Edouard J. Trabulsi, MD, FACS
BASICS
DESCRIPTION
• A palpable bulge in the groin region that can be benign or malignant. The groin has 2 distinct anatomic areas:
– Inguinal canal
– Femoral triangle
EPIDEMIOLOGY
Incidence
• Hernia:
– Estimated that ∼5% of population will develop hernia at some point in their lifetime.
• Cryptorchidism:
– 3–5% in newborn and 0.7–1% by the end of 1st yr.
Prevalence
N/A
RISK FACTORS
• Hernia:
– Low birth weights (<1,500 g)
– Incidence increases with aging as well as complications.
– Full-term newborn has 3.5–5% chance
• Cryptorchidism:
– Low birth weights (<2,500 g)
– Prematurity 30%
– Factors that may lead to late testicular descent include black or Hispanic ethnicity; a family history, low birth weight, and preterm birth delivery; and cola consumption during pregnancy
Genetics
Some connective tissue disorders are inherited and can be associated with a groin hernia (see “Groin Hernia, Adult and Pediatric”)
PATHOPHYSIOLOGY
• The contents of the groin include skin, subcutaneous tissue, the inguinal canal and contents, femoral triangle and contents (including vessels, nerves, and lymph nodes), and musculoskelet al structures (1)
• Lymphadenopathy:
– Infection with STD, skin infection in the lower extremities
– Malignancy such as melanoma, lymphoma, other
• Hernia:
– Persistence of patent processus vaginalis
– Chronic increased intra-abdominal pressure
– Connective tissue disorder altering collagen formation can predispose to hernia
– Prematurity
• Cryptorchidism:
– Endocrine abnormality
– Absence or abnormalities of the gubernaculum
– Reduced intra-abdominal pressure
– Pronounced impairment in germ cell development
ASSOCIATED CONDITIONS
• Chronic increased intra-abdominal pressure.
• STDs associated with lymphadenopathy
• Penile cancer
GENERAL PREVENTION
• Avoid chronic increase in intra-abdominal pressure that may encourage hernia formation.
• Avoid STIs.
DIAGNOSIS
HISTORY
• Onset of the mass (age, activity) and any associated symptoms
• Family history of cryptorchidism
• Symptoms of malignancy (fevers, weight loss)
• Birth history: Premature or low birth weight (for congenital hernia and cryptorchidism)
• History of presence or absence of testes in the scrotum, contralateral testis
• Alteration in the size of the mass with cough or abdominal straining suggests hernia or varicocele.
• Fever, a lesion on genitalia or lower extremity, and weakness may suggest infection and lymphadenitis.
• Surgical history of previous hernia repair
PHYSICAL EXAM
• General:
– Evidence of adenopathy elsewhere, to suggest more systemic disease such as lymphoma
• Groin:
– Patient should be examined in standing position as well as supine, and Valsalva maneuver should be done during exam
A cough impulse usually suggests an inguinal hernia. Erythematous skin suggests infection or strangulated hernia. Pulsatile mass may suggest arterial aneurysm
A finger in the external ring can help to differentiate direct and indirect hernias
Groin tenderness: Likely infection is the etiology
• Genitalia:
– Evaluate for masses, lesions, ulcers
Malignancy may result in groin adenopathy
Ulceration may suggest a sexually transmitted infection
• Scrotum:
– Absent testis suggests undescended testes
– Tender testis suggests epididymitis, testicular torsion, and epididymitis
– Transillumination test, if positive, may suggest a hydrocele/hydrocele of the spermatic cord
• Lower extremity exam:
– Any source of infection or malignancy such as melanoma
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Blood tests:
– Full blood count and ESR
– Renal function tests and electrolytes
– Syphilis serology, if indicated
– HIV serology, if indicated
– LGV (lymphogranuloma venereum) serologic test, if suspected
• Swab and culture the base of any lesions to diagnose genital herpes, syphilitic ulcer, chancroid (Haemophilus ducreyi)
Imaging (2)
• US can confirm hernia and can help to see the testes within the inguinal canal. Not sensitive for intra-abdominal testis.
• Doppler US for vascular conditions (Valsalva maneuver should be performed during exam).
• CT/MRI can help to diagnose obscure hernias. Also can identify related lymphadenopathy.
• Arteriography may help diagnose femoral artery aneurysm.
• Venography or Doppler US will help diagnose saphenous varix.
Diagnostic Procedures/Surgery
• Laparoscopy: Can be diagnostic and therapeutic for hernia and intra-abdominal testes.
• Exploratory surgery is necessary in many cases for both diagnosis and treatment.
• Lymph node biopsy or fine needle aspiration (FNA) for definitive diagnosis of lymphadenopathy.
• Chromosomal and hormonal analysis in situation with bilateral undescended testes.
Pathologic Findings
• Cryptorchidism:
– Decreased number of Leydig and Sertoli cells
– Failure to develop primary spermatocyte
– Peritubular fibrosis
• Lymphadenopathy:
– Can identify neoplastic or inflammatory cause
DIFFERENTIAL DIAGNOSIS
• The mnemonic “MINT” can be used to remember the possibilities (Malformations, Inflammatory, Neoplasms, Trauma):
– Malformations:
Hernia (inguinal or femoral), usually presents with a mass
Hydrocele
Hydrocele of the canal of Nuck
Cryptorchidism (undescended, maldescended, or retractile testicles)
Testicular torsion
Femoral artery aneurysm
Varicocele
Spermatocele
• Inflammatory Lesions:
– Inguinal lymphadenitis (a mass found during exam):
Acute secondary to venereal disease (chancroid, gonorrhea herpes, or syphilis) or skin disease, infection in the groin area, drug reaction, and viral infections
Chronic secondary to TB
– Cellulitis
– Psoas abscess secondary to TB
– Thrombophlebitis of the saphenous or femoral vein (especially postpartum)
– Osteomyelitis
• Neoplasms:
– Lymphadenopathy (penile cancer, melanoma, lymphoma, or metastatic tumor)
– Paratesticular tumors
– Skin tumor, lipoma and sarcoma of the bone
• Trauma:
– A perforation of the femoral vein or artery
– Contusion and fracture, or dislocation of the hip
TREATMENT
GENERAL MEASURES
Management is based on the cause of the mass and can vary from antibiotic therapy, biopsy, or further imaging for more extensive adenopathy.
MEDICATION
First Line
• Lymphadenopathy:
– Infection requires treatment with specific antibiotics.
– For STD-related adenopathy, see specific chapter.
– Malignancy with either requires chemotherapy or lymph node dissection based on the etiology.
– For penile cancer with lymphadenopathy, a course of antibiotics is indicated.
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Cryptorchidism:
– Treatment started at 6–12 mo
– Hormonal treatment efficacy is <20% and is dependent on testis location
– Surgery is the gold standard for management
• Hydrocele:
– Communicating hydrocele with patent processus vaginalis will require surgery
• Testicular Torsion:
– Manual detorsion followed by orchiopexy
• Hernias:
– Congenital hernias are repaired by ligating the processus vaginalis at the internal inguinal ring (60% chance of having a contralateral defect)
– Strangulated, incarcerated hernias require emergency intervention
– Elective surgical repair for hernia is recommended based on surgeon preference
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
• Lymphadenopathy: Requires follow-up for chronic infection, response to treatment.
• Cryptorchidism: Requires follow-up for:
– Malignancy: Increased risk of malignancy in undescended testis, and patient is required to perform monthly self-exam for any abnormality (corrective surgery does not reduce the chances of malignancy).
– Increased risk of trauma and torsion.
– Requires follow-up for fertility.
• Hernia: Follow for recurrences and possible occurrence on the other side in young children.
PROGNOSIS
Depends on the etiology of the mass
COMPLICATIONS
• Cryptorchidism:
– Infertility
– Malignancy
– Increased risk of trauma and torsion
– Hernia
• Hernia:
– Nonreducible and incarceration
– Obstruction
– Strangulation
• Lymphadenopathy can erode into femoral vessels and cause exsanguination and death
FOLLOW-UP
Patient Monitoring
• Cryptorchidism:
– Requires follow-up for fertility
– Self-exam for testicular masses
• Hernia, for recurrence
Patient Resources
N/A
REFERENCES
1. van den Berg JC, Rutten MJ, de Valois JC, et al. Masses and pain in the groin: a review of imaging findings. Eur Radiol. 1998;8(6):911–921.
2. Shadbolt CL, Heinze SBJ, Dietrich BB, et al. Imaging of groin masses: Inguinal anatomy and pathologic conditions revisited. Radiographics. 2001;S261–S271.
ADDITIONAL READING
• Baskin LS, Kogan BA. Handbook of Pediatric Urology, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005;20:51.
• Brunicardi FC, Andersen DK, Billiar TR, et al., eds. Schwartz’s Principles of Surgery, 8th ed. New York, NY: McGraw-Hill, 2005.
See Also (Topic, Algorithm, Media)
• Cryptorchidism
• Groin Hernia
• Groin Inguinal Mass Image 
• Penis Cancer, General
• Sexually Transmitted Infections (STIs) (Sexually Transmitted Diseases [STDs]), General
CODES
ICD9
• 550.90 Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent)
• 752.51 Undescended testis
• 789.39 Abdominal or pelvic swelling, mass, or lump, other specified site
ICD10
• K40.90 Unil inguinal hernia, w/o obst or gangr, not spcf as recur
• Q53.9 Undescended testicle, unspecified
• R19.09 Other intra-abdominal and pelvic swelling, mass and lump
CLINICAL/SURGICAL PEARLS
• The differential diagnosis varies greatly by the age of the patient.
• If the mass is reducible, strongly suggests a hernia.