Inflammatory vasitis is a rare entity and a challenging diagnosis to differentiate from inguinal hernia. We are reporting the case of a 54-year-old man with inguinal pain who underwent emergency surgery for suspicion of an incarcerated inguinal hernia diagnosed by ultrasound. No incarcerated hernia was found at surgery.Instead, inflammation was present around the deferens. Since a small indirect, non-incarcerated hernia and a weakness of the inguinal floor were found, repair with a mesh was done.A physical examination the following morning revealed exactly the same induration associated with inguinal pain. A CT scan was obtained on post-operative day one, and the clinical evolution raised suspicion of a vasitis. The patient was then treated accordingly with antibiotics.Ultrasound did not clearly differentiate vasitis from incarcerated hernia.In case of a questionable incarcerated inguinal hernia, a CT scan should be performed and may lead to an avoidance of surgery.
Keywords: Vasitis; incarcerated inguinal hernia; general surgery, inguinal imaging; differential diagnosis
Vasitis is a condition separated by Chan and Schlegel  into two clinical entities. First, vasitis nodosa is a common asymptomatic urologic disease localized at the vas deferens. This is often associated with a history of vasectomy (50-60%) . Second, the medical literature rarely reports an isolated infection of the vas deferens (inflammatory vasitis) described as an inguino-scrotal pain with the emergence of an irreducible mass that can be easily confused with an incarcerated inguinal hernia.Acute vasitis is mostly caused by backward infections from the prostatic urethra, prostate or seminal vesicles. The common pathogens are Escherichia coli and Haemophilus influenzae . The usual appropriate treatment is antibiotics, as in epididymitis cases [3-5].
A 54-year-old man presented at the emergency department with a complaint of left inguino-scrotal pain including the appearance of a non-reducible mass in the groin. He had a vasectomy 5 years ago, and suffered from type 2 diabetes mellitus. The patient did not report symptoms of urinary tract infection but had a temperature of 38.2 °C. The patient had been with a stable sexual partner for 17 years. He had no history of sexually transmitted infections but was known for previous urinary tract infections. Physical examination revealed a redness of the scrotum and an irreducible mass was palpated in the left inguinal area and in the posterior testes area. Laboratory results revealed a leukocytosis (14.3 x109/L) with 82% neutrophils; the C-reactive protein was elevated at 130.2 mg/L.Urine analysis revealed 11-20 leucocytes count and positive nitrites.
A testicular ultrasound revealed a distension of the inguinal canal with a 4-cm hyperechoic mass extending to the scrotum. The presumed hernia seemed to contain omentum but no bowel loops (Figure 1A). The color doppler imaging showed hypervascularity suggesting venous congestion (Figure 1 B).
Following the diagnosis of an incarcerated inguinal hernia, the patient was brought to the operating room to undergo an inguinal hernia surgery repair.During the operation, a small indirect hernia was noticed with no content and the presence of inflammatory tissue limited around the vas deferens.A mesh was positioned to strengthen the weakness of the inguinal area.The day after surgery, the surgeon noticed the persistence of an inguinalmassandassociatedpain.Urine culture was positive for an E. coli urinary infection with >108 bacteria/L.A new ultrasound was prescribed and the radiologist noticed the persistence of an inguinal mass consistent with a hernia. This diagnosis did not correspond to what was observed during surgery, so a CT scan was done to characterize the condition with more precision.The scan revealed the presence of iatrogenic air densities in the region of the inguinal canal, with inflamed fat and a persistence of fat hernia in the left hemiscrotum. Calcification of the vas deferens was also identified (Figures 2).
With the persistence of pain, a urology consultation was requested for a second opinion. The vasitis was confirmed after reviewing the scanner images.PCR was negative for gonorrhea and Chlamydia [6,7]. Vasitis was treated with the appropriate antibiotics for E.Coli. Therapy brought a very good response and diminution of the pain within a few days. The patient observed resolution of symptoms and hernia surgery repair did not affect recovery.
Vasitis was reported by Wesson  in 1926 and Wolbarst in 1933, being clinically confounded with hernia (Table 1).
In these case reports, it is recommended to use a CT scan [3.5] to differentiate these two entities. In almost all case report of inflammatory vasitis, the CT scan allowed a formal diagnosis of this clinical entity [3-5]. A unique case presenting inconclusive scanner imaging was described by S. Hye You et al . As a case of “Emphysematous Vasitis” in a patient with a history of vasectomy, type 2 diabetes and a urinary infection with E. coli. Another case was confused with Amyand’s hernia. According to the literature review, most of the vasitis cases were due to a urinary tract infection by a microbiological pathogen  in patients with previous vasectomy. Therefore, painful inguinal mass with urinary tract infection and clinical history of vasectomy could guide clinicians to the diagnosis of vasitis.Urinary tract infection is not related to incarcerated omentum, as suspected in this case with the ultrasound. Infectious signs and urinary tract infection should have led to a CT scan, avoiding unnecessary operation.Surgeons and radiologists should be aware of this rare condition.
In conclusion, in case of questionable incarcerated inguinal hernia, a CT scan should be performed. A high level of suspicion by the radiologist and the surgeon is desirable to guide the diagnosis.The symptoms and the patient’s history of vasectomy associated with the urinary tract infection could have led the clinician to a faster diagnosis of inflammatory vasitis and therefore spared him the unnecessary surgery. These symptoms complex should be pointing to differential diagnosis of vasitis. Antibiotherapy is the treatment for vasitis, not surgery [3-5].
Informed consent statement: The patient gave informed, written consent for publication on this case report.
Financial disclosure: None.
Conflict of interest: The authors declare that they have no conflict of interest.
- Chan PTK and Schlegel PN (2002) Inflammatory conditions of the male excurrent ductal system. Part I and II. J Androl 23: 453-469.
- Mo Yang D, Cheol Kim H, Lae Lee H, Won Lim J, Young Kim G (2010) Sonographic Findings of Acute Vasitis. American Institute of Ultrasound in Medicine. J Ultrasound Med 29: 1711-1715.
- Eddy K, Connell D, Goodacre B, Eddy R (2011) Imaging findings prevent unnecessary surgery in vasitis: An under-reported condition mimicking inguinal hernia. Clinical Radiology 66: 475-477.
- Eddy K, Piercy GB, Eddy R (2011) Vasitis: clinical and ultrasound confusion with inguinal hernia clarified by computed tomography. Can UrolAssoc J 5: 74-76.
- Kerkeni W, Saadi A, Ben Miled A, Chakroun M, Ayed H, et al. (2016) Vasitis: An Uncommon Diagnosis Mimicking Incarcerated Inguinal Hernia. Images in clinical Urology 93: 1.
- Hirschowitz L, Rode J, Guillebaud J, Bounds W, Moss E (1988) Vasitis nodosa and associated clinical findings. Journal of Clinical pathology 41: 419-423.
- Hye You S, Jae Sung D, Yeon Han N, Jin Park B, Ju Kim M (2014) Emphysematous vasitis misdiagnosed as strangulated inguinal hernia.The Journal of Emergency Medicine 47: 15-17.
- Wesson MB (1926) Industrial hernia versus seminal vesiculitis and Vasitis. Cal West Med24:212-217.
- Wolbarst AL (1933) Vas deferens, generally unrecognized clinical entity in urogenital disease. J Urol 29:405
- Maitra AK (1970) Odd inguinal swelling. Lancet 1: 45
- Bissada NK and Redman JF (1976) Unusual masses in the spermatic cord: report of six cases and review of the literature. South Med J 69:1410-1412.
- Ryan SP and Harte PJ (1988) Suppurative inflammation of vas deferens: an unusual groin mass. Urology 31:245e6.
- Patel K, Lamb B, Pathak S, Peters J (2014) Vasitis: the need for imaging and clinical acumen. BMJ Case Rep 2014.
- Romero Marcos JM, Baena Bradaschia S , Munoz Perez JM, Cifuentes Rodenas JA (2017) Vasitis mimicking an Amyand’s hernia: A case report. International Journal of Surgery Case Reports 30: 34-36.
- Kerkeni W, Saadi A, Ben Miled A, Chakroun M, Ayed H, et al. (2016) Vasitis: An Uncommon Diagnosis Mimicking Incarcerated Inguinal Hernia.Urology 93: 1.
Figure 1: Pre-operative pelvic sonography: (A) Red arrow on the left: hyperechoic inguinal mass suggestive of hernia; red arrow on the right: testicle, (B) Red arrow: Thickened spermatic cord with hyperemia on color doppler ultrasound.
Figure 2 Post-operative imaging: (A and B): Transverse CT images showing inflammation of the left inguinal canal (red arrow) compared to the normal cord on the right.
(C) Coronal CT image showing abnormal left spermatic cord edema and fat infiltration (red arrow).
(D) Coronal CT image showing prominence of the vessels of the left spermatic cord(red arrow).
|Authors and year of publication||Number of cases of vasitis||Patients||Radiologic Investigation||First Diagnosis||treatment|
|Maitra AK 1970||1||67 yo||None||Incarcerated Inguinal hernia||Surgery: Drainage of an abcess adjacent to the vas deferens. Excision of the cord andtestis|
|1||46 yo||None||Incarcerated Inguinal hernia||Surgery: excision of the vas|
|Ryan SP1988 ||1||25 yo||None||Incarcerated Inguinal hernia||Surgery: drainage of an abcess adjacent to the vas deferens|
|Eddy K 2011 ||3||40, 32 and 61 yo,||Ultrasound
|You SH 2013||1||69 yo||CT||Strangulated Inguinal hernia||Debridement and antibiotics|
|Patel K 2014
|1||55 yo||Ultrasound and MRI||Vasitis||Antibiotics|
|Romero Marcos JM
|1||42 yo||Ultrasound and CT||Amyand’s hernia||Laparoscopic exploration.
Incisional biopsy of the inflamedvas deferens
|Kerkeni W 2016 15||1||31 yo||Ultrasound and CT||Vasitis||Antibiotics|
Table 1: More recent literature lists ten cases of inflammatory vasitis still clinically or radiologically confused with the common diagnosis of incarcerated inguinal hernia.
Citation: Ferrant L, Sabbagh R, Voyer N, McFadden N(2017)Vasitis Vs Incarcerated Inguinal Hernia: A Differential Diagnosis Challenge. J Surg 2017. J125.