By Tedler D. Depaynos, MD
The patient cannot recall exactly when he had the scrotal bulge but it was very noticeable when he was in high school. Throughout the years it gradually enlarged in size and he never sought any consultation. Actually he has been married for the past 12 years and has 2 daughters the eldest being 10 years old. He works as a security guard and drives a tricycle when off duty. Because of his enlarging scrotal bulge he claims that he has been avoiding heavy work.
He diagnosed himself to have an “hernia” but because of his condition, he always felt inhibited and uncomfortable. Despite the strong supporter he always wore, there were times when his bulge appeared noticeable. He denies however feeling any severe pain and he never experienced having it “reduced” or disappear.
It was his wife who finally urged him to undergo surgery and they had to come to this city where his wife assured him that nobody knew them. It is good that her sister knew a surgeon to whom they were referred to.
The “scrotal bulge” was left sided and it was very huge and the surgeon described it literally as “4 times” as big as his fist. No wonder his wife convinced him to undergo surgery! A simple ultrasound (UTZ) confirmed that it was an “indirect inguinal hernia”.
Testicles originate from the kidney area in the abdominal cavity and goes down into the scrotum before the male baby is born. Development in that area may suddenly stop so that the “testicular” canal where the testicle passes fails to close. The canal is actually called “inguinal” canal and since it is open, abdominal contents like intestines and/or fatty tissues may enter or “herniate” and eventually form a “bulge “at the inguinal area and may extend into the scrotal area.
The testicles may or may not have reached the scrotum when development stopped. They are then called “undescended testicles”. Hence in some cases, this scrotal “bulge” may be associated with only a singular testicle from the other side. Since the “bulge” is thru the “inguinal canal” it is termed “indirect hernia”. Bulges that appear in that area because of weakness of the abdominal wall is called “direct hernia”. The abdominal contents are pushing directly the weakened abdominal wall.
The defect then in “indirect hernias” is “congenital” and it is actually one of the most common congenital anomalies.
In some instances, the closure may not just be perfect so that with age and with constant increase of intra-abdominal pressure usually associated with the kind of work or activities of the individual, the pathway may eventually give way causing the hernia. This explains the late appearance of this kind of hernia in older children or young adults.
Normally, the left testicle descends earlier than the right. This is the reason why the left is lower. When development suddenly stops, the inguinal pathway on the right is commonly affected. Hence, hernia is more on the right. For this reason if the hernia is on the left, it is routinely presumed that it is also present in the right. .
In some cases then “inguinal indirect” hernias may be bilateral. They may not be obvious however. If one is found on the left and none is found on the right, some surgeons advocate exploring the right during the repair of the left because of the accepted sequence of the descent. If the left pathway did not close, surely the right pathway is also open or at least potentially open. This could be seen sometimes especially for those associated with undescended testicle on the left by ultrasound examination.
In some cases, the hernia contents cannot be returned or “reduced” into the abdominal cavity because swelling may have occurred. What is dangerous is that the blood supply of the hernia contents may be compromised or “strangulated” and if the contents are the intestines, intestinal gangrene may occur. This is termed “incarceration” and pain in this case is usually very severe and continuous. Operation in these cases are urgent and might be more complicated because they will not only consist of the repair of the hernia but also adequate resection of the “incarcerated intestines” if gangrene occurred due to delayed surgery.
In this patient, the hernia was felt when he was already going to school. Both of his testicular organs were present in the scrotum with the left lower than the right and obviously both were normal because he was able to sire 2 children. The defect may then just be failure of the left inguinal canal to close which eventually gave way.
He never felt any severe pain so that he never experienced “incarceration”. On opening up the patient, the hernia contents were all omentum or the fatty tissues of the intestines which to some extent he was lucky because they rarely “incarcerate”. Putting it back into the abdominal cavity or “reduction” was however difficult during surgery because of the volume and swelling. This was the reason why the scrotal bulge was 4 times as big as the surgeon’s fist. The surgeon was forced to resect part of it. He eventually assured the patient as well as the wife that with time the swollen huge scrotum will reduce in size and may just be as large as a fist.
With the large inguinal canal, the abdominal wall may also have weakened. The opening then was adequately repaired and a “mess” was applied where the fibrous tissues will eventually migrate strengthening the wall and preventing the appearance of a “direct hernia”. **