Fluid Filled hernia ?

[Julius Gachuche]

Hi Stephen

I had this male patient with an interesting hernia.
The hernia is medial to the IEA and appears to be a fluid filled sac. No mental fat or bowel seen. Patient indicated he’s has this for years and when they tried to repair the ‘hernia’, surgeons did not see anything.
This swelling/hernia is prominent on straining or erect views. Not sure what type of hernia is this Stephen , maybe you could shed some light, thanks!

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[Stephen Bird]

Hi Julius,

What an interesting case!

I have a couple of options to consider.

Option 1: Where is the patients urinary bladder?

The cystic area does appear to have a wall that looks remarkably like the urinary bladder wall.
It is possible for the urinary bladder to herniate through a large posterior wall defect into the inguinal canal. This is a possible explanation. You could scan with a convex array concentrating on the bladder and see if it migrates through the posterior wall during straining. This would explain why the cystic area is not present until the patient strains and then it appears.

Option 2: I am less convinced it is an example ion this. In embryological terms the inguinal canal is an open pathway before we are born and then closes at birth or soon after. The open pathway is the funicular process and this becomes atretic when we are born. Sometimes it remains open and this leads to a cystic space appearing in the inguinal canal. You do see this commonly in young boys, but it can occasionally persist into adulthood. When you have an open funicular process and fluid can pass from the peritoneal cavity into the canal it is called a funicular hydrocele. If it reached the scrotum it does not envelope the testicle, but rather it pushes it into the corner of the scrotum with a mass like effect. A traditional hydrocele envelopes the testicle so they look quite different.
It is also possible for the funicular process to have a cystic area in the middle of the canal which does not communicate with the peritoneal cavity or the scrotum and this is called a encysted hydrocele. In a female patient it is called a cyst of the canal of Nuck.
So these events can be possible for fluid in the canal.
But when I see these funicular variants they are typically there all the time and don’t only appear during straining. This is why I prefer my urinary bladder theory.
I have made some nice funicular variant diagrams and they are in the scrotum lecture on the website. They may also be included in the hernia webinar. I will screen shot them and load them to this post.
Please let me know what you think and continue this conversation.

Steve.

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[Julius Gachuche]

Hi Steve.
The patient was recalled and a convex array was used while straining,
And you were right. It was a urinary bladder hernia!! Thanks!

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[Stephen Bird]

That is a great example.

Many things can end up in the inguinal canal.

I have seen ovaries, the appendix in inguinal hernias.

I think your case highlights the importance of opening up your horizons when things look odd and the change to a convex array is a great choice to see where the cystic structure is coming from.

Nice work,

Steve.

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