By Tedler D. Depaynos, MD
The male patient is obviously a gym enthusiast with his bulges emphasized by his tight fitting shirt. During his childhood days he had a “cyst” at his right inguinal area which was neglected. Although it appeared to be getting bigger throughout the years, but because it was painless, no consultation was ever done. It was only when he started going to the gym that the “cyst” suddenly became bigger just like the bulges in his arms and extended into his right scrotal area. He was then forced to seek consultation.
He was diagnosed to have an “indirect inguinal hernia” which was easily confirmed by a simple ultrasound (UTZ).
During development, the testicles descend from the kidney area to the scrotal area. Normally, the pathway has to close. With non-closure, most commonly the small intestines and/or the fatty tissues (omentum) from the abdominal cavity descend following the tunnel causing the bulge. And this is the reason why it is called congenital “indirect hernia”. In “direct hernia” there is just weakness of the abdominal wall where the abdominal contents eventually cause it to bulge.
With non-closure of the pathway, the hernia bulge could be observed in babies especially when they cry. In some instances, the closure may not be so 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 just like in this patient.
Normally, the left testicle descends earlier than the right. This explains why the left is lower. When development suddenly stops, the pathway on the right is commonly affected. Hence, hernia is more on the right. If development is arrested before the descent of the testicle, the hernia is associated with undescended testicle. Fortunately for the patient both of his testicles could be palpated in the scrotum. This was also confirmed on the UTZ done.
In some cases, “inguinal indirect hernias” are bilateral. Sometimes they are not so obvious. If one is found on the left and none 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 UTZ examination.
Early surgery even in two weeks old babies with” indirect hernia” is practiced by most pediatric surgeons. This is to prevent the dreaded “incarceration” of hernia contents manifested by non-disappearance of the bulge and continuous crying of the baby due to pain. The hernia contents cannot be returned or “reduced” into the abdominal cavity and swelling may occur. The blood supply of the hernia contents may later be compromised or “strangulated” and if the contents are the intestines, intestinal gangrene may occur. Operation will be urgent and more complicated because it will not only consist of the repair of the hernia but also adequate resection of the affected intestines. In the patient he never complained of pain and strangulation never occurred because again he was lucky because the contents of his hernia were fatty tissues or “omentum”.
The function of the scrotum is to provide a temperature lower than that of the body so that the production of the sperm will not be impaired. Sperms cannot survive in body temperature. With the non- descent of the testicle therefore, the testicle cannot produce viable sperms because they are exposed to body temperature. It has to be brought down surgically into the scrotal sac. And this is preferably done before the child reaches four years of age for best results. Beyond four years, the testicle has a lesser chance of survival so that upon follow-up, when it is observed to be getting smaller or “atrophied”, it has to be removed or excised. When this was explained to the patient, he was with wide smiles and was tempted to palpate his scrotal sac.
Undescended testicle if left alone has a great tendency to become cancer called seminoma. The chance that it would become malignant in some Journals reaches up to 90%. It is better to be a little imperfect with a singular testicle than to have cancer later on in life that could have been prevented. And there is no truth to the belief that it would make you half manly.
The patient underwent a successful herniorrhaphy and upon discharge he did not only shook hands with his surgeon but gave him a hug. For a moment, the surgeon with graying hair was regretting that he did not increase his professional fee.**
