An incarcerated<unk>  as seen on cross sectional CT scan A frontal view of an incarcerated<unk>  (on the patient's left side) with dilated loops of bowel above. An<unk>  which contains part of the bladder. Bladder cancer also present. There are two types of<unk> , direct and indirect, which are defined by their relationship to the inferior epigastric vessels. Direct<unk> s occur medial to the inferior epigastric vessels when abdominal contents<unk> te through a weak spot in the fascia of the posterior wall of the<unk>  canal, which is formed by the transversalis fascia. Indirect<unk> s occur when abdominal contents protrude through the deep<unk>  ring, lateral to the inferior epigastric vessels; this may be caused by failure of embryonic closure of the processus vaginalis. In the case of the female, the opening of the superficial<unk>  ring is smaller than that of the male. As a result, the possibility for<unk> s through the<unk>  canal in males is much greater because they have a larger opening and therefore a much weaker wall through which the intestines may protrude. Type Description Relationship to inferior epigastric vessels Covered by internal spermatic fascia? Usual onset indirect<unk>  protrudes through the<unk>  ring and is ultimately the result of the failure of embryonic closure of the processus vaginalis after the testicle passes through it Lateral Yes Congenital / Adult direct<unk>  enters through a weak point in the fascia of the abdominal wall (Hesselbach triangle) Medial No Adult<unk> s, in turn, belong to groin<unk> s, which also includes femoral<unk> s. A femoral<unk>  is not via the<unk>  canal, but via the femoral canal, which normally allows passage of the common femoral artery and vein from the pelvis to the leg. In Amyand's<unk> , the content of the<unk> l sac is the vermiform appendix. Ultrasound image of<unk> . Moving intestines in<unk>  canal with respiration. In Littre's<unk> , the content of the<unk> l sac contains a Meckel's diverticulum. Clinical classification of<unk>  is also important according to which<unk>  is classified into # Reducible<unk> : is one which can be pushed back into the abdomen by putting manual pressure to it. # Irreducible/Incarcerated<unk> : is one which cannot be pushed back into the abdomen by applying manual pressure. Irreducible<unk> s are further classified into # Obstructed<unk> : is one in which the lumen of the<unk> ted part of intestine is obstructed. # Strangulated<unk> : is one in which the blood supply of the<unk>  contents is cut off, thus, leading to ischemia. The lumen of the intestine may be patent or not. Direct<unk>  The direct<unk>  enters through a weak point in the fascia of the abdominal wall, and its sac is noted to be medial to the inferior epigastric vessels. Direct<unk> s may occur in males or females, but males are ten times more likely to get a direct<unk> . A direct<unk>  protrudes through a weakened area in the transversalis fascia near the medial<unk>  fossa within an anatomic region known as the<unk>  or Hesselbach's triangle, an area defined by the edge of the rectus abdominis muscle, the<unk>  ligament and the inferior epigastric artery. These<unk> s are capable of exiting via the superficial<unk>  ring and are unable to extend into the scrotum. When a patient suffers a simultaneous direct and indirect<unk>  on the same side, it is called a pantaloon<unk>  or saddlebag<unk>  because it resembles a pair of pants with the epigastric vessels in the crotch, and the defects can be repaired separately or together. Another term for pantaloon<unk>  is Romberg’s<unk> . Since the abdominal walls weaken with age, direct<unk> s tend to occur in the middle-aged and elderly. This is in contrast to indirect<unk> s which can occur at any age including the young, since their etiology includes a congenital component where the<unk>  canal is left more patent (compared to individuals less susceptible to indirect<unk> s). Additional risk factors include chronic constipation, overweight/obesity, chronic cough, family history and prior episodes of direct<unk> s. Indirect<unk>  Ultrasound of an indirect<unk>  containing fat, with testicle seen at right. T2 weighted MRI of the same case (done for another purpose), also demonstrating fat content. Ultrasound showing an indirect<unk>  Incarcerated<unk>  An indirect<unk>  results from the failure of embryonic closure of the deep<unk>  ring after the testicle has passed through it. It is the most common cause of groin<unk> . A double indirect<unk>  has two sacs. In the male fetus, the peritoneum gives a coat to the testicle as it passes through this ring, forming a temporary connection called the processus vaginalis. In normal development, the processus is obliterated once the testicle is completely descended. The permanent coat of peritoneum that remains around the testicle is called the tunica vaginalis. The testicle remains connected to its blood vessels and the vas deferens, which make up the spermatic cord and descend through the<unk>  canal to the scrotum. The deep<unk>  ring, which is the beginning of the<unk>  canal, remains as an opening in the fascia transversalis, which forms the fascial inner wall of the spermatic cord. When the opening is larger than necessary for passage of the spermatic cord, the stage is set for an indirect<unk> . The protrusion of peritoneum through the internal<unk>  ring can be considered an incomplete obliteration of the processus. In an indirect<unk> , the protrusion passes through the deep<unk>  ring and is located lateral to the inferior epigastric artery. Hence, the conjoint tendon is not weakened. There are three main types *Bubonocele: in this case the<unk>  is limited in<unk>  canal. *Funicular: here the processus vaginalis is closed at its lower end just above the epididymis. The content of the<unk> l sac can be felt separately from the testis which lies below the<unk> . *Complete (or scrotal): here the processus vaginalis is patent throughout. The<unk> l sac is continuous with the tunica vaginalis of the testis. The<unk>  descends down to the bottom of the scrotum and it is difficult to differentiate the testis from<unk> . In the female, groin<unk> s are only 4% as common as in males. Indirect<unk>  is still the most common groin<unk>  for females. If a woman has an indirect<unk> , her internal<unk>  ring is patent, which is abnormal for females. The protrusion of peritoneum is not called "processus vaginalis" in women, as this structure is related to the migration of the testicle to the scrotum. It is simply a<unk>  sac. The eventual destination of the<unk>  contents for a woman is the labium majus on the same side, and<unk> s can enlarge one labium dramatically if they are allowed to progress. Medical imaging A physician may diagnose an<unk> , as well as the type, from medical history and physical examination. For confirmation or in uncertain cases, medical ultrasonography is the first choice of imaging, because it can both detect the<unk>  and evaluate its changes with for example pressure, standing and Valsalva maneuver. When assessed by ultrasound or cross sectional imaging with CT or MRI, the major differential in diagnosing indirect<unk> s is differentiation from spermatic cord lipomas, as both can contain only fat and extend along the<unk>  canal into the scrotum. On axial CT, lipomas originate inferior or lateral to the cord, and are located inside the cremaster muscle, while<unk> s lie anteromedial to the cord and are not intramuscular. Large lipomas may appear nearly indistinguishable as the fat engulfs anatomic boundaries, but they do not change position with coughing or straining. Differential diagnosis Differential diagnosis of the symptoms of<unk>  mainly includes the following potential conditions: * Femoral<unk>  * Epididymitis * Testicular torsion * Lipomas *<unk>  adenopathy (Lymph node Swelling) * Groin abscess * Saphenous vein dilation, called Saphena varix * Vascular aneurysm or pseudoaneurysm * Hydrocele * Varicocele * Cryptorchidism (Undescended testes)
Inguinal hernia
Epididymitis
Varicocele
Testicular cancer
Hydrocele
Testicular torsion
Perineal hernia
Hematocele