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Abstract

Inguinal hernias are the most common of all hernias. A complicated hernia is irreducible, and the contents are obstructed or strangulated. Sonography is considered the imaging modality of choice for the diagnosis of abnormalities of the inguinal area. This case study is about a patient with an inguinal hernia that had not been repaired and progressed into a life-threatening, complicated inguinoscrotal hernia. The patient’s complaints and clinical findings required sonographic examinations of the abdomen, pelvis, inguinal canal, and scrotum. Sonographic findings were corroborated by findings with computed tomography (CT). After the compromised intestine was resected and the hernia was repaired, the patient developed a deep vein thrombosis (DVT), identified sonographically. The patient was successfully treated and discharged.

Keywords

complicated inguinoscrotal hernia diagnostic medical sonography

Ruhl and Everhart¹ reported the cumulative incidence of inguinal hernia to be 14.8%, for men aged between 40 and 59 years. An initial diagnosis of an inguinal hernia is based on findings of a physical examination. The physical examination may be challenging if patients are obese, are in pain, have abdominal wall scarring, are women, or have a complicated hernia.^2,3 Sonography is considered to be the diagnostic imaging modality of choice for a patient with suspected abnormalities of the inguinal area, and particularly when an inguinal hernia is suspected.^4–6 Multiple diagnostic imaging services may be necessary to adequately evaluate the patient with a complicated hernia.³ An obstructed, strangulated, or complicated hernia can be sonographically challenging, to differentiate from an uncomplicated hernia, due to the complexity of imaging the tissues. However, sonography is the only modality that allows real-time evaluation of the hernia and its contents.² A patient may not elect immediate surgical repair for fear of hernial accidents (defined as incarcerated hernias), with or without obstruction, or strangulation, which are uncommon.^7–10

This case study provides evidence of a male patient with a complicated, complete, indirect, irreducible, inguinoscrotal hernia. The inguinal hernia had been previously diagnosed, however; the patient declined surgical repair.

Case Report

A man in his late 50s presented to his primary care physician with severe cramping and a burning pain, in his abdomen and pelvis. The exact time of onset was not clear due to chronic intermittent pain in his right groin area, associated with a previously diagnosed long-standing (3–5 years), unrepaired inguinal hernia. The pain was reported to the physician a week earlier, but had become intolerable during the previous 24 hours. The patient was obese, hypotensive, had a fever and chills, as well as reported night sweats and weakness. Two months prior to this episode, he experienced a viral upper respiratory tract infection (URI) and cough. The patient was hospitalized, that afternoon, for a thorough medical evaluation and treatment.

A physical examination revealed a large palpable mass in the right hemi-scrotum. The scrotum was enlarged (Figure 1), and the scrotal skin was excessively warm, thick, reddened, and somewhat edematous. The penis was retracted within the enlarged scrotum, and the testicles could not be palpated. Laboratory results were abnormal and included mild anemia, leukocytosis, thrombocytopenia, and proteinuria. The physician had concerns about hypotension, sepsis, and enlarged scrotum, which could contain an incarcerated, possibly strangulated, right inguinoscrotal hernia. The patient openly expressed fears of dying and concerns about surgery.

Figure 1.

Scrotum enlarged due to herniated contents, with skin that was excessively warm, thick, reddened, and somewhat edematous. The penis was retracted (arrow) within the enlarged scrotum, and the testicles could not be palpated.

On the second hospital day, orders were submitted for a complete abdomen sonogram, as well as a pelvic sonogram. For the sonographic examinations, a Philips iU22 (Philips Ultrasound, Bothel, WA, USA) with a curvilinear transducer (C5-1 MHz) was used. Interpretive findings of the complete abdominal sonogram were not directly related to a hernia. The pelvic sonographic findings and the images were discussed with the requesting physician. The area of interest extended beyond the anatomical limits of the protocol for a pelvic sonogram. Therefore, an inguinoscrotal sonogram was ordered for this patient. All sonographic examinations were performed with the patient in supine position because he could not tolerate the pain of sitting, standing, or rolling to the lateral decubitus position. A Philips iU22 with a linear-array transducer (L12-5 MHz) was used for inguinoscrotal sonogram. The skin of the inguinal and scrotal areas was reddened, swollen, and moist and emanated a fetid odor; therefore, a general-purpose probe cover (Microtek; 13 cm × 122 cm. [5 in × 48 in]) was used. Compression and Valsalva maneuvers were limited due to the patient’s inability to tolerate the pain. Gray-scale sonographic images were consistent with a right inguinal hernia that contained loops of small intestine (Figure 2A). There was a complex septate collection of fluid in the right hemi-scrotum. The right testicle was not visualized (Figure 2B). A midline view of the scrotum showed a large hydrocele, and power Doppler demonstrated decreased vascularity in the area (Figure 2C). Gray-scale sonograms and measurement of left testicle were obtained (Figure 3A). Color Doppler images of the left testicle revealed decreased blood flow to the left testicle (Figure 3B). A spectral Doppler signal was present in the left testicle, which reduced the concern for a possible torsion. The left hemi-scrotum contained complex echogenic debris (Figure 3C), which was edematous, and had thickened skin (Figure 3D). The attending physician considered that the findings supported the clinical evaluation and discussed those with the patient. Concurrent intra-abdominal findings only added to the complicated life-threatening condition of the patient.

Figure 2.

(A) Longitudinal gray-scale images of the right inguinal canal and right hemi-scrotum demonstrating a hernia with loops of bowel (arrow) extending into the right hemi-scrotum; (B) complex septated collection of fluid in the right hemi-scrotum and the right testicle was not visualized—probably due to overlying bowel and fluid collection; (C) transverse view at the midline of scrotum showing a large hydrocele; and power Doppler demonstrating no vascularity within the fluid and some vascularity of surrounding tissue. The power, threshold, persistence, and wall filter were adjusted to maximize the detection of blood flow by color Doppler and power Doppler sonography.

Figure 3.

(A) Longitudinal gray-scale images of left hemi-scrotum and measurement of left testicle; (B) longitudinal view with color Doppler of left testicle revealing decreased blood flow; (C) transverse view of left hemi-scrotum with complex echogenic internal debris; and (D) transverse view of left hemi-scrotum with edema and thick skin (arrow).

The medical management of the patient was continued overnight. On the third day, an abdominal and pelvic computed tomography (CT) with intravenous contrast (150 mL of Isovue 300) was completed (Toshiba Aquilion 8 slice; Toshiba American Medical System, Inc., Otawara, Tochigi Prefecture, Japan). The CT findings were consistent with the sonogram, which included a small bowel obstruction, secondary to a large right inguinal hernia, and contained loops of small intestine (Figure 4). Within the large hernial sac were complex fluid collections that likely represented interloop abscesses. The diagnostic findings of inguinoscrotal sonogram and CT supported and strengthened the clinical diagnosis. The abnormal laboratory results and the patient’s declining clinical condition emphasized the need for surgery.

Figure 4.

Coronal CT image with arrow pointing to a right inguinal hernia. CT, computed tomography.

The patient experienced a progressive clinical deterioration, and results of the imaging procedures were reviewed with the patient. The patient had hoped to forestall surgery but, confronted with the gravity of his condition, he consented to emergent surgical intervention. Emergency exploratory surgery began on the evening of the third hospital day. The surgeon’s approach was to repair the hernia and resect the small intestine that had high probability of perforations and multiple abscesses. During the surgery, the right testicle was identified. It was small and had been displaced by the herniated tissues. The incarcerated intestine was exposed, revealing adhesions, necrotic tissue, and a hydrocele. There was inflammation, edema, and necrosis of the intestinal wall. Approximately 1100 mL of bloody exudate was aspirated from several loculated abscesses within the herniated tissues. Surgery was completed late that evening. A sample of aspirated bloody exudate lacked squamous epithelial cells and white blood cells, but had many Gram-positive cocci and moderate Gram-negative bacilli. Anaerobic cultures produced a few colonies of Streptococcus constellatus. No bacterial growth was obtained within aerobic conditions.

The resected section of small intestine was 50.3 cm long, incarcerated, obstructed, necrotic, and abscessed. Histologically, the small intestine had extensive active neutrophilic inflammation of the serosal surface. Focal partial thickness necrosis of the intestinal wall involved predominantly the serosal surface. Under that area of necrosis was a fibroblastic response. There were patchy congestion and focal fat necrosis among the surrounding adipose tissue.

The surgeon and the attending physician agreed that the hernia was the cause of the patient’s complaints and the focus of his septic condition. The viral URI that occurred 2 weeks prior to his admission was possibly a contributor, but more likely was merely coincidental.

During the ninth day, the patient postoperatively developed swelling in his right lower extremity. A request was submitted for bilateral lower extremity sonographic examination to rule out a deep vein thrombosis (DVT). The venous study was obtained with a Philips iU22 and a linear-array transducer (L9-3 MHz) and revealed multifocal nonocclusive blood clots in both lower extremities. An intravenous anticoagulation protocol was initiated and circulating markers for hypercoagulopathy were monitored. On the 12th day, the patient was ambulatory and able to transition to his home.

The patient responded favorably and had an improved quality of life, less pain, and increased mobility, for a short time. Unfortunately, the patient experienced a recurrent hernia and continued to have persistent issues.

Discussion

A hernia is defined as a protrusion of an anatomical structure through the normal surrounding tissue.^2,5 Hernias result from congenital or acquired anatomical abnormalities that compromise the ability to properly retain the herniated tissue or organ. Physical activities or injury may “push” the tissue out of its normal position. Typically, clinical signs and symptoms of hernia are abnormal enlargement, bulge, or swelling with associated discomfort, or pain. Onset may be insidious to acute, and intermittent to persistent. A burning pain has been associated with the tearing of tissue. Ischemia and distention of intestines are commonly associated with pain. Positional pain may restrict the patient’s ability to perform routine activities or to work.

The degree of organ involvement depends on the type of hernia. There are three general types of hernias: external, diaphragmatic, and internal. External hernias involve the abdominal wall³ and are subclassified as anterior abdominal wall or groin.² Groin hernias include femoral, direct inguinal, and indirect inguinal types.^2,3 Stavros and Rapp¹¹ state that inguinal hernias are the only true groin hernias. Spigelian and femoral hernias are considered as groin hernias because of their respective anatomical proximity to the inguinal areas.¹¹ In a femoral hernia, the peritoneal sac and hernial contents pass through the femoral ring into the femoral canal, located medial to the common femoral vein, and does not involve the inguinal canal.^11–13 A direct inguinal hernia is located medial to the inferior epigastric artery and occurs when the muscles of the abdominal wall are weak, allowing the contents to pass through the inguinal canal.^4,13,14 An indirect inguinal hernia (also known as an oblique, external, or congenital inguinal hernia) occurs as a result of protrusion of the hernial contents through the internal inguinal ring and extension along the inguinal canal, lateral to the inferior epigastric artery.^4,14 An indirect inguinal hernia may be either “complete,” if contents pass completely through the canal, or “incomplete,” if contents are retained within the canal.¹² Indirect inguinal hernias are further subclassified according to the length of the hernial sac: (1) bubonocele—the sac is confined to the inguinal canal and is also called an incomplete indirect inguinal hernia¹³; (2) funicular—the sac extends along the length of the inguinal canal and through the superficial inguinal ring, but does not extend into the scrotum or to the labium/labia majora¹³; or (3) complete, scrotal, or inguinoscrotal—the sac passes through the inguinal canal and superficial inguinal ring, and extends into the scrotum or labium/labia.^2,11,13 Inguinoscrotal hernia is a subtype of inguinal hernia that occurs when the hernial sac extends into the scrotum.¹²

Contents of a “reducible” hernia can be returned to their appropriate location by nonsurgical manipulation.¹⁵ An “irreducible” or “incarcerated” hernia cannot be reduced without surgical intervention.^2,11,12,15 An irreducible hernia is classified as “complicated” if the lumen of the loop(s) of intestine is mechanically “obstructed” or as “strangulated” if there is physical restriction of its blood supply. The scrotal skin over a strangulated hernia may appear reddened as reported in the present case study.¹³

The incidence, risk factors, and clinical course of inguinal hernias are not necessarily the same for women as for men. At the end of a 20-year prospective cohort study of men and women, Ruhl and Everhart¹ reported that the cumulative incidence of hospitalization because of inguinal hernia was higher for men (13.9%) than for women (2.1%) and increased with age. For men aged 24 to 39 years, the incidence was 7.3%; for 40 to 59 years, 14.8%; and for 60 to 74 years, 22.8%.¹ Using age-adjusted analysis, risks of inguinal hernias were directly related to age and doctor-diagnosed hiatal hernia. Obesity was inversely associated with the incidence of inguinal hernia. Factors that cause increased abdominal pressure (e.g., physical activity, constipation, chronic cough, and chronic obstructive pulmonary disease) did not increase the risk of inguinal hernia. Those data may not apply to a patient in a subpopulation with history of inguinal hernia that was not repaired, such as the patient who was the subject of this study report.

Complications after surgery should not be neglected. Adult male patients who had no previous history of a venous thromboembolism were studied after their initial surgical repair of inguinal hernia.^13,16 Fifty-three (0.18%) of 28 782 men who had surgical repair of inguinal hernia developed venous thromboembolism, within 90 days postoperatively. The risk was highest within 30 days of surgery. Factors that enhanced the probability of developing thromboemboli were the following: increasing age, body mass index >30 kg/m², and planned in-patient procedures. Yang and Zhu¹⁷ suggest that coagulation markers, such as prothrombin time, partial thromboplastin time, thrombin time, D-dimer, fibrinogen, and fibrin degradation products, should be monitored preoperatively and postoperatively. This would be especially true for patients greater than 50 years of age, who have undergone surgical repair of hernias.

For a patient-centered approach, the prognosis, choice of treatment, and long-term health of a patient with inguinal hernia should include consideration of the individual’s psychological, cultural, and spiritual concerns, as well as their medical factors. The technical aspects of medical diagnosis, treatment, and repair should be based on the results of scientific studies. Fitzgibbons et al^7,8 and O’Dwyer et al⁹ reported that “watchful waiting” was a reasonable alternative to surgical repair of inguinal hernia with minimal clinical signs in men aged 50 years or older. In a study of 720 male patients, the reason most often reported when patients elected surgery instead of watchful waiting was increased hernia-associated pain.⁷ During 4.5 years of observation, 2 (0.55%) of 364 patients (0.0018 events per patient-year) had hernial accidents requiring emergent surgery. Hernial accidents were defined as incarcerated hernias, with or without obstruction or strangulation. Those investigators continued monitoring 254 patients for another 7 years during which a total of three patients required emergent surgery.⁸ In another study with 496 male patients aged 50 years and older, six patients (2.3%) treated with watchful waiting required emergent surgery because of incarcerated, strangulated intestine.¹⁰ Potentials for recurrent herniation and persistent hypercoagulation were lasting concerns for the patient who was the subject of this report.

Because of the previous diagnosis, differential diagnoses for the patient in this case study were focused on the extent and viability of herniated tissues and concurrent health concerns of sepsis. This would also include potential complications attributed to intra-abdominal abnormalities.

Sonography is considered to be the imaging modality of choice when abnormalities of the groin area are suspected.^2,4–6 Results of a meta-analysis for the detection and diagnosis of inguinal hernias revealed that sonography had greater than 96.6% sensitivity and 84.8% specificity.¹⁸ The American Institute of Ultrasound in Medicine (AIUM), the American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU) collectively published the practice parameters and technical standards for sonographic evaluations of uncomplicated hernias.^19,20 Each of the prescribed studies is reliable within the respective defined anatomical boundaries. A drawback to confining a study to those anatomical boundaries is evaluating the entirety of the herniated tissue(s). In patients with complicated hernias, it may be necessary to perform multiple sonographic protocols/examinations (e.g., “scrotum,” “abdomen limited,” “soft tissue lump,” “musculoskeletal [MSK] limited,” and “pelvic”).

The sonographer should be persistent and patient. Rapp et al² state, “The anatomy differs for each type of hernia; however, the principles of scanning remain the same.” Jacobson et al²¹ remind that a “protocol-driven evaluation with ultrasound is recommended” for patients with groin symptoms. In the present case study, the clinical report and the imaging studies’ anatomical limits were discussed with the attending physician. This resulted in ordering studies that provided complete imaging; therefore, interpretation and options for treatment should be considered.

The sac of a complicated hernia may be challenging to visualize using sonography, especially if there is a small intestinal obstruction.^3,5 Hernial contents may have a varied appearance on a sonogram, such as isoechoic relative to surrounding tissue, if fat is herniated.²² The contents may appear anechoic if there is a collection of fluid or hyperechoic if contents are omental fat, with or without edema due to inflammation or strangulation.² They may appear mixed in echogenicity, with reverberations, due to gas and loops of intestine.^2,4 The sonographic appearance of inflammation, hematomas, tumors, or abscesses may range from hypoechoic fluid to echogenic masses.⁴ Abscesses may have mixed echogenicity, internal echoes, and/or irregular borders with or without a halo.^4,23 The interior of an abscess is an accumulation of exudates, and perhaps necrotic tissue, and can appear avascular, with color or power Doppler.

Because some hernias spontaneously reduce when the patient is placed supine and to differentiate intestinal obstruction from an intestinal ileus, the sonographer performs compression with the transducer.^2,4,11 The sonographer may also request the patient to perform the “Valsalva maneuver.”¹⁸ Dynamic sonographic imaging allows for detecting movement of the contents within the hernia, relative to the surrounding tissues.^4,11,12 Peristalsis of the intestine, as well as reducibility of the hernia, may be judged. Compartmentalized fluid or movement of fluid that communicates with the peritoneal cavity may be visualized. During the Valsalva maneuver, the shape of the hernia sac may change. Sonography is a relatively painless diagnostic tool for noninvasive dynamic assessment of soft tissue.¹² However, during a dynamic sonographic maneuver, the patient may experience more pain, due to the stretching or tearing of tissues around the hernia. This may also cause burning or aching directly at the site of the hernia.²⁴

Conclusion

Diagnostic medical sonography is a real-time, dynamic imaging modality used to characterize the appearance of tissues in the area of interest. When the sonographic imaging protocol is inadequate for the diagnostic purpose, the need to extend the examination or to request/order additional examinations might be indicated. These diagnostic options should be discussed with the attending physician. Because of the complexities associated with the current patient, a complete abdominal study, inguinoscrotal sonogram, and lower extremity venous examination were needed. For a patient with a history of nonrepaired inguinal hernia, the general incidence of hernias, within the population, is of little value. Hernial accidents, in a subpopulation of patients, that follow a “watchful waiting” plan of care are uncommon. It is important to persist with sonographic compression and the Valsalva maneuver regardless of creating pain. It is recommended that novice sonographers take advantage of opportunities to view the tissues during a surgery. These experiences can help sonographers relate the actual appearance to sonographic appearance. The hope is that this case study can be beneficial and encourages experienced sonographers to mentor novice sonographers in diagnostic medical sonography.

Footnotes

The authors thank many coworkers for their respective contribution to this manuscript and to GWB for technical writing.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The authors received no financial support for the research,authorship,and/or publication of this article.

ORCID iD

Martha Liliana Hoyos Brumbaugh

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