By Tedler D. Depaynos, MD
The patient is just 23 years old and works as a private miner in a nearby municipality which makes him carry heavy sacks of mined soil. He claims that his “scrotal bulge” is just 3 months old although it looks like it has been there for quite some time. He was accompanied by her mother who is a vacationing OFW who obviously convinced him to seek treatment.
We could recall another patient who was a mason that also required him to carry heavy sacks of cement. The mason was noticed from time to time by his co-workers to be suddenly lying down in pain in a secluded area and massaging his scrotum. At first they thought that he was doing something that made them smile and even laugh as they whisper among themselves. When the patient seems to be doing it more often especially after carrying heavy loads like cement and bags of sand, their smiles disappeared for obviously there was something wrong. A “bulge” appears from time to time in his scrotal area and he has to massage and push it back into the abdominal cavity to obtain relief. When he was brought to a surgeon by his employer because of continuous pain he was diagnosed to have an “incarcerated 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 or fatty tissues may enter or “herniate” and eventually form a “bulge “at the inguinal area or even in the scrotal area. The testicles may or may not have reached the scrotum when it stopped so that in some cases these “bulges” may be associated with singular testicle in the scrotum. 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” in origin and aside from being the most common type of hernias found in babies it is also actually one of the most common congenital anomalies. It is often observed as a bulge in the inguinal or at the scrotal area especially when the infant cries. The crying increases the abdominal pressure pushing down these structures hence its occurrence during those times.
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 just like the above patients.
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. For this reason if the hernia is on the left, it is routinely presumed that it is also present in the right. .
Hence, in some cases these inguinal indirect hernias are bilateral. Sometimes they are not obvious. 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 especially for those associated with undescended testicle on the left by ultrasound examination.
Early surgery even in two week old babies is practiced by most aggressive 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. This is what happened to the mason. There was “incarceration”! The hernia contents cannot be returned or “reduced” into the abdominal cavity because swelling may have occurred. 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.
Although the “bulge” of the miner was irreducible the contents were the “fatty tissues” or mesentery which was seen on an ultrasound and confirmed by surgery. He actually delayed his consultation because he was afraid that his “eggs” would also be removed and he could no longer produce. This is what happened to a friend of his. We had to take time explaining to him that perhaps his friend had an undescended testicle which is already useless and has to be removed. It might even later develop malignancy.
It is advised then to have your hernia repaired before any complications occur. **
