Ovarian Inguinal Hernia

Have you ever seen a condition or complaint so many times that you feel that there is no way it can surprise you? Yeah… me neither. I am positive every condition can humble us at one point or another. That being said, it is easy to become complacent (hopefully, the PedEM Morsels help to keep you vigilant) and one such case would be Inguinal Hernias. We have discussed how to reduce Inguinal Hernias before, but I forgot to mention, that it is not always so simple. What is in that canal after all? Could that lump in the groin be an Ovarian Inguinal Hernia?

Ovarian Inguinal Hernia

  • The Inguinal Canal [Sameshima, 2017]
    • Is narrow and short
    • Runs medial and parallel to the inguinal ligament
    • In Males it contains:
      • Spermatic cord (including arteries, veins, and nerves)
      • Ilioinguinal nerve
    • In Females it contains:
      • Round ligament of the uterus
      • Ilioinguinal nerve for the labia majora
  • Inguinal Hernias are common! [Tilt, 2014; Cascini, 2013]
    • Overall incidence is 0.8 – 4.4%.
    • Often seen during infancy… most common congenital anomaly in pediatrics.
    • Higher risk for premature infants (as high as 30%).
  • More than the intestine can be entrapped. [Sameshima, 2017; Aydin, 2013; Cascini, 2013]
    • Based on where the processus vaginalis fails to close (it typically closes by 2 months of age), different pathology can be seen:
      • Hydroceles
      • Indirect Inguinal Hernias
      • Herniation of gonads:
        • Cryptorchidism in males
        • Ovarian and Pelvic Organ Herniation in females
      • Herniation of other Pelvic organs:
        • Bladder
        • Omentum
  • Ovarian Herniation [Sameshima, 2017; Aydin, 2013; Cascini, 2013]
    • Uncommon, but…
    • Ovaries are found in 15-20% of the inguinal hernia sacs.
    • Fallopian Tube and even Uterus can also be herniated too!
    • The risk for incarceration of inguinal hernias is higher in female infants.
    • Once herniated, the risk of Ovarian incarceration is also high.

Ovarian Inguinal Hernia: Management

  • Physical exam can be unreliable to discern the true contents of the inguinal canal.
  • Obviously, if there is an inguinal hernia, try to reduce it (provided the region doesn’t already look necrotic!).
  • Have a low threshold for obtaining an Ultrasound with Doppler to better define the contents of the inguinal canal! [Sameshima, 2017; Tilt, 2014; Aydin, 2013; Cascini, 2013; Okada, 2012]
    • Ultrasound can differentiate direct, indirect, and femoral hernias.
    • It can also determine whether the contents are a hydrocele, lymph node or gonads!!
    • Doppler can further help “color” the picture by determining vascular compromise.
      • Be aware, however, that “good” blood flow to the ovary seen on Ultrasound does not change the need for expeditious reduction. [Boley, 1991]
      • Ovaries have two arterial blood supplies.
      • Torsion can still occur even after a reassuring exam.

Moral of the Morsel

  • It isn’t always intestine! Think about the other structures that may herniate and become incarcerated!
  • Incarcerated Hernia in a Female needs an Ultrasound! Distinguish what the contents in the canal are.
  • Even asymptomatic ovarian inguinal hernias need reduction. The blood supply may be good now, but don’t count on it staying that way.

References

Sameshima YT1, Yamanari MG2, Silva MA2, Neto MJ2, Funari MB2. The challenging sonographic inguinal canal evaluation in neonates and children: an update of differential diagnoses. Pediatr Radiol. 2017 Apr;47(4):461-472. PMID: 27832304. [PubMed] [Read by QxMD]
Tilt L1, Kessler DO. Rapid evaluation of an inguinal mass in a female infant using point-of-care ultrasound. Pediatr Emerg Care. 2014 May;30(5):366-7. PMID: 24786996. [PubMed] [Read by QxMD]
Cascini V1, Lisi G, Di Renzo D, Pappalepore N, Lelli Chiesa P. Irreducible indirect inguinal hernia containing uterus and bilateral adnexa in a premature female infant: report of an exceptional case and review of the literature. J Pediatr Surg. 2013 Jan;48(1):e17-9. PMID: 23331833. [PubMed] [Read by QxMD]
Aydin R1, Polat AV, Ozaydin I, Aydin G. Gray-scale and color Doppler ultrasound imaging findings of an ovarian inguinal hernia and torsion of the herniated ovary: a case report. Pediatr Emerg Care. 2013 Mar;29(3):364-5. PMID: 23462392. [PubMed] [Read by QxMD]
Okada T1, Sasaki S, Honda S, Miyagi H, Minato M, Todo S. Irreducible indirect inguinal hernia containing uterus, ovaries, and Fallopian tubes. Hernia. 2012 Aug;16(4):471-3. PMID: 21213003. [PubMed] [Read by QxMD]
Boley SJ1, Cahn D, Lauer T, Weinberg G, Kleinhaus S. The irreducible ovary: a true emergency. J Pediatr Surg. 1991 Sep;26(9):1035-8. PMID: 1941479. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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