535

Sonographic Diagnosis of
Scrotal Hernia

Bala R. Subramanyam1 Sonography was used to evaluate 65 patients with the clinical diagnosis of primary
Emil Balthazar
J.
scrotal mass. A preoperative diagnosis of scrotal hernia was made in six patients and
B. Nagesh Raghavendra confirmed in five cases. There was one false-positive result due to an inguinoscrotal
Steven Horii
abscess. Scanning the inguinal region in addition to the scrotum facilitated the diag-
American Journal of Roentgenology 1982.139:535-538.

C.
nosis of scrotal hernia by identifying intestine and/or omentum within the inguinal
Susan Hilton
canal with extension into the scrotum.

Congenital on acquired inguinal hernia extending into the scrotum is a common

clinical entity. The diagnosis is usually made on the basis of a pertinent history
and a careful physical examination. Occasionally, however, scrotal hernias can
present as hand, nontransilluminant, nonreducible masses clinically indistinguish-
able from primary scrotal masses. The preoperative diagnosis of an incarcerated
scrotal hernia in these cases is essential to plan treatment, especially in selecting
the appropriate surgical approach.
Sonognaphy has been effective in the evaluation of primary scrotal masses
[1 -5]. We have attempted to assess the utility of sonography in the differentiation
of scrotal hernia from other extratesticular or testicular masses by scanning the
inguinal region in addition to the scrotum. This report briefly reviews the anatomy
of the inguinoscrotal region and the pertinent sonognaphic literature, presents
our experience in attempting to assess the nature of a palpable scrotal mass,
and describes reliable and helpful sonognaphic criteria for differentiating ingui-
noscrotal hernias from primary scrotal masses and stresses the importance of
scanning the inguinal region in such cases.

Anatomy

Scrotal hernias are inguinal hernias that are classified into direct and indirect
types. Pertinent anatomy is presented in figure 1.
The superficial (external) inguinal ring, an opening in the aponeunosis of the
external oblique muscle, is located just above and lateral to the pubic crest. The
deep (internal) inguinal ring is located in the tnansvensalis fascia midway between
the anterior superior iliac spine and the symphysis pubis. The inguinal canal
extends from the deep inguinal ring to the superficial inguinal ring in an oblique,
medially directed course.
An indirect inguinal hernia leaves the abdominal cavity at the deep inguinal
Received March 5, 1 982; accepted after revi-
sion June 2, 1982. ring, traverses through the inguinal canal, and may enter the scrotum. A direct
‘All authors: Department of Radiology, New inguinal hernia occurs due to a weakness in the floor of the inguinal canal in
York University Medical Center, 560 First Ave., Hesselbach’s triangle which is formed medially by the lateral border of the nectus
New York, NY 1 001 6. Address reprint requests to
sheath, laterally by the inferior epigastnic artery, and infenionly by the inguinal
B. R. Subramanyam.
ligament. A direct inguinal hernia protrudes immediately forward toward the
AJR 1 39:535-538, September 1982
0361 -8o3x/82/1 393-0535 $00.00 superficial inguinal ring and, on occasion, may extend into the scrotum through
© American Roentgen Ray Society the superficial inguinal ring. Inguinal hernias are often associated with patency
 536 SUBRAMANYAM ET AL. AJR:139, September 1982
American Journal of Roentgenology 1982.139:535-538.

Fig. 1 -Anatomy of inguinoscrotal region. ASIS = anterior superior iliac Fig. 3.-Scrotal hernia containing small bowel. A, Transverse sonogram
spine; IL = inguinal ligament; DIR = deep inguinal ring; SIR = superficial of scrotum. Normal testes (RT, LT). Fluid-filled small bowel seen as anechoic
inguinal ring; HS = hernial sac and contents; T = testes; RS = rectus sheath; mass (M) simulating primary scrotal fluid collection. B, Longitudinal sonogram
EA = epigastric artery; HT = Hesselbach’s triangle. Straight and dashed along axis of inguinal canal. Fluid-filled small bowel (arrows) extends from
arrows represent scanning plane of inguinal canal and Hesselbachs triangle. superficial inquinal ring (SIR) to scrotum.

anterior superior iliac spine to the pubic crest to cover the full extent
of the inguinal canal. When the examination of the inguinal canal
was normal (fig. 2), sonograms were obtained in a similar fashion,
but beginning at Hesselbach’s triangle and extending across the
superficial inguinal ring to the scrotum. In selected cases, a linear-
array real-time scanner (Toshiba) was used to assess bowel pen-
stalsis. The sonographic criteria adapted for the diagnosis of a
scrotal hernia were: (1 ) identification of bowel within the scrotum,
(2) presence of hernia contents in the inguinal region, and (3)
normal testes.

Fig. 2.-Normal sonogram of inguinal canal. DIR = deep inguinal ring;

Results
SIR = superficial inguinal ring; T = testes.
Of the 65 patients studied, 59 had a variety of primary
scrotal pathology. The other six cases were preopenatively
diagnosed by sonography as having scrotal hernias but
of the processus vaginalis which normally obliterates com- otherwise normal scrotal contents. At surgery, five patients
pletely to form a fibrous cord, the ligamentum vaginale. had scrotal hernias and one patient had an inguinal abscess
extending into the scrotum. Among the five cases of hernia,
four were of the indirect and one of the direct type. The
Subjects and Methods
hernia sac contained small bowel in three cases and omen-
During a 1 year period, 65 patients with scrotal swelling and a tum in two cases.
clinical diagnosis of probable or suspected testicular pathology Sonograms of the scrotum revealed an anechoic mass
were referred for sonographic evaluation. Sonography was per-
surrounding normal testicular elements in cases of small
formed using a commercially available contact B-scan unit (Unirad
bowel hernia (fig. 3A) on a highly echogenic mass separate
Sonograph EDP 1 000). Sonograms were obtained through a water-
from the testes in omental hernias (fig. 4A). A definitive
bath in the sagittal and transverse axes using internal-focused, 5
MHz transducers. When the sonograms revealed extratesticular differentiation of scrotal hernia from primary extratesticular
pathology of uncertain etiology, additional contact scans along the fluid collection on solid mass could not be made from the
axis of the inguinal canal and/or Hesselbach’s triangle were per- sonognams of the scrotum alone except in one case, con-
formed (fig. 1). Using a 5 MHz, short-focus transducer, oblique nectly diagnosed on the basis of visible penistalsis on neal-
longitudinal sonograms were obtained at 5 mm increments from the time scanning.
 AJR:139, September 1982 SONOGRAPHY OF SCROTAL HERNIA 537

A
American Journal of Roentgenology 1982.139:535-538.

L
Fig. 5.-Inguinoscrotal abscess simulating scrotal hernia. A, Transverse
sonogram of scrotum. Solid mass (M) separate from left testes (LT). B,
Longitudinal sonogram. Echogenic abscess (M) extends from inguinal region
to scrotum, separate from left testes (LT). SIR = superficial inguinal ring.

Fig. 4.-Scrotal hernia containing omentum. A. Transverse sonogram of

scrotum. Normal testicular elements (RT, LT). Omentum seen as echogenic
mass (M) indistinguishable from primary scrotal mass. B, Longitudinal sono-
gram of inguinal canal. Echogenic mass (M) extends to scrotum from super-
ficial inguinal ring (SIR). Normal testes (RT).

In all cases of scrotal hernia, contact sonograms of the

inguinal region markedly facilitated and/or confirmed the
diagnosis of inguinoscrotal hernia by demonstrating loops
of bowel (fig. 3B) on echogenic omentum (fig. 4B) in the
inguinal canal. There was one false-positive result due to an
inguinoscrotal abscess (fig. 5). Although the extent of the
pathology was precisely shown on sonognaphy, the error in
Fig. 6.-Primary scrotal hematocele simulating scrotal hernia containing
diagnosis was due to the unusual echogenic appearance of fluid-filled small bowel. Longitudinal sonogram. Normal testes (T) and extra-
the abscess. Sonography was not helpful in differentiating testicular complex mass (M) confined to scrotum, thereby excluding scrotal
hernia.
indirect from direct inguinal hernias.

Discussion

Sonography has been used in the diagnosis of abdominal

wall herniations as well as pathologic conditions affecting
the inguinal and femonal regions [6-9]. It provides a rapid
and noninvasive method of imaging the scrotal contents and
has enabled differentiation of testicular from extratesticular
pathology in most cases [1 -5]. Scrotal hernia constitutes a
secondary extratesticular mass with its origin in the abdo-
men. The contents of the hernia sac includes small bowel or
colon and/or omentum in most cases.
If the scrotum alone is scanned, the diagnosis of scrotal L
hernia containing bowel is based on the recognition of Fig. 7.-Primary lipoma of scrotum mimicking scrotal hernia containing
omentum. Transverse sonogram of scrotum. Normal testes (RT, LT) and
valvulae conniventes on haustrations [1 0] and on the detec-
highly echogenic extratesticular mass (M). Scans of inguinal canal (not
tion of penistalsis on real-time sonognaphy. In the absence shown) were normal which excluded omental hernia.
 538 SUBRAMANYAM ET AL. AJR:139, September 1982

of these features, the diagnosis of scrotal hernia is difficult. 2. Leopold GA, Woo VL, Scheible FW, Nachtsheim D, Gosink BB.
Even when these features are present, extratesticular pa- High resolution ultrasonography of scrotal pathology. Radio!-

thology, such as multiloculated hydnocele and hematocele ogy 1979;131 :719-722

3. Phillips GN, Schneider M, Goodman JD, Maachia RJ. Ultra-
containing fibninous septa, can simulate fluid-filled loops of
sonic evaluation of the scrotum. Urol Radiol 1980;1 :157-163
bowel (fig. 6). In addition, fatty tissue and fat-containing
4. Wilson PC, Valvo JA, Gramiak A, Frank IN. Automated water-
masses can produce high-amplitude echoes [1 1 -1 3] similar
bath ultrasonic examination of the scrotum. Urology 1981;
to a primary scrotal mass containing fat (fig. 7). Due to 18: 94-99
similarity in their echo amplitude, these masses may be 5. Arger PH., Mulhern CB Jr, Coleman BG, et al. Prospective
impossible to differentiate from a scrotal hernia containing analysis of the value of scrotal ultrasound. Radiology
omentum. For these reasons, scanning along the plane of 1981;141 :763-766
the inguinal canal and the region of the Hesselbach’s tnian- 6. Fried AM, Meeker WA. Incarcerated Spigelian hernia: ultra-
gle should always be performed when evaluating a scrotal sonic differential diagnosis. AJR 1 980; 1 33 : 1 07-1 10
mass. 7. Sutphen JH, Hitchcock DA, King DC. Ultrasonic demonstration
of Spigelian hernia. AJR 1980;134:174-175
On the basis of our study, we consider the following
8. Deitch EA, Soncrant MC. The value of ultrasound in the diag-
sonographic criteria to be reliable and helpful in diffenen-
nosis of nonpalpable femoral hernias. Arch Surg 1981;
tiating scrotal hernia from primary scrotal pathology: (1)
116: 185-1 87
identification of loops of bowel within the scrotum, (2) exclu- 9. Deitch EA, Soncrant MC. Ultrasonic diagnosis of surgical dis-
sion of testicular pathology by the demonstration of normal ease of the inguino-femoral region. Surg Gynecol Obstet
testicular elements, and (3) presence of hernia sac in the 1981;152:319-322
inguinal region containing bowel and/or omentum. 1 0. Fleischer AC, Dowling AD, Weinstein ML, James AE Jr. Son-
ographic patterns of distended, fluid-filled bowel. Radiology
American Journal of Roentgenology 1982.139:535-538.

1979;133:681 -685
ACKNOWLEDGMENTS
1 1 . Behan M, Kazam E. The echographic characteristics of fatty
We thank Eileen G. Weinstein and Virginia P. ElweII for technical tissues and tumors. Radiology 1 978; 129:143-151
assistance. 1 2. Scheible W, Ellenbogen PH, Leopold GA, Siao NT. Lipomatous
tumors of the kidney and adrenal: apparent echographic spec-
ificity. Radiology 1978;1 29:153-156
REFERENCES
1 3. Bree AL, Schwab RE. Contribution of mesentenic fat to unsat-
1 . Sample WF, Gottesman JE, Skinner DG, Ehrlich AM. Gray isfactory abdominal and pelvic ultrasonography. Radiology
scale ultrasound of the scrotum. Radiology 1 978;1 27 : 225- 1981140:773-776
228