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
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: 56
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 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
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 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.

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

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