A 58 year old male CAPD (peritoneal dialysis) patient presented with scrotal swelling and pain.
The clinical question - ? hydrocele / scrotal oedema
The scrotum was markedly distended.
Examination was performed using the linear and the curlinear probes.
Examination of the scrotum revealed a large hydrocele, but also loops of slowly peristalsing small bowel. These could be followed up through the inguinal canal and back into the abdomen through the deep ring.
The hernia could not be reduced and so this was an incarcerated indirect inguinal hernia.
Scrotal swelling has a broad differential including:
- Scrotal pathology
- Cellulitis / infection, oedema, surgical emphysema
- Scrotal content pathology
- Hydrocele, haematocele, pyocele, hernia
- Testicular and epididymal pathology
- Tumour, infection, torsion
Ultrasound methodically explores the scrotal skin, then contents of the tunica, then testis and epididymis.
If a hernia is found follow the neck to determine whether the content passes throught the inguinal canal and into the abdomen through the deep ring (crossing over the inferior epigastric vessels) or whether is simply dives into the abdomen through the superfical more medial ring without crossing the inferior epigastric vessels.
Explore the contents for evidence of ischaemia (lack of blood flow, absent peristalsis, free air).
Explore the testis ensuring adequate flow.
If there is no evidence of ischaemia and the patient is comfortable reduction of the hernia may be gently attempted. Otherwise surgical review is imperative.