Scrotal mass differential diagnosis: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
Line 177: Line 177:
| style="background: #F5F5F5; padding: 5px; text-align: center;" |±
| style="background: #F5F5F5; padding: 5px; text-align: center;" |±
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Painful local lymphadenopathy
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Painful local lymphadenopathy
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* CBC-[[Leukocytosis]]
* CBC-[[Leukocytosis]]
* raised CRP
* raised CRP
* Immunofluorescent antibody testing
* Immunofluorescent antibody testing
* Urine analysis and culture - normal  
* Urine analysis and culture - normal  
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Increased blood flow in affected side
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Increased blood flow in affected side
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* [[Acute]] infection is characterized by infiltration of [[neutrophils]].
* [[Acute]] infection is characterized by infiltration of [[neutrophils]].
* [[Chronic]] cases are characterized by [[granulomatous]] [[inflammation]].
* [[Chronic]] cases are characterized by [[granulomatous]] [[inflammation]].
| style="background: #F5F5F5; padding: 5px; text-align: center;"|
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* Culture of the organism from blood.  
* Culture of the organism from blood.  
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Antibodies are detected using:
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Antibodies are detected using:
* Serum agglutination (standard tube agglutination)
* Serum agglutination (standard tube agglutination)
* Enzyme-linked immunosorbent assay
* Enzyme-linked immunosorbent assay
Line 199: Line 199:
|-
|-
|Torsion of the appendix testis
|Torsion of the appendix testis
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Unilateral or Bilateral
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Unilateral or Bilateral
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Sudden
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align: center;"| -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Absent
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Absent
| style="background: #F5F5F5; padding: 5px; text-align: center;"| +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;"| -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;"| -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Absent
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Absent
| style="background: #F5F5F5; padding: 5px; text-align: center;"| +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Normal
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Normal
| style="background: #F5F5F5; padding: 5px; text-align: center;"|
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* Normal blood flow to the testis with an occasional increase on the affected side
* Normal blood flow to the testis with an occasional increase on the affected side
| style="background: #F5F5F5; padding: 5px; text-align: center;"| -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;"|
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* In the first 4 hours: testicular appendages shows edema and and desquamation.
* In the first 4 hours: testicular appendages shows edema and and desquamation.
* 4-8 hours partial necrosis of appendix cells.
* 4-8 hours partial necrosis of appendix cells.
* >24 hrs: necrosis
* >24 hrs: necrosis
| style="background: #F5F5F5; padding: 5px; text-align: center;"|
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* scrotal ultrasound shows the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area.
* scrotal ultrasound shows the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area.
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Scrotal wall mayshow the classical "blue dot" sign, which is due to infarction and necrosis of the appendix testis
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Scrotal wall mayshow the classical "blue dot" sign, which is due to infarction and necrosis of the appendix testis
|-
|-
|[[Fourniers gangrene|Fournier's gangrene]]
|[[Fourniers gangrene|Fournier's gangrene]]
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Bilateral
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Bilateral
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Sudden
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Sudden
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* Leukocytosis
* Leukocytosis
* Acidosis
* Acidosis
* Elevated ESR and CRP
* Elevated ESR and CRP
* Blood cultures are positive in majority of patient for streptococcus.
* Blood cultures are positive in majority of patient for streptococcus.
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px; text-align: center;"|Computed tomography (CT) scan shows most useful finding is presence of gas in soft tissues.
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Computed tomography (CT) scan shows most useful finding is presence of gas in soft tissues.
| style="background: #F5F5F5; padding: 5px; text-align: center;"|
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* Patient show signs of  tense edema outside the involved skin, blisters, bullae, crepitus, and subcutaneous gas.
* Patient show signs of  tense edema outside the involved skin, blisters, bullae, crepitus, and subcutaneous gas.
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
Line 263: Line 263:
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Fragile X syndrome|Fragile X]]  [[Macroorchidism]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Fragile X syndrome|Fragile X]]  [[Macroorchidism]]
| style="background: #F5F5F5; padding: 5px;" |Bilateral
| style="background: #F5F5F5; padding: 5px;" |Bilateral
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |Gradual
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |Absent
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | --
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |Absent
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |Normal
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |Increased volume of testis
| style="background: #F5F5F5; padding: 5px;" |FMR1 DNA analysis
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* Long and narrow face with prominent forehead and chin (prognathism)
| style="background: #F5F5F5; padding: 5px;" |
* Large ears
| style="background: #F5F5F5; padding: 5px;" |
* Intellectual Disability
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Testicular Tumors
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Testicular Tumors

Revision as of 19:59, 3 February 2019

Scrotal Mass Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Scrotal Mass from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Studies

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Scrotal mass differential diagnosis On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Scrotal mass differential diagnosis

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Scrotal mass differential diagnosis

CDC on Scrotal mass differential diagnosis

Scrotal mass differential diagnosis in the news

Blogs on Scrotal mass differential diagnosis

Directions to Hospitals Treating bone or soft tissue mass

Risk calculators and risk factors for Scrotal mass differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Preeti Singh, M.B.B.S.[2]

Overview

Scrotal masses may be differentiated according to clinical features, laboratory findings, imaging features, histological features, and genetic studies from other diseases that cause testicular mass with discomfort, back pain, abdominal discomfort, or abdominal mass. Common differential diagnoses include yolk sac tumor, teratoma, choriocarcinoma, embryonal cell carcinoma, seminoma, and testicular lymphoma (usually non-Hodgkin lymphoma).

Differential Diagnosis

The table below summarizes the findings that differentiates scrotal mass according to the clinical features, laboratory findings, imaging features, histological features, and genetic studies.

Scrotal Swelling Diseases Clinical manifestations Para-clinical findings Gold standard Associated
Painful Symptoms Physical examination
Lab Findings Past Medical History Histopathology
Unilateral /Bilateral swelling Onset Fever Urinary symptoms Tenderness Erythema Discharge Inguinal Lymphadenopathy Cremasteric Reflex Blood/Urine Analysis Doppler U/S
Epididymitis[1][2][3][4][5][6][7][8] Unilateral Gradual ± Dysuria, frequency, and/or urgency + - Pyuria

Bacteriuria

Painful local lymphadenopathy +
  • CBC-Leukocytosis
  • Urine culture (pre-pubertal and elderly)
  • NAAT
  • Immunofluorescent antibody testing
  • Decreased epididymal blood flow
Orchitis

(Mumps)[9][10][11][12]
[13][8][7][14]

Bilateral Abrupt ± Dysuria + - ± Painful local lymphadenopathy +
  • CBC-Leukocytosis
  • raised CRP
  • Immunofluorescent antibody testing
  • Urine analysis and culture - normal
  • Increased blood flow in affected side.
  • Tubules are infiltration with neutrophiles, lymphocytes and cells resembling histiocytes
  • Microscopic destruction of spermatogenic cells
  • RT‐PCR
  • Serum immunofluorescence antibody testing.
  • Phen sign +ve
  • Testicular atrophy
  • Infertility
Testicular Torsion[15][16][17][18][19][7] Unilateral Sudden - - + + Blood in semen may be present Absent - Normal
  • Absent or decreased arterial perfusion of the testis
  • In the first 4 hours: testicular parenchyma shows edema and and desquamation of the germ cells
  • 4-8 hours partial necrosis of germ cells.
  • >24 hrs: necrosis
Phen sign +ve
Hematocele Unilateral or bilateral Sudden - + + Blood in semen Absent
  • Ultrasonography: to check for testicular rupture.
Incarcerated Hernia[20][21] Unilateral Sudden + Absent + + - Absent + Normal Normal - -
  • Groin ultrasound or CT scan show presence of bowel and omentum.
Valsalva maneuvers performed while palpating the inguinal canal will push a hernia against the examiner's finger.
Brucellosis Unilateral or Bilateral Sudden ± Dysuria - - ± Painful local lymphadenopathy +
  • CBC-Leukocytosis
  • raised CRP
  • Immunofluorescent antibody testing
  • Urine analysis and culture - normal
Increased blood flow in affected side -
  • Culture of the organism from blood.
Antibodies are detected using:
  • Serum agglutination (standard tube agglutination)
  • Enzyme-linked immunosorbent assay
  • Rose Bengal agglutination
  • Coombs test
  • Immunocapture agglutination (Brucellacapt)
  • 2-mercaptoethanol agglutination
Torsion of the appendix testis Unilateral or Bilateral Sudden - Absent + - - Absent + Normal
  • Normal blood flow to the testis with an occasional increase on the affected side
-
  • In the first 4 hours: testicular appendages shows edema and and desquamation.
  • 4-8 hours partial necrosis of appendix cells.
  • >24 hrs: necrosis
  • scrotal ultrasound shows the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area.
Scrotal wall mayshow the classical "blue dot" sign, which is due to infarction and necrosis of the appendix testis
Fournier's gangrene Bilateral Sudden + - + + - - +
  • Leukocytosis
  • Acidosis
  • Elevated ESR and CRP
  • Blood cultures are positive in majority of patient for streptococcus.
- - - Computed tomography (CT) scan shows most useful finding is presence of gas in soft tissues.
  • Patient show signs of tense edema outside the involved skin, blisters, bullae, crepitus, and subcutaneous gas.
Scrotal Swelling Diseases Unilateral /Bilateral swelling Onset Fever Urinary symptoms Tenderness Erythema Discharge Inguinal Lymphadenopathy Cremasteric Reflex Blood/Urine Analysis Doppler U/S Past Medical History Histopathology Gold standard Additional findings
Painless Fragile X Macroorchidism Bilateral Gradual - Absent -- - + Absent + Normal - - Increased volume of testis FMR1 DNA analysis
  • Long and narrow face with prominent forehead and chin (prognathism)
  • Large ears
  • Intellectual Disability
Testicular Tumors Unilateral or bilateral Gradual ± ± +
Henoch-Schonlein purpura - -
Hydrocele[22] Gradual - Absent - - - Absent + Ultrasound:

simple fluid collection

Transillumination test +ve.
Varicocele[23] Unilateral

(Mainly left)

Gradual Local warmth Absent - ± - Absent + Ultrasonography:

tortuous, tubular, anechoic structures adjacent to the testis corresponding to dilated veins of the pampiniform plexus with calibers of 2–3 mm during the Valsalva maneuver

Spermatocele[24] Gradual - - - Absent +
  • Falling snow, resulting from internal echoes moving away from the transducer
Ultrasonography:

hypoechoic with posterior acoustic enhancement

Inguino-scrotal hernia[25][20] - - Absent
Scrotal edema Bilateral and can extend to perineum - - - Eosinophilia Occurs between 4-12 years of age.
Epididymal cyst[26] ± Ultrasonography:

posterior acoustic enhancement, well defined anechoic lesions, larger cysts may contain septations

Sebaceous cyst
Carcinoma of the scrotum
Chylocele (Filariasis) Gradually/Rapidly
Cystic dysplasia
Srotoliths

References

  1. Yu KJ, Wang TM, Chen HW, Wang HH (2012). "The dilemma in the diagnosis of acute scrotum: clinical clues for differentiating between testicular torsion and epididymo-orchitis". Chang Gung Med J. 35 (1): 38–45. PMID 22483426.
  2. Manavi K, Turner K, Scott GR, Stewart LH (May 2005). "Audit on the management of epididymo-orchitis by the Department of Urology in Edinburgh". Int J STD AIDS. 16 (5): 386–7. doi:10.1258/0956462053888853. PMID 15949072.
  3. Lee YS, Kim SW, Han SW (2018). "Different managements for prepubertal epididymitis based on a preexisting genitourinary anomaly diagnosis". PLoS ONE. 13 (4): e0194761. doi:10.1371/journal.pone.0194761. PMC 5905873. PMID 29668706.
  4. Ralls PW, Jensen MC, Lee KP, Mayekawa DS, Johnson MB, Halls JM (June 1990). "Color Doppler sonography in acute epididymitis and orchitis". J Clin Ultrasound. 18 (5): 383–6. PMID 2161009.
  5. Michel V, Pilatz A, Hedger MP, Meinhardt A (2015). "Epididymitis: revelations at the convergence of clinical and basic sciences". Asian J. Androl. 17 (5): 756–63. doi:10.4103/1008-682X.155770. PMC 4577585. PMID 26112484.
  6. Tracy CR, Costabile RA (April 2009). "The evaluation and treatment of acute epididymitis in a large university based population: are CDC guidelines being followed?". World J Urol. 27 (2): 259–63. doi:10.1007/s00345-008-0338-0. PMID 19002691.
  7. 7.0 7.1 7.2 Pepe P, Panella P, Pennisi M, Aragona F (October 2006). "Does color Doppler sonography improve the clinical assessment of patients with acute scrotum?". Eur J Radiol. 60 (1): 120–4. doi:10.1016/j.ejrad.2006.04.016. PMID 16730939.
  8. 8.0 8.1 Ludwig M (April 2008). "Diagnosis and therapy of acute prostatitis, epididymitis and orchitis". Andrologia. 40 (2): 76–80. doi:10.1111/j.1439-0272.2007.00823.x. PMID 18336454.
  9. Davis NF, McGuire BB, Mahon JA, Smyth AE, O'Malley KJ, Fitzpatrick JM (April 2010). "The increasing incidence of mumps orchitis: a comprehensive review". BJU Int. 105 (8): 1060–5. doi:10.1111/j.1464-410X.2009.09148.x. PMID 20070300.
  10. CHARNY CW, MERANZE DR (July 1948). "Pathology of mumps orchitis". J. Urol. 60 (1): 140–6. PMID 18873054.
  11. Bjorvatn B (1973). "Mumps virus recovered from testicles by fine-needle aspiration biopsy in cases of mumps orchitis". Scand. J. Infect. Dis. 5 (1): 3–5. PMID 4580293.
  12. Beard CM, Benson RC, Kelalis PP, Elveback LR, Kurland LT (January 1977). "The incidence and outcome of mumps orchitis in Rochester, Minnesota, 1935 to 1974". Mayo Clin. Proc. 52 (1): 3–7. PMID 609284.
  13. Gall EA (July 1947). "The Histopathology of Acute Mumps Orchitis". Am. J. Pathol. 23 (4): 637–51. PMC 1934294. PMID 19970951.
  14. Başekim CC, Kizilkaya E, Pekkafali Z, Baykal KV, Karsli AF (2000). "Mumps epididymo-orchitis: sonography and color Doppler sonographic findings". Abdom Imaging. 25 (3): 322–5. PMID 10823460.
  15. Hazeltine M, Panza A, Ellsworth P (2017). "Testicular Torsion: Current Evaluation and Management". Urol Nurs. 37 (2): 61–71, 93. PMID 29240370.
  16. Estremadoyro V, Meyrat BJ, Birraux J, Vidal I, Sanchez O (February 2017). "[Diagnosis and management of testicular torsion in children]". Rev Med Suisse (in French). 13 (550): 406–410. PMID 28714632.
  17. Sharp VJ, Kieran K, Arlen AM (December 2013). "Testicular torsion: diagnosis, evaluation, and management". Am Fam Physician. 88 (12): 835–40. PMID 24364548.
  18. Mikuz G (1985). "Testicular torsion: simple grading for histological evaluation of tissue damage". Appl Pathol. 3 (3): 134–9. PMID 3842075.
  19. Gunther P, Schenk JP, Wunsch R, Holland-Cunz S, Kessler U, Troger J, Waag KL (November 2006). "Acute testicular torsion in children: the role of sonography in the diagnostic workup". Eur Radiol. 16 (11): 2527–32. doi:10.1007/s00330-006-0287-1. PMID 16724203.
  20. 20.0 20.1 Jenkins JT, O'Dwyer PJ (2008). "Inguinal hernias". BMJ. 336 (7638): 269–72. doi:10.1136/bmj.39450.428275.AD. PMC 2223000. PMID 18244999.
  21. Berger D (2016). "Evidence-Based Hernia Treatment in Adults". Dtsch Arztebl Int. 113 (9): 150–7, quiz 158. doi:10.3238/arztebl.2016.0150. PMC 4802357. PMID 26987468.
  22. Yang DM, Kim HC, Lim JW, Jin W, Ryu CW, Kim GY, Cho H (2007). "Sonographic findings of groin masses". J Ultrasound Med. 26 (5): 605–14. PMID 17460003.
  23. Yang DM, Kim HC, Lim JW, Jin W, Ryu CW, Kim GY, Cho H (2007). "Sonographic findings of groin masses". J Ultrasound Med. 26 (5): 605–14. PMID 17460003.
  24. Yang DM, Kim HC, Lim JW, Jin W, Ryu CW, Kim GY, Cho H (2007). "Sonographic findings of groin masses". J Ultrasound Med. 26 (5): 605–14. PMID 17460003.
  25. Berger D (2016). "Evidence-Based Hernia Treatment in Adults". Dtsch Arztebl Int. 113 (9): 150–7, quiz 158. doi:10.3238/arztebl.2016.0150. PMC 4802357. PMID 26987468.
  26. Yang DM, Kim HC, Lim JW, Jin W, Ryu CW, Kim GY, Cho H (2007). "Sonographic findings of groin masses". J Ultrasound Med. 26 (5): 605–14. PMID 17460003.