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: 5’6” 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? 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

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