The case of the mysterious mass
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The Case of the Mysterious Mass. Andrew Williams Ken Koncilja Aravind Reddy Meghan Kaumaya. Patient and Chief Complaint. 12 year old male with walnut size enlargement left of pubic tubercle Enlargement changes with body position and activity level

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The Case of the Mysterious Mass

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The case of the mysterious mass

The Case of the Mysterious Mass

Andrew Williams

Ken Koncilja

Aravind Reddy

Meghan Kaumaya


Patient and chief complaint

Patient and Chief Complaint

  • 12 year old male with walnut size enlargement left of pubic tubercle

  • Enlargement changes with body position and activity level

  • Exacerbated by weight training, “barely noticeable” in the morning

  • Physical exam revealed normal size and position of external genitalia


Physical exam

Vital Signs

Pulse: 80

Rhythm: Regular

Temperature: 98.4 F

Respiratory Rate: 15

Height: 5’6”

Weight: 110 lbs.

Physical Examination

HEENT: Normal

Lungs: Normal

Cardiovascular: Normal

Abdomen: Small palpable mass in groin, lateral to pubic tabercle

Genitourinary: Normal

Musculoskeletal: Normal

Neurological: Normal

Physical Exam


Gross anatomy

Gross Anatomy

  • Inguinal Canal

  • Oblique intermuscular passage through inferior anterior abdominal wall

  • Contains spermatic cord in males, round ligament in females

  • Extends from deep inguinal ring (lateral) to the superficial inguinal ring (medial), both rings are lateral to the pubic tubercle

  • Boundaries

  • Anterior: External abdominal oblique aponeurosis

  • Posterior: Transversalis fascia, conjoined tendon

  • Floor: Inguinal ligament

  • Roof: Internal abdominal oblique and transverse abdominal muscles


Spermatic cord

Spermatic Cord

Contains 3 layers

External spermatic fascia: from external oblique muscle

Cremasteric muscle: from internal oblique muscle

Internal spermatic fascia: from transversalis fascia


Possible causes

Possible Causes

  • Neoplasm: Unlikely

  • Fluid build up: Hydrocele (communicating or non-communicating) of testis or cord, hematocele of testis, varicocele

  • Inguinal Hernia: Direct or Indirect


Types of inguinal hernias

Types of Inguinal Hernias

Indirect

Leaves abdominal cavity lateral to inferior epigastric vessels

Enters deep inguinal ring and runs inside spermatic cord

Sac formed from persistent processus vaginalis

Direct

Leaves abdominal cavity medial to inferior epigastric vessels, through inguinal triangle

Travels through medial portion of inguinal canal, runs parallel to spermatic cord

Sac formed by peritoneum and transversalis fascia

Less common


Congenital or acquired

Congenital

Processus Vaginalis does not seal after the descent of the testes

Fluid or intestines occupy the space in the inguinal canal left open by the patent processus

The processus vaginalis remains patent in 25% of adults

Indirect are far more common in younger males

Acquired

Exercise or strain can induce a direct hernia

Direct Hernias are more common in males over 40

Problem lies in a weak falx inguinalis (conjoint tendon) either by trauma or lack of exercise.

Congenital or Acquired?


Diagnosis and plan

Diagnosis and Plan

  • Indirect or Direct hernia or Communicating Hydrocele.

  • Determine with further testing, use illumination to rule out hydrocele

  • Avoid sports and heavy lifting until repaired

  • Requires surgical treatment: be cautious of ilioinguinal nerve and genitofemoral nerve


References

References

  • Deveney Karen E, "Chapter 32. Hernias & Other Lesions of the Abdominal Wall" (Chapter). Doherty GM: CURRENT Diagnosis & Treatment: Surgery, 13e: http://www.accessmedicine.com/content.aspx?aID=5310246.

  • Albanese Craig T, Sylvester Karl G, "Chapter 43. Pediatric Surgery" (Chapter). Doherty GM: CURRENT Diagnosis & Treatment: Surgery, 13e: http://www.accessmedicine.com/content.aspx?aID=531604.Albanese Craig T, Sylvester Karl G, "Chapter 43. Pediatric Surgery" (Chapter). Doherty GM: CURRENT Diagnosis & Treatment: Surgery, 13e: http://www.accessmedicine.com/content.aspx?aID=5316074.

  • Moore, Keith L., Dalley, Arthur F., Agur, Anne M.  Clinically Oriented Anatomy.  6th ed.  Baltimore: Lippincott Williams & Wilkins; 2010. 

  • Moore, Keith L., Persaud, T.V.N. The Developing Human: Clinically Oriented Embryology. 8th ed. Philadelphia: Saunders; 2008.

  • Edelman D.S., Selesnick H.: “Sports” hernia: Treatment with biologic mesh (Surgisis). A preliminary study.  Surg Endosc  2006; 20(6):971-973

  • Saad Samy, Duckett Olly, "Chapter 139. Urologic and Gynecologic Problems in Children" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: http://0-www.accessmedicine.com /content.aspx?aID=598506.


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