This large scrotal swelling was an inguinoscrotal hernia. The swelling was not confined to the scrotum
and with difficulty it could be reduced. The swelling was separate from the testis and it did not
transilluminate. Its size prevented the adequate demonstration of a cough impulse, If it had been a
hydrocele it would have been irreducible, would not have had a cough impulse and the testis would have been
impalpable. The examiner would have been able to get above it and it would have transilluminated brightly.
Other causes of scrotal swellings include testicular tumours, acute epididymo-orchitis, epididymal cysts and
rarely haematoceles and gummas. All of these swellings are confined to the scrotum. Testicular
tumours usually present as painless lumps arising from and rarely replacing the testis. Epididymo-orchitis
usually causes a painful erythematous swelling of the hemi-scrotum. Both the testis and epididymis are
swollen and exquisitely tender. An epididymal cyst causes a painless epididymal lump palpable separate
from the testis. Gummas and haematoceles, like tumours, present as painless scrotal swellings, but unlike
tumours, the testis and epididymis can not be easily defined.
In those patients who are considered fit for operation, large indirect hernias usually require surgery.
Surgery is offered both to relieve symptoms and prevent the risk of strangulation, the mortality of which has
not improve over the past 30 years. Whether all elderly men with easily reducible direct hernias require surgery
is a controversial issue. Many different types of hernia repair have been described over the last 100
years. The Bassini repair involved apposition of the conjoint tendon, under tension, down to the inguinal
ligament. Such a repair has been associated with recurrence rates as high as 10%. Today, the
techniques that have been shown to be associated with the lowest recurrence rates have been the Lichtenstein
mess repair and the Shouldice repair. The Shouldice repair is more technically demanding, involving a four
layer reconstruction of the transversalis fascia, but in good hand recurrence rates as low as 0.1% have been
reported. All mesh repairs are based on tension-free reinforcement of the posterior wall of the inguinal
canal. This is the commonest technique used in the United Kingdom today.
Hydrocele are usually seen in elderly men. Asymptomatic small hydrocele require no treatment.
They can be aspirated but this method of treatment is associated with both a high recurrence rate and also with
the risk of infection. Various operative techniques have been described. In all of these procedures
the scrotum is incised and the hydrocele drained. The sac of the hydrocele can be excised.
Alternatively, the sac can be plicated (Lord's or Riddle's procedure). In a Jaboulay procedure the sac is
everted and sutured behind the testis.
Working Party of the Royal College of Surgeons. Clinical
guidelines on the management of groin hernias in adults. RCS
Kingsnorth A N. Modern hernia management.
In: eds. Taylor I Johnson C D Recent Advances in surgery 18.
Churchill Livingston 1995. 159 - 178.
Kingsnorth A N. Inguinal hernia repair.
Current Practice in Surgery 1993; 5: 202 - 206.