Correct answer to Q1 is: Irreducible inguinal hernia

Correct answer to Q2 is: Hypoperfusion secondary to inguinal hernia

Additional discussion

In light of the finding of an incarcerated inguinal hernia, this is the most likely cause of the testicular hypoperfusion. Especially since symptoms resolved after mild sedation and manual hernia reduction.

Discussion

Inguinal hernias, the most common hernia and far more likely in men, arise when intraabdominal or extraperitoneal organs protrude into the inguinal canal, either directly or indirectly. [1]Direct inguinal hernias usually develop gradually over time, and are more commonly seen in adults. They are caused by a weak spot (i.e. thinning) in the fascia transversalis, and develop as a consequence of physical strain. [2]

Indirect hernias predominately arise in children. They occur because of a patent processus vaginalis which is formed in the 8^th gestational week, in boys by the descending testes into the scrotum, and in girls from the migration of the ligamentum rotundum. The processus vaginalis usually closes within the first year of life, but will remain patent in 12-19% of children into adulthood. Individuals with a patent processus vaginalis do not necessarily develop a hernia, but are at higher risk. The indirect hernia (as opposed to the direct hernia) is far more likely to cause bowel obstruction, since the hernia may descend all the way into the inguinal canal, which is narrow and long, and may cause strangulation of the tissue. If untreated, it may lead to necrosis within a couple of hours. [3]

With a clinical history of a sudden inguinal bulge and accompanying pain in a child, the most likely diagnosis is an indirect inguinal hernia, howerever differential diagnoses to consider are lymphadenopathy, abscess, hematoma, epidydimitis, hydrocele, femoral hernia, tersticular torsion, cryptorchidism with/without torsion, and amyand hernia. [1]

An inguinal hernia is primarily a clinical diagnosis, but in cases of doubt, ultrasound may guide the clinician in confirming the diagnosis or ruling out potential differential diagnoses. Be aware that a patient without complaints with an incidental finding of a patent processus vaginalis on ultrasound, does not require surgical management nor a consultation [4].

The management of a pediatric inguinal hernia, as in this case, is first and foremost done with manual hernia reduction. If manual hernia reduction fails, the treatment is emergency surgery. If manual hernia reduction is succesful, elective surgery is usually scheduled. (5)

Conclusion

Ultrasound is a readily available tool to evaluate scrotal emergencies in pediatric and adult patients.

Conflicts of Interest:

“The authors declare no conflict of interest.”

References

1. Hammoud, M., & Gerken, J. (2023, August 8). Inguinal Hernia. StatPearls – NCBI Bookshelf.
2. Morrison, Z., Kashyap, S., & Nirujogi, V. L. (2023, August 28). Adult Inguinal Hernia. StatPearls – NCBI Bookshelf.
3. Öberg, S., Andresen, K., & Rosenberg, J. (2017). Etiology of Inguinal Hernias: A Comprehensive Review. Frontiers in Surgery, 4.
4. Jamadar, D. A., Jacobson, J. A., Morag, Y., Girish, G., Ebrahim, F., Gest, T., & Franz, M. (2006). Sonography of Inguinal Region Hernias. American Journal of Roentgenology, 187(1), 185–190.
5. Christoffer Skov Olesen, Kristoffer Andresen, Stina Öberg & Jacob Rosenberg. Lyskebrok hos børn. Ugeskrift for læger. 2019.