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Too small to be “real hernia” …. ultrasound vs MRI?
Thank you for the opportunity to ask questions directly to expert doctors.
I have consistent pain in the testicle, scrotum, and following up above the groin crease towards the hip bone. It’s kind of similar to the feeling of getting lightly hit in the testicles but hard to describe otherwise, it’s deep, not on the skin. I’m a regular guy, office job, reasonably in-shape weekend warrior type. After a bit of web research I thought maybe the pain is a hernia and get the referral.
Ultrasound tech sees 4 millimeters of hernia fat after really digging deep directly into the painful zone of the crease area.
Surgeon dismisses ultrasound, says it probably picked up some abdominal fat and that 4 millimeters is “too small” to be a hernia. Described the ultrasound as “like a rorschach ink blot test where you will see anything you want to see with the ultrasound.” Recommends MRI instead.
MRI of hips and pelvis. No findings.
Next recommendation was colonoscopy, but have not done that yet because it feels like the wrong direction.
I have taken 6 months of rest off of any physical activity to try and “heal” the problem but the pain remains. It doesn’t seem like it’s healing itself which makes me think it is not a muscle problem. There isn’t anything popping out and I have passed multiple multiple cough tests.
Is something “too small” to be a “real hernia” or painful? Is the ultrasound inaccurate? Is MRI conclusive? Have you seen something like this? What next?
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6 Replies
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Too small to be “real hernia” …. ultrasound vs MRI?
Robo – Neither the ultrasound or MRI are definitive. Be sure however to check the MRI report for evidence of tendon inflammation, especially the adductor tendon. The only definitive way to check for a hernia is an operation, which I would suggest be done laparoscopically. Because the herniated contents may only be a small amount of fat, I usually don’t only place a mesh if I see something, rather decide up front whether or not to do a hernia repair. In my experience, about 60-70% of people get better with this approach. Since pain is your primary problem, it doesn’t make sense to do an open approach, which is known to have a higher risk of post-op pain. So it really boils down to how bad the pain is. If you can take it, and do all your normal stuff, then maybe watch it. If not, then maybe opt for a lap hernia repair with an experienced surgeon that is willing to get on board. Hope this helps!
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Too small to be “real hernia” …. ultrasound vs MRI?
I see a lot of women and they tend to have very very small but symptomatic hernias. Hernia repair cures their pain. We presented our data in Milan about this at the World Hernia Congress, to prove that 87% of these patients with hidden/occult hernias are cured of their pain.
In my world, with the right exam and history, yes, a 4mm piece of fat can cause hernia pain.
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Too small to be “real hernia” …. ultrasound vs MRI?
Thanks for the follow up Robo. Appreciate your kind thanks and not a problem at all. So they are definitely identifying something on the ultrasound which is hard to interpret as whether it is causing your pain. I asked the belt question because this is a common cause of irritation of the nerves in that area with tool belts. Any exercises you have started (p90X, crossfit, etc) recently that may be to blame. Any specific circumstances at work? As far as the block goes that would require a referral to a pain management specialist that specializes in nerve blocks. Most surgeons know “the guy” in their area and your PCP or surgeon could refer you. All it really does is say that if we numb the nerve does the pain go away. In some cases it is yes and that indicates there is inflammation associate with the nerve or something impinging it. In that case I often explore, repair the hernia, and if the nerve looks super inflammed or like it is bow stringing on the external ring in a thin patient (which happens more often than we think, then I will often excise the nerve at the orginal surgery. Not ideal but alleviates the pain and fixes any hernia or weakness in the floor of the inguinal canal. I am not sure this will be of super benefit unless it helps guide your decision on surgery or no surgery. With neurectomy you will often get numbness on the medial thigh, lateral scrotum, and sometime in suprapubic area to varying degrees. Most often I tell my male patients to think about when they are walking and they dont feel their testicles clanging against their legs for the most part so you really will not even notice that much and everything will work just fine in the bedroom. I have never had someone complain about this long term but I have had patients with chronic pain that is worse to deal with. Best of luck and happy to review the films if you wanted to send them over to my office. Just let me know. Paul pszotek@iupui.edu
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Too small to be “real hernia” …. ultrasound vs MRI?
Dr. Szotek and Dr. Lederman, thank you both for taking the time to answer my questions.
The ultrasound was done while bearing down and also normally, but don’t recall during which part they noticed it. The paper report mentioned the 4 mm fat hernia in the groin region. Not sure how it was measured but they were using a cursor on the reading screen making little marks throughout the scan. They also did a scrotum ultrasound which assume was normal because never heard anything about that part. MRI was laying down, no contrast used.
I don’t wear a belt, stopped wearing belts and tighter pants because the waist area seems to fall in the area that can hurt and aggravate it. I did the basic urology urine workup and went through antibiotics for good measure but it had no effect.
Is the nerve block idea promising? Is that attempted to inject into nerve or into the possible hernia area itself? This may be a stupid question but can something be injected that would dissolve the fat to see if that tiny piece of fat is the problem? Who is best to do accurate nerve blocks?
Is there a definitive way to rule in or out a hernia? If there is a hernia, is there one type of hernia repair that would be preferred over another for this type of situation?
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Too small to be “real hernia” …. ultrasound vs MRI?
To answer your question directly – yes, 4 mm is really too small to be a groin hernia. I have seen very small symptomatic hernias at the umbilicus (belly button) but not in the groin, and I would seriously doubt ultrasound could pick up a small hernia that size.
I hope that helps.
Dr. Andrew Lederman
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Too small to be “real hernia” …. ultrasound vs MRI?
Robo,
Thanks for using the forum for your question. I think this is a difficult situation. Do you wear a belt at work? Unfortunately radiographically it seems like very little is turning up. Did the final report on the ultrasound say the same as the tech? Often techs tell patients what they see but may be misinterpreting the images which are then later confirmed or denied by the radiologist. Also did the tech notice this when you were bearing down?
One way to confirm or deny the pain is coming from a possible hernia is to have a nerve block and see if it relieves the pain. If it does then I would consider a hernia repair with possible neurectomy. Might be a bit aggressive but if any defect is causing pain then I think it needs to be fixed. Often what is found in these cases is a week floor with the nerves being bow stringed on the external ring and this often cases the pain. I don’t think any of the other work up studies would help very much after the two studies you had. One thing to consider is an appointment from a urologist to check the testicle if you are concerned. Hope that helps a bit. Take care and good luck. Dr. Szotek
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