Spermatic cord abscess after coronary angiography via femoral artery mimicking incarcerated inguinal hernia.

Emergency presentation of a groin lump has many possible causes. Spermatic cord abscess is an extremely rare condition with only two cases published. Both published cases of spermatic cord abscess were an extension from the primary intra-abdominal pathologic process [1,2]. We report the first case of external inoculation of the bacteria (Staphylococcus aureus) into the spermatic cord during coronary angiography via femoral artery. The patient presented as incarcerated inguinal hernia. A 70-y-old man presented to the emergency department with a 5-d history of painful mass in the right groin. During that period the mass increased in size with increasing pain. The patient was afebrile without vomiting or abdominal pain, with regular daily passage of stool and flatus. The mass was tender, irreducible, 3 cm in diameter, and did not increase with Valsalva maneuver. The mass was not pulsatile. Overlying skin was normal without signs of previous puncture or hematoma ( F1c Fig. 1) and pseudo-oaneurysm was excluded clinically. The scrotal skin and testicles were normal without signs of tumor or infection. The patient had undergone a coronary angiography through the right femoral artery 1 mo ago due to angina pectoris. There was no history of groin hernia. There was no other infective process in the body present. Plain abdominal radiograph was unremarkable. The conclusion was that the primary pathology was localized in the groin and emergency operation due to incarcerated inguinal hernia was indicated. During the operation, an irreducible mass in the spermatic cord was found. After division of the cremaster muscle, an oval encapsulated mass 4 · 2 cm was found without elements of the groin hernia ( F2c Fig. 2). The abscess with the complete capsule mimicking indirect inguinal hernia was removed ( F3c Fig. 3 AU1c ). Because dense white-yellowish pus was present, empiric antibiotic therapy against Staphylococcus aureus with cloxacillin 4 · 1 g and garamycin 2 · 120 mg was administered. The wound was left open with daily cleansing with skin sutures placed on the third post-operative day. Cultures confirmed S. aureus sensitive to cloxacillin that was continued for 5 d postoperatively. During hospitalization the patient was afebrile. After 3 mo the patient was symptomless. The differential diagnosis of groin mass includes variety of conditions that could be divided into primary groin conditions and distant primary pathologic processes extending into the groin. The most common primary spermatic cord pathology includes tumors—rare primary tumors of the spermatic cord [3] or metastatic tumors to the cord [4]. Tumors often manifest as a painless, slow growing masses in the groin. Features suggestive of malignancy include rapid growth, large size, and symptomatic presentation. Another group are infections presenting as tender masses with other symptoms and signs of infection. Infective process can be inoculated, extension from the surrounding infection or hematogenous. The third group consists of spermatic cord hematomas that may be idiopathic, traumatic, secondary to anticoagulation therapy, or as an extension of a retroperitoneal hemorrhage [5]. While common inguinoscrotal swellings (hernias and hydrocoeles) can be diagnosed on clinical examination, all the atypical swellings should be further investigated before surgical exploration. In our case there was no fever or signs of inflammation on the overlying skin. This is due to the small size of the abscess and its location in the deeper structures where only tender mass was present. Ultrasonography is the modality of choice to detect and evaluate spermatic cord