British Journal of Radiology 75 (2002),913-915 © 2002 The British Institute of Radiology
An unusual arrival of a hydrocoele
I R Daniels, FRCS1,
F G M Taylor, MRCS1 and
C D George, FRCS, FRCR2
Departments of 1 Surgery and 2 Radiology, Epsom District General Hospital, Epsom, Surrey, UK
Correspondence: Mr I R Daniels, 1 Cyprus Villas, Junction Road, Dorking, Surrey RH4 3HB, UK
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Abstract
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Acute hydrocoele is a previously unreported complication of herniography that may be explained on the basis of inguinal-scrotal embryology.
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Case report
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A 23-year-old, left-footed football player presented with a 6-month history of left groin pain. Clinically there was no evidence of an inguinal hernia and there was no previous history of inguinal-scrotal swelling. At herniography, using 70 ml contrast medium (Iopamidol, Niopam 370TM; Bracco, UK) through a midline puncture of the abdominal wall, a very small, direct left inguinal hernia was demonstrated (Figure 1
). Approximately 6 h after this procedure the patient re-presented with the right side of his scrotum swollen. Clinically the patient had developed a tense right hydrocoele that was confirmed by ultrasound (Figure 2). Radiographic assessment of the scrotum was not undertaken. This was treated conservatively with reassurance and non-steroidal anti-inflammatory drugs, and at out-patient review the hydrocoele had completely resolved. A diagnosis of iatrogenic transient hydrocoele complicating herniography was made, and to our knowledge this adverse effect has not previously been described in the radiological literature.
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Figure 2. Ultrasound of the right side of the scrotum showing a large hydrocoele around a normal testicle.
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Discussion
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In this case, the iatrogenic hydrocoele developed because of the presence of a patent processus vaginalis. This is the mechanism of a primary or idiopathic hydrocoele. A secondary hydrocoele may develop due to disease of the testis. A hydrocoele is a collection of fluid, usually serous, in some part of the processus vaginalis, usually in the tunica. A hydrocoele can be produced by excessive production of fluid within the sac, defective absorption of hydrocoele fluid, interference with the lymphatic drainage of the testicle and scrotum or a direct connection with the peritoneal cavity.
The hydrocoele development in our patient can be explained by embryological anatomy. Towards the end of the second month of development, the testis and the mesonephros (primitive kidney) are attached to the posterior abdominal wall. As the mesonephros degenerates it remains only as a band attachment for the primitive gonad and will form part of the gubernaculum. As the body grows rapidly, because of the failure of the gubernaculum to elongate, the testis descends to the inguinal region. Independent of this, the peritoneum of the coelomic cavity forms bilateral pockets that follow the gubernaculum and these form the processus vaginalis. As the testis moves down the inguinal canal the processus vaginalis envelopes the testis to form the tunica vaginalis, and the narrow canal connecting it to the peritoneal cavity is normally obliterated. If the canal remains open then peritoneal fluid may surround the testis by the action of gravity.
This allows a better understanding of the radiographic anatomy seen at herniography (Figure 3). On the peritoneal aspect, the lateral umbilical ligament that contains the inferior epigastric vessels, branching from the common iliac artery prior to it passing under the inguinal ligament, divides the area into medial and lateral fossae. The deep inguinal ring is sited in the area lateral to this fold and is the site of origin of an indirect hernia. A direct hernia arises medial to the lateral umbilical fold.
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Figure 3. Diagram of herniogram. A, median umbilical fold; B, medial umbilical fold; C, lateral umbilical fold. On the left side of the drawing one indirect, and two direct inguinal hernias can be seen from left to right. On the right is a femoral hernia. Reproduced with permission of the Radiological Society of North America, from [2].
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The medial area is divided again into medial and lateral areas by the medial umbilical fold, which contains the obliterated umbilical artery. It is important to know that direct hernias can arise on both sides of the medial umbilical fold and more than one may be present. Failure to detect and correct a second defect at operation can be responsible for some incorrectly described "recurrences". The midline ligament is known as the median umbilical ligament and contains the remnant of the urachus extending between the urinary bladder and umbilicus. These folds will not be visible in approximately 20% of herniograms and, while this will not affect the diagnosis of a hernia, it may make it difficult to distinguish the exact type.
Although herniography was originally described in 1967, it is not widely employed. It was initially described for use in children, but today the most common indication is in the investigation of patients with groin pain in whom an occult hernia is suspected.
Herniography is a simple and safe procedure. The patient empties their bladder and is then placed supine on an X-ray screening table. Using an aseptic technique, local anaesthesia and a midline approach halfway between the umbilicus and pubic symphysis, the peritoneum is punctured using an 18 G vascular needle. 50 ml non-ionic contrast media is injected under screening. If the peritoneum has been entered, contrast flows freely and delineates the bowel loops. The needle is then removed. Images are taken in supine, prone and erect positions. If no hernia is seen on these views a further image is taken after the patient has taken a short walk.
Herniography detects hernias in 36–54% of this group of patients. The false-positive rate varies between 0% and 18.7%, and the false-negative rate between 2% and 7.9%. False-negative findings are thought to be mostly owing to fat plugging the hernial orifice [1].
In one of the largest series of herniograms published in 1980, of 146 examinations performed in patients with groin pain, 59 hernias (40%) were found, the remainder showing no abnormality. Interestingly, 20% of patients had bilateral hernias, although asymptomatic on the contralateral side [2].
An overall major complication rate of 5% has been reported, including perforation of the sigmoid colon, injection into the stomach and left iliac vein, haematoma of bowel causing intestinal obstruction, and cellulitis of the abdominal wall causing septicemia. However, up to 42% of patients describe minor complications occurring within 24 h of herniography. These include painful haematomas at the site of puncture, adverse reaction to the injection of contrast medium and abdominal pain requiring hospitalization for 24 h owing to suspected peritonitis [3–6].
In conclusion, it appears that herniography is a safe and reliable procedure provided it is both carried out and interpreted by an experienced radiologist. The demonstration of an occult hernia as the cause of chronic groin pain is very important. However, although major complications are rare, many patients develop minor complications that may require detailed knowledge of the groin anatomy to explain their development.
Received for publication March 29, 2001.
Revision received April 8, 2002.
Accepted for publication April 15, 2002.
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References
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- Toms AP, Dixon AK, Murphy JM, Jamieson NV. Illustrated review of new imaging techniques in the diagnosis of abdominal wall hernias. Br J Surg 1999;86:1243–9.[Medline]
- Ekberg O. Inguinal herniography in adults: technique, normal anatomy and diagnostic criteria for hernias. Radiology 1981;138:31–6.[Abstract/Free Full Text]
- Brierly RD, Hale PC, Bishop NL. Is herniography an effective and safe investigation? J R Coll Surg Edinb 1999;44:374–7.[Medline]
- Yilmazalr T, Kizil A, Zorluoglu A, Ozguc H. The value of herniography in football players with obscure groin pain. Acta Chir Belg 1996;96:115–8.[Medline]
- Ekberg O. Complications after herniography in adults. AJR 1983;140:491–5.[Abstract/Free Full Text]
- Ducharme JC, Guttman FM, Poljicak M. Hematoma of bowel and cellulitis of the abdominal wall complicating herniography. J Ped Surg 1980;15:318–9.[Medline]
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