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Perineal lipoma simulating perineal hernia
PERINEAL JOSEPH
LIPOMA SIMULATING N.
MCMAHAN,
M.D.
PERINEAL
AND RALPH
S.
HERNIA*
BLASIOLE,
M.D.
M’ashington, Pennsylvania
A
presenting through the ischiorecta1 fossa offers various diagnostic probIems in differentiating it from a perinea1 hernia of the ischiorectal type described by Krieg.’ PerineaI hernia is an exceedingIy rare form of hernia and a tumor arising in the peIvis and, by extension into the perineum, simuIating a perineaI hernia is even more rare.2 In March, Igog, Mr. Lawrie McGavin showed at a meeting of the CIinicaI Section of the RoyaI Society of Medicine a woman aged thirty-six who had a sweIIing in the perineum appearing through the Ieft ischiorecta1 fossa. This was diagnosed a perinea1 hernia owing to its easy and compIete reduction and expansiI& imp&e on coughing. Mr. McGavin reported the resuIt of operation in this case the foIIowing month. A tumor had been found compIeteIy extraperitonea1 and extending down to the Ieft of the rectovagina1 septum. The tumor was removed with diffIcuIty and found to be continuous with the perinea1 sweIIing. Microscopic examination showed it to be a myxoma.3 Diagnosis of a perinea1 hernia is made upon the history of trauma or unusua1 physica effort foIIowed by sweIIing in the perineum. The tumefaction may be tympanitic on percussion, imparts an impuIse on coughing, is reducibIe and its course may be traced by paIpation as the hernia is reduced.4 AudibIe peristaIsis in the mass may be an additiona sign in arriving at a diagnosis of perinea1 hernia. The simiIarity between the accepted signs and symptoms of hernia and those presented in this case of perinea1 Iipoma makes apparent the dificuIty that may be experienced in differentia1 diagnosis. LIPOMA
*
From the
SurgicaI Service
of Paul P.
RiggIc,
740
CASE
REPORT
Mrs. A. G., a twenty-four year old white female, was admitted to the hospital on September I I, 1946, with a mass in the perineum which she first noticed in December, 1945, during the fifth month of her first pregnancy. She was delivered of a 7 pound, I I ounce living child on March 30, 1946, after a normal labor and spontaneous delivery. The mass became larger following her pregnancy; it did not decrease in size at any time. The patient had had no pain, nausea or vomiting associated with the mass; her appetite had been excellent and bowel habits had been regular but she had noted blood in her stool on several occasions. No urinary symptoms had been noted. She had experienced sudden, sharp pain accompanied with cramps in the upper thighs, particuIarly the right, for four weeks before admission. The patient had had no serious illness or injury; an appendectomy had been performed in 1943. The patient was well deveIoped and well nourished but not obese. Her temperature, pulse and respirations were normal. Her blood pressure was I 10/60. Examination of the head, neck, chest, abdomen and extremities was essentiahy normal. Rectal examination revealed a large, non-tender, irreducible mass presenting through the right ischiorectal fossa. (Figs. I and 2.) The skin over the mass was redundant, striated and dilated vessels were visible. (Figs. 3 and 4.) The mass was of doughy consistency and freely movable. Attempts to reduce the mass were not successful but a defect in the roof of the ischiorectal fossa which admitted two fingers could be easily feIt through the mass. A cough impulse was present. Percussion note was dull and peristalsis was audible over this site. The mass could not be felt when the paIpating finger was introduced into the rectum. The erythrocyte count was 3,900,0oo, hemoglobin 77 per cent and leukocytes 4,050. The urinalysis, blood sugar and urea nitrogen determinations were normal. The brood Kline reaction was negative. M.D.,
Washington
Hospital,
American
Washington,
Journal
Pa.
of Surgery
2
1
3
FIGS. J and 2. Mass presenting through the right ischiorectal fossa; the patient ing position without straining. FL: 3. Mass showing redun&nt, striated skin and dilated vessels.
FIG. 4. Same
as Figure
3.
A provisional diagnosis of posterior perineal hernia bras made. A roentgen study of the gastrointestinal tract with barium failed to rcvca1 any portion of this tract protruding into the mass. Operation was advised and on September 17, 1946, the abdomen was opened through a Iower midline incision into the peritoneal cavity. No hernial opening was found in the peritoneal hning of the pelvis but a mass could be palpated to the right and anterior to the urinary bIadder. The peritoneum was dissected away from the abdominaI waI1; the tumor mass was reached The bIadder was freed from extraperitoneally. its anterior attachments. Dissection was continued through the fascial pIanes of the floor of the pelvis and through the right levator ani muscle. The tumor was freed from surrounding dissection and retissues by careful, blunt moved. The bed of the tumor and fascial layers were approximated; the urinary bladder was sutured in its normaI position and a soft rubber drain was inserted extraperitoneally to the site
May,
1950
FIG. 5. This photograph removal from the pelvis.
is in a normal
stand-
representsthe Iipoma after
of the tumor. The peritoneum, fascia and skin of the abdomen were closed in layers. The postoperative course WE. uneventful and the drain was removed on the sixth postoperative day. The patient was discharged from the hospital on the tenth postoperative day. The pathologic study revealed a tumor 13 by 7 by 3 cm. in size surrounded by a thick caps&. (Fig. 5.) The tumor cut with resistance and the cut surface was pale yekw in color and ~vas granular. Sections of the tumor showed it to be a lipoma. COMMEKTS
This articIe is the report of a case of perineaI Iipoma which simuIated a posterior perinea1 hernia of the ischiorecta1 type which was operated upon successfully. PreoperativeIy, it was beiieved that the mass which presented through the right ischiorecta1 fossa was a hernia1 sac containing omentum which had become adherent,
742
McMahan,
BIasioIe-Perineal
thus causing it to be irreducible. It was thought that the sac probabIy contained some portion of the intestina1 tract at times because peristalsis had been heard on more than one occasion. The presence of a cough impulse and dullness on percussion helped to substantiate the diagnosis of posterior perinea1 hernia. Postoperatively and in retrospect it wouId seem that the occurrence of the Iipoma was coincidenta with pregnancy and no direct relationship existed between the Iipoma and the pregnancy. The occasiona1 bIoody stooIs and attacks of pain and cramps in the upper thighs can be expIained by the presence of this space-taking Iipoma in the bony peIvis, and as it became Iarger, causing compression of vesseIs and nerve pathways to the thighs. The cough imp&e was present because of the descent of the Iipoma when the intra-abdomina1 pressure was increased as the patient coughed. The
Lipoma
peristalsis that was heard over the protruding mass must have been transmitted through the solid structure of the Iipoma due to its position adjacent to the pelvic peritoneum in much the same manner that the whispered voice is cIearIy transmitted to the stethoscope through the consoIidated Iung of Iobar pneumonia. SUMMARY
An attempt has been made in this report to point out the simiIarity in physical signs that exists between posterior perineal hernia and perineal Iipoma. REFERENCES
I. KRIEG, E. G. Posterior vaginal enteroceIe. J. Michi-
gan M. Sot., 38: 47-49, 1939. I. PeIvic and perinea1 tumor simulating perinea1 hernia. &it. J. Surg., 30: 276278, 1943. 3. MCGAVIN, L. PTOC.Roy. Sot. Med., 156: 185, agog. 4. YOEMANS, F. C. Levator hernia, perinea1 and pudendaI. Am. .I. Surg., 43: 6959697, 1939.
2.
MATHESON,
American
Journal
of Surgery
LIPOMA SIMULATING N.
MCMAHAN,
M.D.
PERINEAL
AND RALPH
S.
HERNIA*
BLASIOLE,
M.D.
M’ashington, Pennsylvania
A
presenting through the ischiorecta1 fossa offers various diagnostic probIems in differentiating it from a perinea1 hernia of the ischiorectal type described by Krieg.’ PerineaI hernia is an exceedingIy rare form of hernia and a tumor arising in the peIvis and, by extension into the perineum, simuIating a perineaI hernia is even more rare.2 In March, Igog, Mr. Lawrie McGavin showed at a meeting of the CIinicaI Section of the RoyaI Society of Medicine a woman aged thirty-six who had a sweIIing in the perineum appearing through the Ieft ischiorecta1 fossa. This was diagnosed a perinea1 hernia owing to its easy and compIete reduction and expansiI& imp&e on coughing. Mr. McGavin reported the resuIt of operation in this case the foIIowing month. A tumor had been found compIeteIy extraperitonea1 and extending down to the Ieft of the rectovagina1 septum. The tumor was removed with diffIcuIty and found to be continuous with the perinea1 sweIIing. Microscopic examination showed it to be a myxoma.3 Diagnosis of a perinea1 hernia is made upon the history of trauma or unusua1 physica effort foIIowed by sweIIing in the perineum. The tumefaction may be tympanitic on percussion, imparts an impuIse on coughing, is reducibIe and its course may be traced by paIpation as the hernia is reduced.4 AudibIe peristaIsis in the mass may be an additiona sign in arriving at a diagnosis of perinea1 hernia. The simiIarity between the accepted signs and symptoms of hernia and those presented in this case of perinea1 Iipoma makes apparent the dificuIty that may be experienced in differentia1 diagnosis. LIPOMA
*
From the
SurgicaI Service
of Paul P.
RiggIc,
740
CASE
REPORT
Mrs. A. G., a twenty-four year old white female, was admitted to the hospital on September I I, 1946, with a mass in the perineum which she first noticed in December, 1945, during the fifth month of her first pregnancy. She was delivered of a 7 pound, I I ounce living child on March 30, 1946, after a normal labor and spontaneous delivery. The mass became larger following her pregnancy; it did not decrease in size at any time. The patient had had no pain, nausea or vomiting associated with the mass; her appetite had been excellent and bowel habits had been regular but she had noted blood in her stool on several occasions. No urinary symptoms had been noted. She had experienced sudden, sharp pain accompanied with cramps in the upper thighs, particuIarly the right, for four weeks before admission. The patient had had no serious illness or injury; an appendectomy had been performed in 1943. The patient was well deveIoped and well nourished but not obese. Her temperature, pulse and respirations were normal. Her blood pressure was I 10/60. Examination of the head, neck, chest, abdomen and extremities was essentiahy normal. Rectal examination revealed a large, non-tender, irreducible mass presenting through the right ischiorectal fossa. (Figs. I and 2.) The skin over the mass was redundant, striated and dilated vessels were visible. (Figs. 3 and 4.) The mass was of doughy consistency and freely movable. Attempts to reduce the mass were not successful but a defect in the roof of the ischiorectal fossa which admitted two fingers could be easily feIt through the mass. A cough impulse was present. Percussion note was dull and peristalsis was audible over this site. The mass could not be felt when the paIpating finger was introduced into the rectum. The erythrocyte count was 3,900,0oo, hemoglobin 77 per cent and leukocytes 4,050. The urinalysis, blood sugar and urea nitrogen determinations were normal. The brood Kline reaction was negative. M.D.,
Washington
Hospital,
American
Washington,
Journal
Pa.
of Surgery
2
1
3
FIGS. J and 2. Mass presenting through the right ischiorectal fossa; the patient ing position without straining. FL: 3. Mass showing redun&nt, striated skin and dilated vessels.
FIG. 4. Same
as Figure
3.
A provisional diagnosis of posterior perineal hernia bras made. A roentgen study of the gastrointestinal tract with barium failed to rcvca1 any portion of this tract protruding into the mass. Operation was advised and on September 17, 1946, the abdomen was opened through a Iower midline incision into the peritoneal cavity. No hernial opening was found in the peritoneal hning of the pelvis but a mass could be palpated to the right and anterior to the urinary bIadder. The peritoneum was dissected away from the abdominaI waI1; the tumor mass was reached The bIadder was freed from extraperitoneally. its anterior attachments. Dissection was continued through the fascial pIanes of the floor of the pelvis and through the right levator ani muscle. The tumor was freed from surrounding dissection and retissues by careful, blunt moved. The bed of the tumor and fascial layers were approximated; the urinary bladder was sutured in its normaI position and a soft rubber drain was inserted extraperitoneally to the site
May,
1950
FIG. 5. This photograph removal from the pelvis.
is in a normal
stand-
representsthe Iipoma after
of the tumor. The peritoneum, fascia and skin of the abdomen were closed in layers. The postoperative course WE. uneventful and the drain was removed on the sixth postoperative day. The patient was discharged from the hospital on the tenth postoperative day. The pathologic study revealed a tumor 13 by 7 by 3 cm. in size surrounded by a thick caps&. (Fig. 5.) The tumor cut with resistance and the cut surface was pale yekw in color and ~vas granular. Sections of the tumor showed it to be a lipoma. COMMEKTS
This articIe is the report of a case of perineaI Iipoma which simuIated a posterior perinea1 hernia of the ischiorecta1 type which was operated upon successfully. PreoperativeIy, it was beiieved that the mass which presented through the right ischiorecta1 fossa was a hernia1 sac containing omentum which had become adherent,
742
McMahan,
BIasioIe-Perineal
thus causing it to be irreducible. It was thought that the sac probabIy contained some portion of the intestina1 tract at times because peristalsis had been heard on more than one occasion. The presence of a cough impulse and dullness on percussion helped to substantiate the diagnosis of posterior perinea1 hernia. Postoperatively and in retrospect it wouId seem that the occurrence of the Iipoma was coincidenta with pregnancy and no direct relationship existed between the Iipoma and the pregnancy. The occasiona1 bIoody stooIs and attacks of pain and cramps in the upper thighs can be expIained by the presence of this space-taking Iipoma in the bony peIvis, and as it became Iarger, causing compression of vesseIs and nerve pathways to the thighs. The cough imp&e was present because of the descent of the Iipoma when the intra-abdomina1 pressure was increased as the patient coughed. The
Lipoma
peristalsis that was heard over the protruding mass must have been transmitted through the solid structure of the Iipoma due to its position adjacent to the pelvic peritoneum in much the same manner that the whispered voice is cIearIy transmitted to the stethoscope through the consoIidated Iung of Iobar pneumonia. SUMMARY
An attempt has been made in this report to point out the simiIarity in physical signs that exists between posterior perineal hernia and perineal Iipoma. REFERENCES
I. KRIEG, E. G. Posterior vaginal enteroceIe. J. Michi-
gan M. Sot., 38: 47-49, 1939. I. PeIvic and perinea1 tumor simulating perinea1 hernia. &it. J. Surg., 30: 276278, 1943. 3. MCGAVIN, L. PTOC.Roy. Sot. Med., 156: 185, agog. 4. YOEMANS, F. C. Levator hernia, perinea1 and pudendaI. Am. .I. Surg., 43: 6959697, 1939.
2.
MATHESON,
American
Journal
of Surgery