inguinal hernia occurs in 1 to 5 percent of all newborns and 10 percent of those born
prematurely. The incidence increases with lower birth weight. The incidence is highest during
the first year of life and peaks during the first month. The incidence in boys is higher than in
girls, with the right side being affected more commonly in both sexes. This is due to the later
descent of the right testicle and later obliteration of the processus vaginalis. The incidence of
bilateral hernias is approximately 10 percent in full-term infants with hernias and nearly 50
percent in premature and low-birth-weight infants with hernias.
This case represents the differences in clinical presentations between different scrotal masses
and the importance of early clinical recognition of an incarcerated hernia to improve the infant’s
outcome.
CASE PRESENTATION
This 6 month old male presented to the clinic for an upper respiratory infection. During
examination, it was observed that he had large bilateral scrotal masses predominantly on the left
side that did not seen to be causing him any discomfort. The mother stated that these masses
were present since birth and that a scrotal ultrasound soon after birth had revealed them to be
bilateral hydroceles.
Figure 1
On physical examination this was an alert 6 month old male in no acute distress. HR
130/min and regular, RR29/min and regular, tem 98.9F. Saturating 98% in room air.
The mass was examined on visual inspection the scrotum was seen to be somewhat lumpy in
appearance with no overlying color change. The masses combined were approximately the size
of a tennis ball and involving both sides. However the mass was bigger and more lumpy on the
left side. On palpation it was felt to be solid, non tender, non compressible and non reducible.
The right side felt somewhat compressible. Every time the infant coughed or strained, the mass
neither increased nor decreased in size. The mass did not transilluminate on the left side and did
transilluminate on the right side. When auscultated, bowel sounds could be faintly heard on the
left side. No pulse was palpated over the mass.
The rest of the physical exam including cardiac, respiratory, gastrointestinal and neurologic
examination was normal.
Figure 2
The infant was not feeding well as per mother and last had passed stool one day before
coming to clinic. He was passing urine frequently. Otherwise, the mother reported no changes in
the infant’s behavior.
The infant was born via normal vaginal delivery at full term and with no intrauterine or
postpartum complications. He was observed to have a large compressible mass in the delivery
room approximately the same size as at this presentation. It transilluminated bilaterally. A scrotal
USG in the newborn nursery revealed bilateral large hydroceles. The parents were reassured as
to the benign nature of the mass and that it usually regresses.
The infant lived at home with his parents and sister. No other significant past medical
history and no significant family history.
INVESTIGATIONS
Initial investigations included a CBC with differential and a basic metabolic panel that were
normal.
Figure 3
Figure 4
Figure 5
USG of the Scrotum: The testes are within the scrotum bilaterally and appear normal, measuring
up to 1.5 cm each. Normal color Doppler flow identified to each testis. Hydroceles surround each
testis. The right hydrocele measures up to 3.8 x 2.4 x 1.8 cm. The left hydrocele measures up
to 4 x 2.9 x 2 cm.
In order to confirm the diagnosis and help convince the parents an abdominal x ray was
performed.
Figure 6
DIFFERENTIAL DIAGNOSIS
This 6 month old male presented with a painless scrotal mass at 6 months of age. This could
possibly be a hydrocele (fluid collection occurring anywhere along the past of descent of a testis
or an ovary) or a spermatocele (painless fluid dilled cyst of the head of the epididymus), an
inguinal hernia, a retractile testicle, testicular cancer or a varicocele[1]. Hydroceles,
spermatoceles or a varicoceles are compressible. Hydroceles and spermatoceles transilluminate.
A testicular cancer does present as a painless testicular mass. However, the presence of bowel
sounds over the mass made it more likely to be an indirect inguinal hernia. The clinical diagnosis
of an inguinal hernia if missed can lead to bowel strangulation and bowel perforation whereas a
spermatocele, varicocele, hydrocele or a retractile testicle may be present all through life without
causing any significant side effects. A testicular cancer may have serious consequences if
ignored.
A retractile testicle can be brought down with slight pressure but this mass was not movable
as by now the hernia had incarcerated. A femoral hernia is a painless mass that is located at the
top of the thigh whereas an inguinal hernia is located above it.
Other conditions that can look like an inguinal hernia could be torsion of the testis, torsion
of the appendix testis or epididymitis which are all associated with pain and swelling. The
cremasteric reflex is absent on the affected side in a testicular torsion and a tender blue dot
appears on the upper pole of the affected testicle in torsion of the appendix testis. These
conditions can be serious especially torsion of the testis or epididymitis. Torsion of the appendix
testis usually does not affect the testicular perfusion.
A scrotal USG is a noninvasive method of differentiating between all the above conditions.
Laboratory studies or extensive imaging studies are generally not necessary in differentiating
them from each other.
TREATMENT
Suspecting an incarcerated indirect inguinal hernia, a surgical consult was called. The surgeon
confirmed the above findings. He initially tried manual reduction of the hernia which was
unsuccessful after 2 attempts. He stated that this was a case of a bilateral incarcerated indirect
inguinal hernia.
The patient was taken to the operating room where successful reduction of the indirect
inguinal hernia with bilateral mesh repair was performed.
The infant was sent to the ward for observation. The next day feeding with water and then
milk were started. He tolerated this well. He was advanced to baby food and tolerated well. Then
he was discharged home to follow up in clinic the next day.
OUTCOME AND FOLLOW-UP
The infant was started on fluids and advanced to foods the day after the surgery and tolerated
well. He was discharged home 1 day after the hernia repair and was tolerating well oral fluids
and baby food. He continued to do well at home after discharge and was followed up in
pediatrics clinic and surgical clinic where the scrotal swelling did not appear again and the infant
had no further complaints.
DISCUSSION
A hydrocele is a fluid filled collection that can occur somewhere along the path of descent of
an ovary or a testis.
A hernia is when a portion of an organ or a tissue protrudes through an abnormal opening in
the wall that contains it.
Incarceration means a hernia that cannot be reduced by manipulation. An incarcerated hernia
may or may not be strangulated.
Strangulation is actually the vascular compromise of the contents of an incarcerated hernia,
caused by progressive edema from venous and lymphatic obstruction.[2]
Figure 7
Figure 8 [3]
An inguinal hernia arises from persistence of a patent processus vaginalis (a projection of the
peritoneum which accompanies the testis as it descends into the scrotum). In females, the projection of
peritoneum accompanies the round ligament.
An inguinal hernia may be direct or indirect. Indirect inguinal hernias are far more common in
males and females. They develop at the internal inguinal ring and are more common on the right side.
Direct inguinal hernias form through the Hasselbach’s triangle and are more common with a weakness in
the abdominal wall.
Figure 9
Primary inguinal hernia occurs in 1 to 5 percent of all newborns and 10 percent of those
born prematurely. Among children with incarcerated inguinal hernias, as many as 85 percent occur
before the first birthday.
Femoral hernias are more common in females and are less common than inguinal hernias but
strangulate or incarcerate more commonly.
The incidence of incarceration ranges from 14 to 31 percent, usually occurring in infants
younger than one year of age. Incarceration occurs more frequently in girls (17.2 %) compared
with boys (12 %).
Inguinal hernias are more common in children with abdominal wall defects (Eagle-Barrett
[prune belly] syndrome), ventriculoperitoneal shunts, ascites, chronic respiratory disease,
connective tissue disease ( Ehlers-Danlos syndrome), abnormalities of the genitourinary system
(ambiguous genitalia, hypospadias, bladder exstrophy, cryptorchid testis). Complete androgen
insensitivity is more common in infants with inguinal hernias.
The presentation of children with inguinal hernias varies from case to case. Most children
with an inguinal hernia present with no mass. The parents describe a history of an infant who
gets an intermittent inguinal mass. Many times inguinal hernias present with a reducible mass
that has not spontaneously reduced. Incarcerated or obstructed hernia is when the hernia mass is
irreducible. However it then develops erythema of the overlying skin with tenderness. The
testicle may appear dark blue due to venous congestion from pressure on the spermatic cord.
Certain investigations can be used to diagnose an inguinal hernia though they are not
necessary and it is usually a clinical diagnosis. Imaging is usually not necessary in the diagnosis
of an inguinal hernia. However, USG is 90% accurate in diagnosing an inguinal hernia.
Laboratory evaluation is generally not diagnostic. [4]
Definite treatment [5] is always surgical. It should be repaired as soon as possible to avoid
strangulation. Inguinal hernias in females are rare however may contain reproductive organs and
manual reduction should not be attempted.
Incarcerated or strangulated hernias are a surgical emergency [6]. Elective hernia repair
after manual reduction has better outcome. Elective repair is done within 2-5 days of a successful
hernia reduction to prevent reherniation.
Bowel infarction as a result of strangulation is the most serious side effect of strangulation.
Infarction can occur within 2 hours after incarceration.
Recurrence of hernia occurs in 5% after surgical repair. Risk factors for recurrence
include malnutrition, ascites, cystic fibrosis, raised intra abdominal pressure due to
ventriculoperitoneal shunt.
Differential diagnosis of painless scrotal mass in children[7]
MASS
PALPATION
TRANSILLUMINATION
Tumour
Varicocele
Noncommunicating
hydrocele
Spermatocele
Firm
Fluid-filled
Fluid-filled
No
No
Yes
EFFECT OF
VALSALVA
MANUEVER
No
Yes
No
Fluid-filled
Yes
No
Inguinal hernia
Solid
No
Yes
A similar case report was published by the International Journal of Urology (2004)11,
789–791 Case Report Torsion of the hernia sac within a hydrocele of the scrotum in a child
by AKIHIKO MATSUMOTO, YUTAKA NAGATOMI, MASATO SAKAI AND MASAYA
OSHI who reported the case of a 10-year-old boy who presented with pain and swelling of his
right scrotum. Ultrasonography revealed a hypo echoic region adjacent to the normal right testis.
The inflammatory changes of the right scrotum persisted. The patient underwent surgery and a
necrotic cyst was recognized within a hydrocele of the scrotum. The cyst was not connected with
the testis or epididymis and was twisted at an angle of 270 degrees. The cause of the necrotic
cyst observed was anatomical and pathological torsion of the hernia sac.
LEARNING POINTS/TAKE HOME MESSAGES
- Inguinal hernias are a very common condition that specially occurs in premature infants.
-
Even though it is easy to recognize clinically but sometimes it can be missed early in the
course.
Inguinal hernias can mimic other causes of scrotal swelling and thus complications such
as incarceration or strangulation can occur.
The diagnosis of inguinal hernias is mostly clinical and costly and time consuming
investigations are usually not needed.
Parents and caregivers should be given appropriate education by health care providers
regarding the onset of an inguinal hernia and signs of incarceration or strangulation
especially in presence of large hydroceles
REFERENCES
1. Aiken JJ. Inguinal hernias. In: Nelson Textbook of Pediatrics, 17th, Behman RE,
Kliegman RM, Jenson HB. (Eds), Saunders, Philadelphia 2004. p.1293.
2. Paidas C, Kayton ML. inguinal hernia. In:Oski’s Pediatrics: Principles and Practice, 4th,
McMillan JA, DeAngelis CD, Feigin RD, et al. (Eds), Lippincott William and Wilkins,
Philadelphia 2006. P.1925.
3. Langman, J. Urogenital system. In: Medical Embryology, 4th ed, Williams and Wilkins,
Baltimore 1981. p.264
4. From Kapphahn, C, Schlossberger, N. Diagnostic approach to scrotal masses. Adolescent
Health Update 1992; 5:1.
5. Clark M. Hernia reduction. In: Textbook of Pediatric Emergency Procedures, 1st,
Henretig FM, King C. (Eds), Williams & Wilkins, Baltimore 1997. p.927.
6. Spurbeck WW, Prasad R, Lobe TE. Two year experience with minimally invasive herniorrhaphy
in children. Surg Endosc 2005; 19:551
7. Shalaby R, ismail M, Dorgham a, et al. laparoscopic hernia repair in infancy and childhood:
evaluation of 2 different techniques. J pediatr Surg 2010; 45:2210.
Figure captions
Figure 1: Bilateral large hydroceles at birth
Figure 2: Left indirect inguinal hernia at 6 months
Figure 3: USG at birth to assess for scrotal masses showing bilateral hydroceles.
Figure 4: Normal Doppler color flow is identified to each testicle.
Figure 5: Normal Doppler color flow is identified to each testicle.
Figure 6: X ray abdomen showing large scrotal mass with air in loops of bowel in left
hemiscrotum.
Figure 7: A noncommunicating hydrocele (there is no connection between the hydrocele and the
peritoneum; the fluid comes from the mesothelial lining of the tunica vaginalis ).
Figure 8: A patent processus vaginalis allows open communication between the peritoneal cavity
and the scrotum.
Figure 9: Indirect inguinal hernias develop at the internal inguinal ring and are lateral to the
inferior epigastric artery. Direct inguinal hernias occur through Hesselbach's triangle (outlined in
blue) formed by the inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the
rectus muscle medially. Femoral hernias develop in the empty space at the medial aspect of the
femoral canal, inferior to the inguinal ligament.
PATIENT’S PERSPECTIVE
The parents reported that they did not expect the mass to turn out to be an inguinal hernia. They felt very
glad that it had been recognized in time and that appropriate care had been provided thus avoiding potential
complications such as bowel strangulation or even perforation.