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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 - PowerPoint PPT Presentation
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The Case of the Mysterious
MassAndrew Williams
Ken KonciljaAravind 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
• 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
Gross AnatomyInguinal 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
Contains 3 layers
External spermatic fascia: from external oblique muscle
Cremasteric muscle: from internal oblique muscle
Internal spermatic fascia: from transversalis fascia
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 HerniasIndirectLeaves abdominal cavity lateral
to inferior epigastric vessels Enters deep inguinal ring and
runs inside spermatic cord Sac formed from persistent
processus vaginalis
DirectLeaves abdominal cavity medial to inferior epigastric vessels, through inguinal triangleTravels through medial portion of inguinal canal, runs parallel to spermatic cordSac 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.
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• 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.