Acute inguinal hernia with suspected haematocele and patent procceus vaginialis

INTERESTING CASE

Submitted by : Mr Stephen Moore, Greater Glasgow and Clyde NHS Scotland, Dr Gibran Yusuf, King's College NHS Foundation Trust, London

Patient Presentation/ Clinical information: 

A 51 year old male patient presented for a scrotal ultrasound following an acute episode of right sided groin and testicular pain following sitting up in bed the night before. Clinical examination demonstrated an acutely swollen right hemiscrotum with a tender right testis and epididymis. Note was made of an atrophic left testis. Initial concerns were of right sided epididymo orchitis or intermittent torsion.

B-mode ultrasound demonstrated fluid within the tunica vaginalis of the right hemiscrotum which contained low level echogenic debris. This fluid could be seen extending superiorly into the distal aspect of the right inguinal canal (fig1).

Figure 1 Low level echogenic fluid seen occupying the right hemiscrotum and extending superiorly over the pubic bone (star) into the distal right inguinal canal

Further interrogation of the right groin demonstrated a fat containing non-reducible, indirect inguinal hernia seen extending along the proximal 2/3rds of the right inguinal canal. The distal 1/3rd of the right inguinal canal became continuous with the low level echogenic fluid seen extending into the right hemiscrotum (fig2 and fig3). There was no previous medical history of a right sided inguinal hernia.

	Figure 2 Low level echogenic fluid seen within the tunica vaginalis of the right hemiscrotum seen extending proximally into the right inguinal canal
	Figure 3 A cross section of the right spermatic cord within the right inguinal canal showing the continuation of the fluid within the inguinal canal

Given the clinical history, the presence of the previously unknown right sided indirect inguinal hernia and the imaging findings of low level echogenic fluid within the right hemiscrotum becoming continuous with the right inguinal canal; a diagnosis of a possible right sided haematocele following an acute right sided inguinal hernia was made. The likely origin of this pathological occurrence was a patent processus vaginalis.

Both testis were otherwise atrophic and heterogeneous throughout with preserved vascularity seen on colour doppler imaging. The right epididymis demonstrated a simple cyst in the caput epididymis. There was no evidence of epididymitis on ultrasound. 

There was no evidence of free fluid in the abdomen or pelvis at the time of the ultrasound being conducted.

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