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Overview Testicular pain, or any pain in one or both sides of the scrotum (sac that holds the testicles), should be taken seriously. Pain in the scrotum can occur in males of any age, including newborns. The testicles, or testes, are the two male reproductive glands that produce sperm. These glands are very sensitive and even a minor injury can cause pain or discomfort. Many types of testicular or scrotal pain need medical attention. Testicular or scrotal pain that is sudden or severe, pain that is associated with a puncture wound, pain that occurs with swelling after an injury and lasts more than one hour, and pain that is accompanied by nausea or vomiting are emergencies and require immediate medical attention. Pain or tenderness in the scrotum that is associated with a lump, fever, unusual warmth or redness, blood in urine (hematuria), unusual discharge from the urethra, mumps exposure, or chronic pain should be reported to a doctor as soon as possible. If untreated, some conditions can lead to infertility, erectile dysfunction (ED), severe or chronic pain, or cause tissue death that may make removal of the testicle necessary. Anatomy In some cases, the actual source of testicular pain is not the testicles, but a structure located in the scrotal region. The testes, or testicles, are the two male reproductive glands that produce sperm. Located above each testicle is an epididymis, another important part of the sperm development process. The epididymes are more prone to infection than the testicles. The scrotum is the sac that holds and protects the testes and epididymes. The perineum is the area between the scrotum and the anus. Groin is a term often mistakenly used interchangeably with testicles or scrotum. However, groin technically refers to the fold or line between the abdomen and inner thigh, and the term may also be used to refer to this general region. Testicular Pain Causes The main causes for testicular or scrotal pain include the following:
Infection or inflammation the most common condition related to testicular inflammation and infection is epididymitis (inflammation of one or both epididymes). As the epididymis is attached to the testicle, infection often spreads to the testicle (called epididymoorchitis). Orchitis is inflammation of the testicle, which only rarely occurs by itself. These conditions, which can occur at any age, may cause severe, sudden pain. Most infections related to scrotal pain in adolescent and young adult males are caused by sexually-transmitted bacterial infections, especially chlamydia and gonorrhea.
Trauma or injury Sports injuries are common causes of testicular trauma. A puncture wound or pain that continues more than one hour after blunt force to the scrotum should be treated as a medical emergency. Lumps found after an injury may or may not be related to the injury. In fact, tumors are commonly discovered when the testicles are examined after an injury. Especially because testicular cancer is easily treated if found early, any lump should be assessed by a doctor as soon as possible.
Torsion
o
Testicular torsion is a relatively rare, urgent situation in which the spermatic cord twists, blocking blood flow to the testicles. Testicular torsion causes acute (severe) scrotal pain and swelling. It can lead to tissue death that requires removal of the affected testicle(s) if not treated within 5-6 hours. It most commonly occurs in newborns and adolescent males under 18, but can occur at any age. Torsion of testicular appendages (e.g., testicular appendix, epididymis appendix) may feel similar to testicular torsion, but involves twisting of unnecessary appendages that are remnants from embryonic development. It is more common in boys who have not yet entered puberty, and is a leading cause of acute scrotal pain in boys. Proper diagnosis is urgent in order to rule out testicular torsion, but torsion of testicular appendages is not itself an emergency. The pain usually subsides within one week with no complications.
o
Other causes for pain in the scrotal area include the following:
Testicular tumors Testicular tumors do not usually cause pain, but it is possible. Since testicular cancer is common in young men (between the ages of 18 and 32) and is often cured if treated early, prompt medical attention to any lump is important. Inguinal hernia In an inguinal hernia, part of the intestines protrudes through the inguinal canal (passageway connected to the scrotum). Inguinal hernia is suspected if swelling or pain above the scrotum worsens with coughing, sneezing, movement, or lifting. This condition is fairly common, especially in young boys, and it occasionally causes pain in the scrotal area. Premature infant boys have the highest risk for inguinal hernia. This condition usually results from an abdominal wall weakness present at birth, but symptoms may not appear until adulthood.
Hernias do not resolve without treatment and may cause serious complications if not treated. Hernia repair surgery is usually required to treat this condition.
Pudendal nerve damage Pudendal nerve damage (neuropathy), also called "bicycle seat neuropathy," may cause numbness or pain. Pudendal nerve damage can result from the pressure of prolonged or excessive bicycle riding (e.g., competitive cycling), especially improper seat position or riding techniques are used. Special bicycle seats have been designed to decrease pressure on the perineum, potentially preventing or resolving this problem. Pudendal neuralgia is the painful type of this nerve damage. Sometimes called "cyclist's syndrome," pudendal neuralgia is painful inflammation of the pudendal nerve. The pudendal nerve carries sensations to the genitals, urethra, anus, and perineum (area between the scrotum and anus), so the pain can be felt in any of these areas. Pain can be piercing and is more likely to be noticed while sitting. According to The Society for Pudendal Neuralgia, pudendal neuralgia also may result from structural abnormalities, repetitive stress from sports or chronic constipation, or surgery. If untreated, nerve damage can lead to erectile dysfunction or problems with bowel movements or urination, such as involuntary loss of feces or urine (e.g., urinary incontinence).
Surgery Temporary testicular pain and swelling can be expected after surgical procedures in the pelvic area, such as hernia repair and vasectomy. Post-surgery pain that lasts longer than expected should be reported to a physician. Chronic or recurring pain may be the result of a surgical complication or an unrelated problem, and may need treatment. Kidney stones Stones usually cause abdominal pain, but the pain radiates into the testicular area in some cases. Intense, sudden, and severe pain in the scrotum that cannot be explained by a problem in the scrotum may be caused by kidney stones. Swelling with mild discomfort Conditions that cause swelling in the scrotal area also may occasionally result in mild discomfort. These conditions include varicocele, hydrocele, and spermatocele. Many cases are benign (mild and non-threatening), but swelling and discomfort in the scrotal area should be addressed by a doctor. If a hydrocele (an abnormal fluid-filled sac around the testicles) becomes infected, it can lead to epididymitis, which can cause severe pain. Unrelieved erection An erection that does not end in ejaculation sometimes can cause a dull ache in the testicles. This minor ache, commonly called "blue balls," is harmless and usually goes away within a few hours or when ejaculation occurs.
Diagnosis Doctors may use the following tests to determine the cause of pain in the testicles or scrotum:
Physical examination Ultrasound of testicles Urinalysis Examination of prostate secretions
Depending on the initial findings and the patient history, additional tests may be used. These tests include magnetic resonance imaging (MRI) scan, prostate exam, urethral smear (to check for presence of chlamydia and gonorrhea), blood tests, and testicular scan. Exploratory surgery may be necessary if testicular torsion cannot be ruled out by other tests. Treatment Treatment for testicular or scrotal pain depends on the diagnosis. It may involve selfcare at home, pain relief medication, antibiotics for a bacterial infection, untwisting of the testicles by a doctor, or surgery (e.g., to treat testicular torsion, hernia, varicocele). Self-care for scrotal pain may include over-the-counter pain relievers (e.g., ibuprofen), applying ice to the scrotum, and reduced activity, placing a rolled towel under the scrotum while lying down, and wearing scrotal support. Prevention Some types of testicular or scrotal pain can be prevented. The following measures may be helpful:
Practice safer sex to prevent sexually transmitted infections. Protect the scrotal area from injury by wearing a protective cup or athletic supporter while playing sports. Limit repetitive stress on the perineum and pudendal nerve, which may occur with excessive bicycling or weight-lifting. Perform regular testicular self-exams for early detection of tumors. Promptly treat urinary tract infections (UTIs) and prostatitis, and address any underlying causes. Learn about prevention of urinary tract infections and kidney stones.
Introduction Strangulated Inguinal hernia is one of the most common surgical emergencies dealt with by surgeons worldwide. Usually the narrow internal inguinal ring or the external inguinal ring is the site of constriction of the viscus, which forms the content of the hernia resulting in strangulation. We report a rare case of strangulated inguinal hernia where the constricting element is not the internal or external inguinal ring, but an omental band adhesion causing closed loop small bowel obstruction and gangrene within the hernial sac in the inguinal canal. Case Report A 56 year old Caucasian gentleman presented with a six hour history of a non-reducible tender lump in his right inguinal region. He was known to have bilateral inguinal hernia for the past three months and was waiting for an elective repair. His past medical history includes systemic hypertension for which he is on anti-hypertensive medications. There is no history of previous abdominal operations or any episodes of abdominal sepsis. On clinical assessment, his temperature was 37.5 degree Celsius, heart rate was 90 beats per minute and blood pressure was 130/90 mm of Hg. Local examination revealed a 15 cm × 7 cm sized non-reducible tender swelling in his right inguinal region with no cough impulse. Contralateral side revealed a non-tender, reducible inguinal hernia. Examination of the abdomen revealed mild distension. Blood biochemistry results were as follows: Haemoglobin 14.5 gm/dl, White cell count 25,000 cells/mm, Neutrophil count 22,500 cells/mm, Urea 4.0 mmol/L, Creatinine 68 mmol/L, Potassium 4.0 mmol/L, Sodium 135 mmol/L, C – Reactive protein 67 mg/l. Plain abdominal x-ray showed multiple loops of distended small bowel seen centrally in the abdomen consistent with distal small bowel obstruction. He was taken to the operation theatre urgently with a diagnosis of strangulated inguinal hernia and the right inguinal region was explored under general anaesthesia. Gangrenous small bowel of 20 cm with closed loop obstruction caused by a single omental band adhesion was noted. The neck of the hernial sac at the level of the internal inguinal ring as such was found to be very wide. The omental band adhesion was divided and the gangrenous small bowel was resected and primary stapled anastomosis was performed through the same inguinal incision. The widened internal inguinal ring was narrowed and the posterior wall of the inguinal canal was repaired with sutures rather than mesh due to the presence of infection. The patient made an uneventful post-operative recovery and was discharged home on the third post-operative day. Histology of the resected specimen was reported as transmural infarction of the small bowel with viable resection margins and no evidence of intravascular thrombosis or vasculitis. He was followed up in the out-patient clinic four weeks later and found to have no problems and has been booked for an elective hernia repair on the contralateral side. Discussion Strangulated Inguinal hernia is one of the common surgical emergencies dealt with by surgeons worldwide and it is one of the most common causes of intestinal obstruction in all age groups. There are various intra-abdominal conditions, which can present within the inguinal hernial sac and clinically mimic as strangulated inguinal hernia. Of note, pathologies like obstructed and perforated sigmoid tumors have been reported in the
literature on many occasions manifesting as strangulated inguinal hernia. Sigmoid diverticular abscess presenting as strangulated inguinal hernia has also been reported. Other conditions like acute pancreatitis and bilioma secondary to spontaneous rupture of biliary system have also been reported as manifesting clinically as strangulated inguinal hernia. Omental band adhesion causing small bowel obstruction and gangrene within the inguinal hernial sac and clinically presenting as strangulated inguinal hernia is one another type of this special clinical entity. To the best of our knowledge, this is the first ever case reported in the world literature of such type. Omental band adhesion causing acute small bowel obstruction inside the general peritoneal cavity is a very well recognized entity. The aetiology of the omental band formation could be congenital, adhesions secondary to previous operations, inflammation etc., the most likely explanation in our case, though not impossible in his age, would be congenital as he did not undergo any abdominal operations in the past and there was no history of any inflammatory abdominal conditions. Most of the other pathological conditions develop inside the general peritoneal cavity and then track along the normal anatomical pathways and enter the inguinal hernial sac. In women, sigmoid diverticular abscess can track along the round ligament and enter the inguinal canal mimicking as strangulated inguinal hernia. Bilious fluid secondary to peptic ulcer perforation and spontaneous biliary perforation and pancreatic fluid collections secondary to pancreatitis enter the inguinal hernial sac through the internal ring. Hence one should be cautious in making a decision to explore the inguinal canal in such situations, as most of the times; the situation resolves when the primary pathology settles down. Nevertheless, anyone presenting with clinical features of strangulated inguinal hernia with small bowel obstruction mandates prompt surgical exploration of the inguinal canal as was done in our case. Most of the times, small bowel resection can be performed safely through the inguinal incision if the viability of the necessary extent of the bowel could be assessed in a satisfactory manner.
Expert: Arthur Goldstein, M.D. - 12/19/2005 Question Hello, I am a 28 year old male. About 3 months ago, I began feeling pain in the right side of my scrotum. I went to my doctor, who ran some urine tests and found nothing, but gave me antibiotics to treat epididymitis. The antibiotics (amoxycilin) had no effect. I went back and was given a longer course of antibiotics (Trimethoprim). Midway through the course, I went to a GUM clinic to discuss the problem. A swab was taken and we discussed the symptoms and again a diagnosis of epididymitis was given, I was given a month's worth of another antibiotic (I forget the name of it). This helped a little and some of the swelling went down on my right testicle. But the pain had not fully gone and has now returned to about the same as it was at its worst before I started taking the last course of anti-biotics. I returned to the GUM clinic who have referred me for an ultrasound scan. I am just curious; do these symptoms sound as though they could be caused by a cancer? Neither myself nor any of the 3 doctors who have performed an examination of my testicles have found a lump. Could it be that I needed a longer course of antibiotics? (I had two nights during the month where I drank alcohol. I was led to believe by a pharmacist relative that I would be safe to drink as long as there was no warning about alcohol in the informational leaflets which come with the antibiotics). If these symptoms are caused by a cancer; how quickly do they grow? am I in any danger that it has taken 3 months to get to a stage where an ultrasound has been requested? Any help would be greatly appreciated. I'm a little worried now, and wished I'd asked more questions when I was told I was being referred for an ultrasound. Thanks in advance, Martin Answer Martin, the most common cause of these complaints is an inflammation of the prostate gland, so called prostatitis. Symptoms that might occur with prostatitis include frequency of urination, slowing of the urinary stream, burning with voiding or ejaculation, burning in the penile tip unrelated to voiding, sexual dysfunction (such as difficulty with erection), aching in the penis, testicles, and discomfort in the lower abdomen, low back, groin, rectum or perineum (the area between the scrotum and rectum – betwixt the “wind and the rain”). Often, the only symptom one experiences is referred pain in the testicle. On other occasions, infection can spread from the prostate into the epididymis causing epididymitis. In this case, the affected testicle typically become enlarged and painful
and the overlying scrotal red and edematous (so that the normal scrotal folds are temporarily lost). The prostate is the organ that produces the majority of the semen in response to sexual stimulation. At the time of orgasm, the prostate contracts and forces its fluid into the urethra (urinary canal). Too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horseback riding, and excessive spicy foods, alcohol, and caffeine in the diet can predispose you to this. One should avoid any of the above that apply and ejaculate in moderation (about once or twice a week). Ejaculation beyond the tolerance of the prostate to fill and empty may also cause discomfort. Likewise if one does so infrequently, fluid still builds up from thoughts, dreams, fantasies, etc. and has to be released periodically to decompress the gland and relieve the symptoms. Whether epididymitis or prostatitis, the treatment is essentially the same. A daily warm bath for 10-15 minutes also lessens the discomfort. Attention to sexual activity and warm bathes should be utilized regardless of the type of prostatitis and whether or not medications are prescribed. There are several types of prostatitis. Sometimes prostatitis can be due to an infection of the gland with bacteria. This usually requires an initial 4 week course of an appropriate antibiotic (the commonest prescribed are the fluoroquinolones, but tetracyclines, sulfas and other agents can also work). Typically, pus cells and bacteria are found in the prostatic fluid. Abacterial prostatitis has several varieties. In one, the prostatic fluid demonstrates pus cells but no bacteria. In the other, called prostadynia, there are neither pus cells nor bacteria in the fluid, just the symptoms. In all types of prostatitis, the urinalysis generally is normal unless the infection spreads into the bladder. Abacterial prostatitis usually responds to the general measures mentioned above. Medications that sometimes help include the over-the-counter natural supplement saw palmetto 320 mgm daily and alpha blockers (such as Flomax, Hytrin & Cardura). The latter require a prescription from your physician if he thinks it is indicated. Prostatitis may also be classified as acute (severe), subacute (mild), or asymptomatic. It may also occur as a single episode, be recurrent or chronic. A man should learn to listen to his body. The ultrasound of your scrotum will most likely be normal. Cancer of the testicle (or prostate) do not usually present in the manner you describe. However, it is reasonable to do one to ensure their normality. Good luck!
Conclusion Strangulation of the inguinal hernial content is usually due to the tight constriction at the level of internal inguinal ring or at external inguinal ring. Uncommonly strangulation of the contents can occur due to other causes like omental band adhesion. Anyone presenting with clinical features of strangulated inguinal hernia with small bowel obstruction mandates prompt exploration of the inguinal canal. Although it may not change the treatment approach, one should be aware about this special entity. Resection of the gangrenous small bowel and primary anastomosis can be safely performed through the same inguinal incision.
Reaction Strangulated Inguinal hernia is one of the most common surgical emergencies dealt with by surgeons worldwide. Usually the narrow internal inguinal ring or the external inguinal ring is the site of constriction of the viscus, which forms the content of the hernia resulting in strangulation. We report a rare case of strangulated inguinal hernia where the constricting element is not the internal or external inguinal ring, but an omental band adhesion causing closed loop small bowel obstruction and gangrene within the hernial sac in the inguinal canal. This kind of disease can be prevented if a person practice safer sex to prevent STDs, protect the scrotal area from injury by wearing a protective cup or athletic supporter while playing sports, limit repetitive stress on the perineum and pudendal nerve, which may occur with excessive bicycling or weight-lifting, perform regular testicular selfexams for early detection of tumors,promptly treat urinary tract infections (UTIs) and prostatitis, and address any underlying causes, learn about prevention of urinary tract infections and kidney stones. These are just simple ways in order to prevent this disease. The great tragedy is that many hernias are allowed to degenerate to the point where only surgery can resolve the problem. With an appropriate support, exercises and other treatments, resolve the problem without allowing it to get worse. There is absolutely no reason why a hernia cannot be cured in a matter of months, as long as you get it diagnosed immediately, get a support that fits and does not invaginate the hernia, practice the dietary and herbal recommendations and do the exercises and make sure you take a good steady walk every day – there is nothing like walking for strengthening the lower abdomen.
Readings
(WVSUMC (SLR))
Submitted By: Alicaya, Colleen L. BSN III-C
Submitted To: Mrs. Claire L. Occeño, R.N. Clinical Instructor
Infection or inflammation the most common condition related to testicular inflammation and infection is epididymitis (inflammation of one or both epididymes). As the epididymis is attached to the testicle, infection often spreads to the testicle (called epididymoorchitis). Orchitis is inflammation of the testicle, which only rarely occurs by itself. These conditions, which can occur at any age, may cause severe, sudden pain. Most infections related to scrotal pain in adolescent and young adult males are caused by sexually-transmitted bacterial infections, especially chlamydia and gonorrhea.
Trauma or injury Sports injuries are common causes of testicular trauma. A puncture wound or pain that continues more than one hour after blunt force to the scrotum should be treated as a medical emergency. Lumps found after an injury may or may not be related to the injury. In fact, tumors are commonly discovered when the testicles are examined after an injury. Especially because testicular cancer is easily treated if found early, any lump should be assessed by a doctor as soon as possible.
Torsion
o
Testicular torsion is a relatively rare, urgent situation in which the spermatic cord twists, blocking blood flow to the testicles. Testicular torsion causes acute (severe) scrotal pain and swelling. It can lead to tissue death that requires removal of the affected testicle(s) if not treated within 5-6 hours. It most commonly occurs in newborns and adolescent males under 18, but can occur at any age. Torsion of testicular appendages (e.g., testicular appendix, epididymis appendix) may feel similar to testicular torsion, but involves twisting of unnecessary appendages that are remnants from embryonic development. It is more common in boys who have not yet entered puberty, and is a leading cause of acute scrotal pain in boys. Proper diagnosis is urgent in order to rule out testicular torsion, but torsion of testicular appendages is not itself an emergency. The pain usually subsides within one week with no complications.
o
Other causes for pain in the scrotal area include the following:
Testicular tumors Testicular tumors do not usually cause pain, but it is possible. Since testicular cancer is common in young men (between the ages of 18 and 32) and is often cured if treated early, prompt medical attention to any lump is important. Inguinal hernia In an inguinal hernia, part of the intestines protrudes through the inguinal canal (passageway connected to the scrotum). Inguinal hernia is suspected if swelling or pain above the scrotum worsens with coughing, sneezing, movement, or lifting. This condition is fairly common, especially in young boys, and it occasionally causes pain in the scrotal area. Premature infant boys have the highest risk for inguinal hernia. This condition usually results from an abdominal wall weakness present at birth, but symptoms may not appear until adulthood.
Hernias do not resolve without treatment and may cause serious complications if not treated. Hernia repair surgery is usually required to treat this condition.
Pudendal nerve damage Pudendal nerve damage (neuropathy), also called "bicycle seat neuropathy," may cause numbness or pain. Pudendal nerve damage can result from the pressure of prolonged or excessive bicycle riding (e.g., competitive cycling), especially improper seat position or riding techniques are used. Special bicycle seats have been designed to decrease pressure on the perineum, potentially preventing or resolving this problem. Pudendal neuralgia is the painful type of this nerve damage. Sometimes called "cyclist's syndrome," pudendal neuralgia is painful inflammation of the pudendal nerve. The pudendal nerve carries sensations to the genitals, urethra, anus, and perineum (area between the scrotum and anus), so the pain can be felt in any of these areas. Pain can be piercing and is more likely to be noticed while sitting. According to The Society for Pudendal Neuralgia, pudendal neuralgia also may result from structural abnormalities, repetitive stress from sports or chronic constipation, or surgery. If untreated, nerve damage can lead to erectile dysfunction or problems with bowel movements or urination, such as involuntary loss of feces or urine (e.g., urinary incontinence).
Surgery Temporary testicular pain and swelling can be expected after surgical procedures in the pelvic area, such as hernia repair and vasectomy. Post-surgery pain that lasts longer than expected should be reported to a physician. Chronic or recurring pain may be the result of a surgical complication or an unrelated problem, and may need treatment. Kidney stones Stones usually cause abdominal pain, but the pain radiates into the testicular area in some cases. Intense, sudden, and severe pain in the scrotum that cannot be explained by a problem in the scrotum may be caused by kidney stones. Swelling with mild discomfort Conditions that cause swelling in the scrotal area also may occasionally result in mild discomfort. These conditions include varicocele, hydrocele, and spermatocele. Many cases are benign (mild and non-threatening), but swelling and discomfort in the scrotal area should be addressed by a doctor. If a hydrocele (an abnormal fluid-filled sac around the testicles) becomes infected, it can lead to epididymitis, which can cause severe pain. Unrelieved erection An erection that does not end in ejaculation sometimes can cause a dull ache in the testicles. This minor ache, commonly called "blue balls," is harmless and usually goes away within a few hours or when ejaculation occurs.
Diagnosis Doctors may use the following tests to determine the cause of pain in the testicles or scrotum:
Physical examination Ultrasound of testicles Urinalysis Examination of prostate secretions
Depending on the initial findings and the patient history, additional tests may be used. These tests include magnetic resonance imaging (MRI) scan, prostate exam, urethral smear (to check for presence of chlamydia and gonorrhea), blood tests, and testicular scan. Exploratory surgery may be necessary if testicular torsion cannot be ruled out by other tests. Treatment Treatment for testicular or scrotal pain depends on the diagnosis. It may involve selfcare at home, pain relief medication, antibiotics for a bacterial infection, untwisting of the testicles by a doctor, or surgery (e.g., to treat testicular torsion, hernia, varicocele). Self-care for scrotal pain may include over-the-counter pain relievers (e.g., ibuprofen), applying ice to the scrotum, and reduced activity, placing a rolled towel under the scrotum while lying down, and wearing scrotal support. Prevention Some types of testicular or scrotal pain can be prevented. The following measures may be helpful:
Practice safer sex to prevent sexually transmitted infections. Protect the scrotal area from injury by wearing a protective cup or athletic supporter while playing sports. Limit repetitive stress on the perineum and pudendal nerve, which may occur with excessive bicycling or weight-lifting. Perform regular testicular self-exams for early detection of tumors. Promptly treat urinary tract infections (UTIs) and prostatitis, and address any underlying causes. Learn about prevention of urinary tract infections and kidney stones.
Introduction Strangulated Inguinal hernia is one of the most common surgical emergencies dealt with by surgeons worldwide. Usually the narrow internal inguinal ring or the external inguinal ring is the site of constriction of the viscus, which forms the content of the hernia resulting in strangulation. We report a rare case of strangulated inguinal hernia where the constricting element is not the internal or external inguinal ring, but an omental band adhesion causing closed loop small bowel obstruction and gangrene within the hernial sac in the inguinal canal. Case Report A 56 year old Caucasian gentleman presented with a six hour history of a non-reducible tender lump in his right inguinal region. He was known to have bilateral inguinal hernia for the past three months and was waiting for an elective repair. His past medical history includes systemic hypertension for which he is on anti-hypertensive medications. There is no history of previous abdominal operations or any episodes of abdominal sepsis. On clinical assessment, his temperature was 37.5 degree Celsius, heart rate was 90 beats per minute and blood pressure was 130/90 mm of Hg. Local examination revealed a 15 cm × 7 cm sized non-reducible tender swelling in his right inguinal region with no cough impulse. Contralateral side revealed a non-tender, reducible inguinal hernia. Examination of the abdomen revealed mild distension. Blood biochemistry results were as follows: Haemoglobin 14.5 gm/dl, White cell count 25,000 cells/mm, Neutrophil count 22,500 cells/mm, Urea 4.0 mmol/L, Creatinine 68 mmol/L, Potassium 4.0 mmol/L, Sodium 135 mmol/L, C – Reactive protein 67 mg/l. Plain abdominal x-ray showed multiple loops of distended small bowel seen centrally in the abdomen consistent with distal small bowel obstruction. He was taken to the operation theatre urgently with a diagnosis of strangulated inguinal hernia and the right inguinal region was explored under general anaesthesia. Gangrenous small bowel of 20 cm with closed loop obstruction caused by a single omental band adhesion was noted. The neck of the hernial sac at the level of the internal inguinal ring as such was found to be very wide. The omental band adhesion was divided and the gangrenous small bowel was resected and primary stapled anastomosis was performed through the same inguinal incision. The widened internal inguinal ring was narrowed and the posterior wall of the inguinal canal was repaired with sutures rather than mesh due to the presence of infection. The patient made an uneventful post-operative recovery and was discharged home on the third post-operative day. Histology of the resected specimen was reported as transmural infarction of the small bowel with viable resection margins and no evidence of intravascular thrombosis or vasculitis. He was followed up in the out-patient clinic four weeks later and found to have no problems and has been booked for an elective hernia repair on the contralateral side. Discussion Strangulated Inguinal hernia is one of the common surgical emergencies dealt with by surgeons worldwide and it is one of the most common causes of intestinal obstruction in all age groups. There are various intra-abdominal conditions, which can present within the inguinal hernial sac and clinically mimic as strangulated inguinal hernia. Of note, pathologies like obstructed and perforated sigmoid tumors have been reported in the
literature on many occasions manifesting as strangulated inguinal hernia. Sigmoid diverticular abscess presenting as strangulated inguinal hernia has also been reported. Other conditions like acute pancreatitis and bilioma secondary to spontaneous rupture of biliary system have also been reported as manifesting clinically as strangulated inguinal hernia. Omental band adhesion causing small bowel obstruction and gangrene within the inguinal hernial sac and clinically presenting as strangulated inguinal hernia is one another type of this special clinical entity. To the best of our knowledge, this is the first ever case reported in the world literature of such type. Omental band adhesion causing acute small bowel obstruction inside the general peritoneal cavity is a very well recognized entity. The aetiology of the omental band formation could be congenital, adhesions secondary to previous operations, inflammation etc., the most likely explanation in our case, though not impossible in his age, would be congenital as he did not undergo any abdominal operations in the past and there was no history of any inflammatory abdominal conditions. Most of the other pathological conditions develop inside the general peritoneal cavity and then track along the normal anatomical pathways and enter the inguinal hernial sac. In women, sigmoid diverticular abscess can track along the round ligament and enter the inguinal canal mimicking as strangulated inguinal hernia. Bilious fluid secondary to peptic ulcer perforation and spontaneous biliary perforation and pancreatic fluid collections secondary to pancreatitis enter the inguinal hernial sac through the internal ring. Hence one should be cautious in making a decision to explore the inguinal canal in such situations, as most of the times; the situation resolves when the primary pathology settles down. Nevertheless, anyone presenting with clinical features of strangulated inguinal hernia with small bowel obstruction mandates prompt surgical exploration of the inguinal canal as was done in our case. Most of the times, small bowel resection can be performed safely through the inguinal incision if the viability of the necessary extent of the bowel could be assessed in a satisfactory manner.
Expert: Arthur Goldstein, M.D. - 12/19/2005 Question Hello, I am a 28 year old male. About 3 months ago, I began feeling pain in the right side of my scrotum. I went to my doctor, who ran some urine tests and found nothing, but gave me antibiotics to treat epididymitis. The antibiotics (amoxycilin) had no effect. I went back and was given a longer course of antibiotics (Trimethoprim). Midway through the course, I went to a GUM clinic to discuss the problem. A swab was taken and we discussed the symptoms and again a diagnosis of epididymitis was given, I was given a month's worth of another antibiotic (I forget the name of it). This helped a little and some of the swelling went down on my right testicle. But the pain had not fully gone and has now returned to about the same as it was at its worst before I started taking the last course of anti-biotics. I returned to the GUM clinic who have referred me for an ultrasound scan. I am just curious; do these symptoms sound as though they could be caused by a cancer? Neither myself nor any of the 3 doctors who have performed an examination of my testicles have found a lump. Could it be that I needed a longer course of antibiotics? (I had two nights during the month where I drank alcohol. I was led to believe by a pharmacist relative that I would be safe to drink as long as there was no warning about alcohol in the informational leaflets which come with the antibiotics). If these symptoms are caused by a cancer; how quickly do they grow? am I in any danger that it has taken 3 months to get to a stage where an ultrasound has been requested? Any help would be greatly appreciated. I'm a little worried now, and wished I'd asked more questions when I was told I was being referred for an ultrasound. Thanks in advance, Martin Answer Martin, the most common cause of these complaints is an inflammation of the prostate gland, so called prostatitis. Symptoms that might occur with prostatitis include frequency of urination, slowing of the urinary stream, burning with voiding or ejaculation, burning in the penile tip unrelated to voiding, sexual dysfunction (such as difficulty with erection), aching in the penis, testicles, and discomfort in the lower abdomen, low back, groin, rectum or perineum (the area between the scrotum and rectum – betwixt the “wind and the rain”). Often, the only symptom one experiences is referred pain in the testicle. On other occasions, infection can spread from the prostate into the epididymis causing epididymitis. In this case, the affected testicle typically become enlarged and painful
and the overlying scrotal red and edematous (so that the normal scrotal folds are temporarily lost). The prostate is the organ that produces the majority of the semen in response to sexual stimulation. At the time of orgasm, the prostate contracts and forces its fluid into the urethra (urinary canal). Too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horseback riding, and excessive spicy foods, alcohol, and caffeine in the diet can predispose you to this. One should avoid any of the above that apply and ejaculate in moderation (about once or twice a week). Ejaculation beyond the tolerance of the prostate to fill and empty may also cause discomfort. Likewise if one does so infrequently, fluid still builds up from thoughts, dreams, fantasies, etc. and has to be released periodically to decompress the gland and relieve the symptoms. Whether epididymitis or prostatitis, the treatment is essentially the same. A daily warm bath for 10-15 minutes also lessens the discomfort. Attention to sexual activity and warm bathes should be utilized regardless of the type of prostatitis and whether or not medications are prescribed. There are several types of prostatitis. Sometimes prostatitis can be due to an infection of the gland with bacteria. This usually requires an initial 4 week course of an appropriate antibiotic (the commonest prescribed are the fluoroquinolones, but tetracyclines, sulfas and other agents can also work). Typically, pus cells and bacteria are found in the prostatic fluid. Abacterial prostatitis has several varieties. In one, the prostatic fluid demonstrates pus cells but no bacteria. In the other, called prostadynia, there are neither pus cells nor bacteria in the fluid, just the symptoms. In all types of prostatitis, the urinalysis generally is normal unless the infection spreads into the bladder. Abacterial prostatitis usually responds to the general measures mentioned above. Medications that sometimes help include the over-the-counter natural supplement saw palmetto 320 mgm daily and alpha blockers (such as Flomax, Hytrin & Cardura). The latter require a prescription from your physician if he thinks it is indicated. Prostatitis may also be classified as acute (severe), subacute (mild), or asymptomatic. It may also occur as a single episode, be recurrent or chronic. A man should learn to listen to his body. The ultrasound of your scrotum will most likely be normal. Cancer of the testicle (or prostate) do not usually present in the manner you describe. However, it is reasonable to do one to ensure their normality. Good luck!
Conclusion Strangulation of the inguinal hernial content is usually due to the tight constriction at the level of internal inguinal ring or at external inguinal ring. Uncommonly strangulation of the contents can occur due to other causes like omental band adhesion. Anyone presenting with clinical features of strangulated inguinal hernia with small bowel obstruction mandates prompt exploration of the inguinal canal. Although it may not change the treatment approach, one should be aware about this special entity. Resection of the gangrenous small bowel and primary anastomosis can be safely performed through the same inguinal incision.
Reaction Strangulated Inguinal hernia is one of the most common surgical emergencies dealt with by surgeons worldwide. Usually the narrow internal inguinal ring or the external inguinal ring is the site of constriction of the viscus, which forms the content of the hernia resulting in strangulation. We report a rare case of strangulated inguinal hernia where the constricting element is not the internal or external inguinal ring, but an omental band adhesion causing closed loop small bowel obstruction and gangrene within the hernial sac in the inguinal canal. This kind of disease can be prevented if a person practice safer sex to prevent STDs, protect the scrotal area from injury by wearing a protective cup or athletic supporter while playing sports, limit repetitive stress on the perineum and pudendal nerve, which may occur with excessive bicycling or weight-lifting, perform regular testicular selfexams for early detection of tumors,promptly treat urinary tract infections (UTIs) and prostatitis, and address any underlying causes, learn about prevention of urinary tract infections and kidney stones. These are just simple ways in order to prevent this disease. The great tragedy is that many hernias are allowed to degenerate to the point where only surgery can resolve the problem. With an appropriate support, exercises and other treatments, resolve the problem without allowing it to get worse. There is absolutely no reason why a hernia cannot be cured in a matter of months, as long as you get it diagnosed immediately, get a support that fits and does not invaginate the hernia, practice the dietary and herbal recommendations and do the exercises and make sure you take a good steady walk every day – there is nothing like walking for strengthening the lower abdomen.
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Submitted By: Alicaya, Colleen L. BSN III-C
Submitted To: Mrs. Claire L. Occeño, R.N. Clinical Instructor
