Labial hernia: demonstration by herniography

138

Downloaded from www.ajronline.org by 50.116.19.84 on 04/15/16 from IP address 50.116.19.84. Copyright ARRS. For personal use only; all rights reserved Labial Hernia: Demonstration by Herniography

Roger A. Berg1

Labial hernia is the result of a musculofascial defect in muscle. The patient did well postoperatively and she was dis-
changed 7 days after surgery. She has remained asymptomatic and
the anterior pelvic outlet, through which bulges abdominal leads a normal life 1 8 months after hernionnaphy.

viscera. The lesion has been described only infrequently

and has never before been diagnosed by intraperitoneal

contrast injection. The case described here demonstrates Discussion

the use of opaque herniography in the diagnosis of this

entity. The first case report in American literature of a perineal

hernia was by Chase [1 ] in 1 922. Koontz [2] added an

Case Report additional case in 1 951 . In 1 963, Hermann [3] described a

patient quite similar to my case, a 60-year-old woman with

A 60-year-old white woman, para 4, gravida 4, was admitted a history of several pelvic operations who had a large labial

because of swelling of the left labia majus. The patient had a vaginal hernia. At surgery, a defect in the transverse perinei muscle

hysterectomy with anteropostenior repair 2’/2 years earlier else- was found and successfully repaired. In 1 968, Anderson [4]

where. Prolapse occurred within 1 year. A third degree rectoenter- described a perineal hernia in a 64-year-old woman who

ocoele was clinically diagnosed and surgical repair was performed had had two ‘ ‘difficult’ ‘ deliveries, a hysterectomy, vaginal

at the same hospital. She was asymptomatic for 6 months after

discharge, but then began to note a bulge in the perineum, for repair, and a cystocele repair. She was seen with a posterior

which she was evaluated at Morristown Memorial Hospital. The vulvar hernia from a transverse perinei muscle defect. The

patient complained of no urinary or bowel symptoms. author listed many kinds of vulvar masses, but conceded

Physical examination was unremarkable except for the penineal that each could be clinically distinguished from hernia by

findings. The rectoenterocoele was well healed. There was a 3 x the typical history and physical findings. Cawkwell [5] re-

5 cm bulging mass in the posterior aspect of the left labium majus. ported right perineal hernias that follow abdominoperineal

Clinically the mass was considered to be a hernia which had resection for rectal cancer.

dissected into the tissues lateral to the vagina. The hernia could be Labial hernias may be distinguished from posterior pen-

partly reduced through a palpable 2 cm defect in the pelvic floor neal hernias [6]. Libial hernias usually contain small bowel,

musculature. There was no sign of bowel infarction nor any evidence

of penitoneal irritation. but may have colon and occasionally bladder also. Posterior

Herniography was performed using a 1 9 gauge, 9 cm spinal penineal hernias are somewhat more common than labial

needle. A small opening in the skin of the anterior abdominal wall and result from a defect in the posterior levator ani fibers,

2.5 cm below the umbilicus was made with a scalpel point (without or between the levator and coccygeus muscles. These are
anesthesia) to facilitate puncture. The intrapenitoneal injection of 50
found in the ischiorectal fossa, often containing a loop of

ml of Conray 60 was confirmed with fluoroscopic control. The sigmoid. They occur posterior to the labia, in the buttock.

patient tolerated the procedure well, with no side effects other than Sciatic hernia is an extremely rare condition which may be

a transient crampy feeling in the lower abdomen. Upright frontal found in the posterior labia in the upright position. However,

and lateral views of the pelvis were done after the patient had been when the patient is prone and the hernia is reduced, the
standing for 5 mm. These films (fig. 1 ) clearly showed a huge defect
in the pelvic floor through which the large hernia sac filled with defect is palpable over the sciatic notch rather than in the

contrast material; some loops of what was probably small intestine anterior pelvis.

protruded. It was not possible to tell if any of the loops were colon. Hermann [3] uses the term ‘ ‘ pudendal’ ‘ to signify the

It was believed that barium studies of the alimentary tract would not posterior pelvic hernia. Obviously confusion could be
‘ and ‘ ‘ pos-
be of additional value. Since the patient had no urinary symptoms, avoided by using the anatomic terms ‘ ‘ anterior’

excretory urography was not performed either. tenor’ ‘ penineal hernia, rather than either ‘ ‘labial’ ‘ or
At surgery a combined abdominal and left labial approach was
‘ ‘ pudendal. ‘ ‘ All cases of labial and sciatic hernias have
used to resect the hernia sac and close the defect in the levator ani been in elderly patients, but Doig and Nixon [7] reported two

cases of posterior ischiorectal hernias in children.

Received November 6. 1 978; accepted after revision March 20, 1979. Labial hernia is surgically treated, with the abdominal
Memorial Hospital, Morristown, NJ
Department of Radiology, Morristown approach preferred. Penineal incision, as in this case, is
07960.
often reserved for those penitoneal sacs that cannot be
AJR 133:138-139, July 1979
removed through the abdominal incision alone. Even though
© 1 979 American Roentgen Ray Society

0361-803X/79/1331-0138 $00.00 the hernia is more directly visible via the penineal route,

AJR:133, July 1979 CASE REPORTS 139

Fig. 1 . Erect frontal (A) and lateral (B)

views of pelvis shortly after intraperito-

neal injection of contrast material. Large

pelvic defect. Hernia sac extends into

perineum, just left of midline. Loops

(probably small intestine) in wide neck

of hernia sac.

Downloaded from www.ajronline.org by 50.116.19.84 on 04/15/16 from IP address 50.116.19.84. Copyright ARRS. For personal use only; all rights reserved closure of the pelvic defect is always more effective through a herniated loop of colon. The examination has been nec-

the abdomen. ommended in an elderly woman with a probable left flank

Henniography has been used almost exclusively in the incisional hernia, but the patient has refused further medical

pediatric age group [8]. In adults, the examination is more cane.

difficult because there tends to be more fat in the adult Adultherniognaphy is used quite differently than it is in

penitoneal cavity than in the child’s, and intrapenitoneal children. In the adult, the herniogram confirms on denies a

injection may not be possible. Also, a larger bore needle suspected clinical diagnosis. In the child, it tells the status

must be used because a much greater volume of contrast of the clinically normal side where a unilateral hernia is

has to be injected (often 50-1 00 ml). known.

In this case, the herniogram changed a presumptive din-

ical diagnosis of a rare condition into a certainty. This was REFERENCES

a decided benefit to the patient’s mental state, as she had 1 . Chase HC: Levator hernia. Surg Gynecol Obstet 35: 71 7-732,

already been through several surgical procedures and was 1922

relieved to know the surgeon knew exactly what he was 2. Koontz AR: Penineal hernia. Ann Surg 133:255-260, 1951

going to find, and what had to be done. Actually, the hernia 3. Hermann G: Pudendal (libial) hernia. N. EngI J Med 265 : 435-

was already reduced when the patient was on the operating 436, 1961

table, but the radiographic appearance of the size and site 4. Anderson WR: Pudendal hernia-unusual case of a labial

of the defect guided the surgeon to prompt exploration of mass. Obstet Gynecol 32 : 802-804, 1968

the pelvic floor. 5. Cawkwell I: Penineal hernia complicating abdomino-penineal

I also performed herniography in an adult with chronic resection of the rectum. Br J Surg 50 : 431 -433, 1963

recurring right groin pain, which he claimed was due to a 6. Tracklen RT, Koehlen PR: The radiographic findings in posterior

hernia caused by his strenuous job. There were no abnormal penineal hernia. Radiology 91 : 950-951 , 1968

7. Doig CM, Nixon HH: Pelvic hernias in children. J. Pediatr Surg

physical findings, and the normal herniogram convinced the 7:44-47, 1972

patient he had no hernia. In one adult with a suspected 8. White J, Parks L, HaIler J: The inguinal henniogram: a radiologic

Spigelian hernia, the normal herniogram allowed the sun- aid for accurate diagnosis of inguinal hernia in infants. Surgery

geon to aspirate the local seroma without fear of puncturing 63:991-997, 1968

This article has been cited by:

1. Philippe E. Zimmern, Fred Miyazaki. 1994. Pudendal enterocele with bladder involvement. Urology 44, 918-921. [CrossRef]
2. Norman C. Estes, Ed W. Childs, Glendon Cox, James H. Thomas. 1991. Role of herniography in the diagnosis of occult hernias.

The American Journal of Surgery 162, 608-610. [CrossRef]

Downloaded from www.ajronline.org by 50.116.19.84 on 04/15/16 from IP address 50.116.19.84. Copyright ARRS. For personal use only; all rights reserved