Choice of imaging modality in the diagnosis of sciatic hernia
An 80-year-old lady was referred to the on-call surgical team by her GP with a 3-week history of a right-sided swelling of the buttock. Although associated with a mild discomfort, there were no urinary or bowel symptoms. Her GP had prescribed a trial of clarithromycin to no effect. She had a past medical history of hypertension, osteoarthritis and pemphigus vulgaris and a past surgical history of a perianal abscess requiring incision and drainage. She was allergic to penicillin and took regular oral betamethasone, xylometazoline nasal spray and topical aqueous cream. She did not consume alcohol, was a non-smoker and lived in warden-controlled accommodation. On examination, her cardiac, respiratory and abdominal examinations were normal. Digital rectal examination revealed a non-tender stool-filled rectum with no palpable masses. On standing, a swelling on the medial aspect of the right buttock became apparent which was easily reducible, had audible bowel sounds and a positive cough impulse. Admission bloods were unremarkable. She was reviewed by the on-call consultant who discharged her with a working diagnosis of possible obturator hernia, with a plan for an outpatient CT of her pelvis and follow-up in clinic.\nCT scan of the pelvis did not identify a cause for the swelling (Fig. ). Due to the positional nature of the swelling, a gluteal ultrasound was organized, which revealed a large colonic sciatic hernia (Fig. ). As the patient had minimal symptoms and was not keen for surgical intervention, a plan for conservative management was agreed and the patient was discharged from clinic.