CASE
A 40-year-old male was seen in the emergency department (ED) of another facility with complaints of increasingly severe pain, pressure, and swelling in the left groin and in the skin of the penis and scrotum. The patient believed his symptoms, which had begun 5 days earlier, resulted from a groin strain he sustained while installing wiring in a ceiling. An ultrasound done before the patient's visit to the ED showed left testicular microlithiasis, a small varicocele, and a hydrocele. An abdominal radiograph done as part of that same evaluation showed no evidence of ileus or small bowel obstruction. According to the patient, the presumed diagnosis was left inguinal hernia (LIH), varicocele, and hydrocele. He was given morphine for pain in the ED, advised to follow up with his primary care physician (PCP), and sent home on hydrocodone, which relieved the pain temporarily.
The pain was adequately controlled with hydrocodone and acetaminophen until day 8, when the patient presented to our ED. At that time, he complained of generalized groin pain, which he rated as 10 on a 10-point scale, and lower abdominal pain, which he described as constant and gradually increasing. He reported decreased appetite and nausea with several episodes of emesis and said that he had not had a bowel movement for 4 days. There had been no trauma to the area. The patient admitted to being sexually active but denied recent unprotected sex. The medical history was significant for alcohol abuse. He had no history of surgery.
Physical examination revealed tachycardia (heart rate, 118 beats per minute); other vital signs were unremarkable. Swelling and induration were noted along the pubic symphysis and left groin. Tense, cordlike swelling was visible along the left inguinal canal, and palpation detected a firm mass extending beyond the external inguinal ring into the scrotum. The mass was nonreducible, and the area along the left groin was exquisitely tender to palpation. The skin of the penis and scrotum was edematous, and the testes were mildly tender to palpation bilaterally. There was no evidence of trauma.
Laboratory results were remarkable for a WBC count of 25,970 /µL, with a left shift and 19% bands. Results of urinalysis (UA) were unremarkable. Concerned about a possible incarcerated hernia, the clinician in the ED consulted a surgeon, who agreed with the diagnosis. He obtained consent for an exploratory laparotomy and LIH repair and ordered abdominal/pelvic CT with contrast (Figure 1 and Figure 2, see Slideshow). Because the genitalia were involved, the surgeon consulted a urologist, who also agreed with the diagnosis of an incarcerated LIH. What do the CT scans show?