A 36-year-old man presents to you complaining of right scrotal swelling. He states that the swelling has been present for 1 week. He initially noticed the swelling sholy after moving furniture for his new living room. He denies any nausea, vomiting, change in bowel habits, abdominal pain, or urinary tract symptoms. He has no other significant medical or surgical history. On examination, he has an enlarged right hemi-scrotum with a mass that appears to be originating at the level of the external inguinal ring. With the patient completely relaxed, the physician is able to reduce the mass by pushing it back through the external inguinal ring. With the mass reduced, the physician instructs the patient to perform a Valsalva maneuver, upon which a protrusion is felt at the external inguinal ring. Once the mass is reduced, the testicle appears normal in size and consistency. Which of the following is the most likely diagnosis?
This patient has a reducible inguinal hernia. A hernia is a protrusion of a structure, usually intestine, through tissue that normally contains it. Inguinal hernias are either direct or indirect. Indirect inguinal hernias occur through the internal inguinal ring in a protrusion of peritoneum along the spermatic cord in the internal spermatic fascia. Direct inguinal hernias occur through the floor of the inguinal canal, separate from the spermatic cord as a result of breakdown of the transversus abdominis aponeurosis and transversalis fascia. If the mass, i.e., hernia, is easily returned back to its normal position, then it is called reducible. If the mass is not reducible, then this is called incarcerated. And, if the mass becomes incarcerated and develops compromised blood supply, it is termed strangulated. Strangulated hernias require emergent repair because the intestinal contents will necrose and cause the patient to become sick. As long as the mass is reducible, surgical repair can be performed on an outpatient basis. A hydrocele is a fluid collection contained within the tunica vaginalis that surrounds the testicle. It presents as a painless swelling of the scrotum, which transilluminates light when it is placed against the mass. A hydrocele cannot be reduced. Femoral hernias are more common in women, presenting as swellings in the upper pa of the thigh. The neck of the hernia sac lies at the femoral ring, below and lateral to the pubic tubercle, distinguishing these from inguinal hernias, which are above and medial to the tubercle. A mass caused by testicular cancer cannot be reduced either. Patients will complain of a dull, heavy, aching feeling within the testicle. The testicle itself is usually enlarged, hard, irregular, and non tender.
Hydrocele
Femoral hernia
Inguinal hernia
Testicular cancer