What is the best diagnostic approach for a patient with testicular swelling and pelvic pain 11 years after inguinal hernia (IH) repair, should I consider a computed tomography (CT) scan of the pelvis and abdomen and an ultrasound (US) of the testicles to rule out complications from the hernia repair?

Diagnostic Approach for Testicular Swelling and Pelvic Pain After Inguinal Hernia Repair

Ultrasound of the scrotum should be the first-line imaging modality for evaluation of testicular swelling and pelvic pain in a patient with previous inguinal hernia repair. 1

Initial Evaluation

• Testicular swelling with pain after inguinal hernia repair may indicate several potential complications, including retained hernia contents, focal testicular ischemia, or inflammatory processes 2, 3, 4
• Ultrasound with Duplex Doppler of the scrotum is the most appropriate initial imaging study due to its high sensitivity for detecting testicular and scrotal abnormalities 1
• Duplex Doppler ultrasound combines grayscale and color Doppler examination, providing both anatomical detail and assessment of blood flow, which is crucial for evaluating potential vascular complications 1

Ultrasound Findings to Look For

• Grayscale ultrasound can identify structural abnormalities such as:

  • Retained hernia contents ("omentaloma") appearing as well-defined hypoechoic lesions 4
  • Focal areas of testicular infarction appearing as hypoechoic regions 3
  • Inflammatory changes in the epididymis or testis 1

• Color Doppler assessment is essential to evaluate:

  • Testicular perfusion to rule out ischemic complications 1
  • Hyperemia suggesting inflammatory processes 1
  • Vascular abnormalities that may have resulted from the hernia repair 3, 5

When to Consider CT Abdomen and Pelvis

• CT abdomen and pelvis should be considered as a second-line imaging modality when:

  • Ultrasound findings are equivocal or nondiagnostic 1
  • There is suspicion of a more extensive process extending into the abdomen or pelvis 1
  • Clinical concern for complications such as mesh migration, infection, or recurrent hernia that may not be fully visualized on ultrasound 2

• CT with intravenous contrast provides better assessment of:

  • Potential recurrent hernia extending into the inguinal canal 1
  • Inflammatory processes that may involve both scrotal contents and pelvic structures 1
  • Vascular complications that may not be fully appreciated on ultrasound 1

Common Complications After Inguinal Hernia Repair

• Potential complications to consider in this clinical scenario include:
  • Focal testicular infarction due to vascular compromise during surgery 3
  • Retained hernia contents in the scrotum ("omentaloma") 4
  • Mesh-related complications including migration or infection 5
  • Neuropathic pain from injury to the genital branch of the genitofemoral nerve 6
  • Recurrent hernia 5

Diagnostic Algorithm

1. Start with scrotal ultrasound with Duplex Doppler as the first imaging study 1
2. If ultrasound is inconclusive or suggests pathology extending beyond the scrotum, proceed to CT abdomen and pelvis with IV contrast 1
3. If there is concern for chronic pain syndrome related to nerve entrapment, consider MRI of the pelvis as a problem-solving tool 1

Important Caveats

• Testicular pain after hernia repair may be neuropathic in origin, related to injury or entrapment of the genital branch of the genitofemoral nerve, which may not be apparent on imaging 6
• Chronic pain after inguinal hernia repair occurs in approximately 5.1% of cases and should be considered in the differential diagnosis 5
• Vasal injury during hernia repair is reported in 0.1% to 0.53% of cases and may contribute to scrotal symptoms 5
• The timing of symptom onset (11 years post-repair in this case) is unusual for immediate post-surgical complications, suggesting either a late complication or an unrelated process 2, 3, 4