Inguinoscrotal hernia

Presentation

Good morning, sir. I examined a 62-year-old farmer who has had a swelling in the right groin for 8 years. It started small, appearing on lifting heavy loads and disappearing when he lay down, and has gradually extended into the scrotum. It now causes a dragging discomfort and interferes with farm work, but he has never had an episode in which it became painful and would not go back. He has poor urinary stream, hesitancy and nocturia twice a night, but no chronic cough or constipation. Standing, there is a 14 × 8 cm pear-shaped swelling in the right groin extending into the right hemiscrotum. It has an expansile cough impulse, is non-tender and soft, and I cannot get above it. The right testis is felt separately at the bottom. Lying down, it reduces completely upwards and laterally with a gurgle, and deep ring occlusion controls it. It is resonant with bowel sounds. The left groin, both femoral regions and the left testis are normal. His abdomen is otherwise normal. I would like to complete my examination with a digital rectal examination to assess the prostate.

Diagnosis

Right indirect, complete (inguinoscrotal), reducible inguinal hernia containing bowel, without complications, with lower urinary tract symptoms suggesting benign prostatic enlargement as a contributing factor.

Differential diagnoses

• Direct inguinal hernia — broad-based forward bulge, rarely reaches the scrotum, not controlled at the deep ring
• Pantaloon (combined direct and indirect) hernia — found at operation
• Large hydrocele — can get above it, transilluminates, no cough impulse, testis not separately palpable
• Hydrocele of the cord — oval swelling in the cord that moves with traction on the testis
• Varicocele — "bag of worms", left side more commonly, decompresses on lying
• Femoral hernia — below and lateral to the pubic tubercle; does not enter the scrotum
• Scrotal filariasis (lymphoscrotum, chylocele) — thickened scrotal skin, endemic areas, milky fluid

Investigations

Classification

Management

I would explain the nature of the hernia, the risks of watchful waiting and of surgery, and agree a plan with him. Because it is symptomatic and inguinoscrotal, I would recommend elective repair.

Non-pharmacological

• Treat prostatism before or alongside repair — urology review; he may need a catheter or prostatectomy if retention is likely after anaesthesia
• Stop smoking, lose weight, control constipation
• Watchful waiting is acceptable only for men with minimal symptoms; most (about 70%) eventually need surgery, and repairing an emergency hernia carries far higher mortality
• Avoid heavy lifting for 2–4 weeks after open repair, less after laparoscopic repair; resume normal activity as comfort allows
• A truss is not recommended except in patients unfit for surgery

Pharmacological

• Alpha-blocker (tamsulosin 400 micrograms daily) for prostatism
• Antibiotic prophylaxis is not required routinely for elective open mesh repair in low-infection settings, but a single dose of cefazolin is reasonable where SSI rates are high
• Analgesia: paracetamol and NSAIDs, local anaesthetic infiltration or ilioinguinal block
• VTE prophylaxis according to risk

Surgical and interventional

• Lichtenstein tension-free mesh repair — the standard open repair, under local, spinal or general anaesthesia. Recurrence about 1–4%
  1. Groin incision, divide external oblique aponeurosis, protect the ilioinguinal nerve
  2. Mobilise the cord; identify, dissect and reduce or transfix the indirect sac
  3. Lightweight polypropylene mesh fixed to the pubic tubercle (with overlap), along the inguinal ligament and to the conjoint tendon, with a slit around the cord
• Laparoscopic repair (TEP or TAPP) — for bilateral and recurrent hernias after open repair, and a good option for primary unilateral hernias; less chronic pain and faster return to work; needs general anaesthesia and expertise
• Tissue repair (Shouldice, or Desarda) when mesh is not available or is contraindicated (contaminated field)
• Very large inguinoscrotal hernias — open repair is usually preferred; a large sac in the scrotum may be divided and left open distally to reduce haematoma
• Emergency repair of an obstructed or strangulated hernia — resuscitate, nasogastric tube, catheter, antibiotics; open the sac, inspect the bowel after releasing the constriction (warm packs), resect non-viable bowel; mesh can still be used in a clean-contaminated field without resection

Complications and follow-up

• Early: haematoma and scrotal swelling, seroma, urinary retention, wound infection
• Late: chronic postoperative inguinal pain (about 10%, severe in 1–3%) from ilioinguinal, iliohypogastric or genital nerve injury; recurrence; ischaemic orchitis and testicular atrophy from cord injury; mesh infection; injury to the vas deferens
• Emergency repair: bowel resection, anastomotic leak, higher mortality

Review at 2–6 weeks for the wound and pain, then discharge with advice to return if the swelling recurs.

Examiner questions

References

• O'Connell PR, McCaskie AW, Sayers RD, eds. Bailey & Love's Short Practice of Surgery. 28th ed. Boca Raton: CRC Press; 2023.
• HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22:1–165.