A 60 y.o. male with a hx of L inguinal hernia for 20 years comes in the scrotal swelling

What appears to be wrong?

A CT scan was done

Our patient had a strangulated inguinal hernia.  Why do the testes exist outside the body cavity allowing hernias to develop?

The hypothesis is that the evolution of the scrotum happened when body temperatures began to increase after the rise of mammals in the Cenozoic. Body temperature rose as mammals began to run and Boreoeutheria (mammals comprising lagomaorphs, carnivores , bat, ungulates,rodents and primates) preserved lower temperatures for spermatogenesis to prevent mutations.

In the elephant the testes are inside the body and this is felt to be due to gene mutations late in the evolution of mammals. They belong to Afrotheria as do manatees. The defect is in gene RXFP2.

Hernias are common and it is estimated that 5% of individuals will develop an abdominal wall hernia over their lifetime.  The most common type of groin hernia in both men is the indirect inguinal hernia.  Often the inguinal ring is dilated at birth and gradually enlarges over time although hernias can also be acquired due to trauma. The risk of developing  incarceration or strangulation is estimated at 1-3%.

While the inguinal hernia was obvious in this case,  occult hernias are common and not palpable on physical examination. Occult inguinal hernias may be even more difficult to diagnose in women where the inguinal ring is small and carries the round ligament. MRI is recommended to make the diagnosis because it can be missed on US and CT. The patient also exhibited another problem common in scrotal edema,  the “vanishing penis syndrome”. 

Our patient was taken to the OR on 2/8 where an extensive inguinal hernia was found that was ischemic and could not be reduced through the inguinal ring. The R colon was removed and he was left in discontinuity. He developed septic shock and was taken back 2/9 for resection involving the splenic flexure.  Because of the distention of the scrotum a large area of skin became necrotic and a graft was performed.  The arterial supply of the L testes was compromised and an orchiopexy was performed to maintain flow.  His post op course was prolonged because he needed treatment for CLL.  The pt eventually was discharged.

femoral hernias are more common in women

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