hernia

"... Allah will grant after hardship, ease. " [V65:7]

I have been longing to write a new entry, but still the pressure of time on me is unbearable and I guess not till next week, I'd be 'free'. It is something that I've learnt today that doing things together worth more than anything else in the world. Co-operation that is. However, still I'd say people would only appreciate it with the constraint of time rather than being persistent. After all we are only human.

I have not any topic to discuss on today but as I am revising my Surgery, guess I'd like to chip an entry on a not very interesting yet the most common exam questions on earth- Scrotal lumps/swelling.

It is simple to be said really but when it comes to examination spot, I guess with the stress on you, patient and examiners, with the ethical issue when comes to examining such a restricted part of the body would be a big challenge, you'd find yourself clueless - well, I'd fine myself so in fairness.

In cases where the patient presented with an scrotal swelling, the top most differentials are:
- indirect inguinal hernia
- hydrocoele
- testicular tumor

Usually by saying this, you'd next be directed by the examiners to the next question. But don't hesitate on saying ..'Next, I'd like to differentiate between those differentials with few simple examinations'. Bring along your pen-torch for this assessment. Assess the separatability of the swelling, the transilluminability, comment the character of the swelling be it cystic or solid in nature, try to get above the swelling and most importantly listen with your stethoscope for any bowel sound.

In summary,
-separated or not?
-transilluminate?
-solid or cystic?
-can get above the swelling?
-any bowel sound heard over the swelling?

Based on the findings, if the swelling is able to be seperated and transilluminate on light examination and cystic in nature, then it is a most possibly a hydrocoele. If you can't get above the swelling, which means you can't assess the upper border of the swelling, the most likely diagnosis is an inguinal hernia. You can confirm this by a positive gurgling bowel sound heard on auscultation. At this stage a direct or indirect inguinal hernia cannot be yet differentiated. Further test still need to be done.

So, if it is an inguinal hernia, mention next that you'd like to do further test on differentiating whether it is a direct or indirect hernia.

How? Locate the pubic tubercle, to outline the inguinal ligament. Track up laterally (to the side) towards the Anterior superior iliac spine (ASIS). Mid point of this line between ASIS and pubic tubercle is the mid point of the inguinal ligament corresponding to the deep inguinal ring. Use two fingers, one to occlude or press on the mid point and another on the pubic tubercle (superficial ring). Ask the patient to cough, and look for any bulges. If there is any bulges seen, then it is a direct hernia, but if the 'bulge' is held by the fingers then it is more consistent with an indirect hernia. Repeat the cough test with patient standing up. Finish the examination and thank the patient.

Next, the accessories questions.
1) how to differentiate whether the swelling is a tumor or hydrocoele if it is seperated?
-- Depending on the age of the patient, testicular tumor are more common in younger and vice verse for hydrocoele.

2) Further investigation you'd like to do
-- Ultrasound and plain film abdomen (? bowel coming down towards the scrotum)

3) Risk factors for indirect inguinal hernia
-- patent processus vaginalis, premature male infant, 4% of male infant, chronic cough, straining, post surgical


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Well, I guess that's all about it!
And seemed that I don't have to be worried of any of that for my baby! ;) She'll be well beyond prematurity by now. Alhamdulillah.

See you!