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A Not-So-Simple Groin Mass

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 55-year-old man with a history of Childs B cirrhosis presented with a 2.5-year history of right groin pain and increased urinary frequency with difficulty voiding. On examination, he had a 5 cm × 3 cm palpable and partially reducible right groin mass that extended into the scrotum. He had a leukocytosis with a leukocyte count of 16 400/μL (to convert to ×109/L, multiply by 0.001), his creatinine level was 1.14 mg/dL (to convert to micromoles per liter, multiply by 88.4), and urinalysis showed leukocyturia with cultures that had positive results for Streptococcus viridians. Axial and sagittal (Figure) computed tomography scans with contrast are shown. A renography using mercaptoacetyltriglycine showed a 34% reduction of right renal function.

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A. Sliding hernia

Inguinal hernias are one of the most common surgical diseases and account for up to 28% of all elective surgical cases performed in the United States.1 Because other diseases may mimic this condition, it is important to recognize other pathologies, as treatment may be different. Saphena varix may also present as a “groin bulge,” but it is a dilation of the saphenous vein due to valvular incompetence. Amyand hernia is an inguinal hernia containing the appendix. Therefore, an appendectomy may also be indicated at the time of inguinal hernia repair. Communicating hydrocele is when fluid flows between the scrotum and peritoneal cavity because of a patent processus vaginalis. Sliding hernias occur when a retroperitoneal organ constitutes part of the hernia sac.

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Article Information

Corresponding Author: Ashkan Moazzez, MD, MPH, Harbor-UCLA Medical Center, 1000 W Carson Street, F10, Torrance, CA 90502 (amoazzez@dhs.lacounty.gov).

Published Online: September 26, 2018. doi:10.1001/jamasurg.2018.3352

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Jenkins  JT, O’Dwyer  PJ.  Inguinal hernias.  BMJ. 2008;336(7638):269-272. doi:10.1136/bmj.39450.428275.ADPubMedGoogle ScholarCrossref
2.
Kraft  KH, Sweeney  S, Fink  AS, Ritenour  CW, Issa  MM.  Inguinoscrotal bladder hernias: report of a series and review of the literature.  Can Urol Assoc J. 2008;2(6):619-623. doi:10.5489/cuaj.980PubMedGoogle ScholarCrossref
3.
Percival  WL.  Ureter within a sliding inguinal hernia.  Can J Surg. 1983;26(3):283-286, 286.PubMedGoogle Scholar
4.
He  L, Herts  BR, Wang  W.  Paraperitoneal ureteroinguinal hernia.  J Urol. 2013;190(5):1903-1904. doi:10.1016/j.juro.2013.08.005PubMedGoogle ScholarCrossref
5.
Frenkel  A, Roy-Shapira  A, Shelef  H,  et al.  Case report: inguinal herniation of the urinary bladder presenting as recurrent urinary retention.  Case Rep Surg. 2015;2015:1-3. doi:10.1155/2015/531021Google ScholarCrossref
6.
Yong  GL, Siaw  MY, Yeoh  AJL, Lee  GEG.  Inguinal bladder hernia: case report.  Open J Urology. 2013;3(5):217-218. doi:10.4236/oju.2013.35040Google ScholarCrossref
7.
Hwang  CM, Miller  FH, Dalton  DP, Hartz  WH.  Accidental ureteral ligation during an inguinal hernia repair of patient with crossed fused renal ectopia.  Clin Imaging. 2002;26(5):306-308. doi:10.1016/S0899-7071(02)00437-0PubMedGoogle ScholarCrossref
8.
Oh  HK, Kim  H, Ryoo  S, Choe  EK, Park  KJ.  Inguinal hernia repair in patients with cirrhosis is not associated with increased risk of complications and recurrence.  World J Surg. 2011;35(6):1229-1233. doi:10.1007/s00268-011-1007-9PubMedGoogle ScholarCrossref
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