Table 1. A simple guide to groin lumps | |
Condition |
Features to determine |
Inguinal hernia |
Reducible, irreducible or strangulated |
Femoral hernia |
Reducible, irreducible or strangulated |
Lymphadenopathy: inflammatory |
Local, regional or generalised |
Lymphadenopathy: malignant |
Primary: lymphoma |
Secondary: local or regional | |
Infective |
Abscess |
Saphena varix |
Varicose veins |
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THIS is a particularly sensitive region. Inform the patient they will be palpated and explain the reasons for this.
The physical characteristics of the lump and its precise anatomical location will lead to the correct diagnosis. Consider the lump in terms of its close relationship to the hip, abdominal wall, pelvic bones, pelvis and anal region. The surface markings of the pubic tubercle, pubic crest, inguinal ligament, anterior superior iliac spine, mid inguinal point and groin skin crease are all utilised to identify the nature of the lump.
The structures and conditions to be considered include the lateral cutaneous nerve of the thigh( meralgia paraesthetica), femoral artery( aneurysm), long saphenous vein( saphena varix), fatty tissue( lipoma), sweat glands( hidradenitis suppurativa) and lymph nodes( infective or malignant).
Inspection and palpation will identify the presence of a femoral or inguinal hernia.
A cremasteric reflex may be the first sign elicited when examining the scrotum with cold hands. This reflex is due to the contraction of the cremaster muscle and may be the cause of pain in a condition termed retractile testis. Occasionally
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, this requires surgery in adults.
In children, excessive retraction may falsely arouse the suspicion of an undescended testis. However, in both children and adults, the retractile testis can be manipulated back down into its normal scrotal position.
The pinch test( see figure 3) for scrotal conditions will determine if the lump is a hernia, a testis or an appendage. The cord is pinched between the fingers to palpate the vas. If the lump is below the pinched fingers it is a testicular or related condition. If the lump
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Figure 3. Pinch test.
is above the cord, it is almost always an inguinal hernia. If the fingers cannot be approximated, then a hernia descending into the scrotum is the most likely diagnosis and you cannot get‘ above the lump’. Common scrotal swellings include epididymal cyst, hydrocele or epididymo-orchitis. Less common, but important, are testicular tumours and torsion of the testis.
Hernias Femoral hernias and inguinal hernias are often confused, both clinically and on ultrasound.
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Box 3. Taxis for early acutely irreducible hernias
In the early stages, an acutely irreducible hernia may be reduced by a process termed taxis. 7 This was an important manoeuvre before safe anaesthesia but can still be useful in many cases. Taxis is achieved by placing the patient supine and elevating their legs. Analgesia and then gentle compression and manipulation may reduce the hernia. This may avoid emergency surgery, which is more dangerous because of oedema, as well as the risk associated with comorbid conditions.
If you successfully reduce the hernia, you must still observe the patient to ensure the reduced contents are viable. Early elective surgery is then mandatory to prevent subsequent strangulation.
Inspect and palpate the patient while they are standing and recumbent, coughing and straining. This detects a cough impulse or descent of a hernia. Examine femoral and inguinal canal orifices, including the opposite side. Differentiation if the hernia is reducible should be fairly simple as its point of emergence from the respective canals can be palpated with the patient coughing. Patients sometimes describe a recurring swelling that cannot be demonstrated at the time of examination. In my experience, these patients usually have a hernia confirmed at surgery.
Differentiation of an inguinal hernia from a femoral hernia if irreducible or strangulated can be more difficult. The landmarks and ring may be harder to identify because of pain and swelling.
Remember, femoral and inguinal hernias may occasionally coexist. The irreducible hernia must be differentiated from other groin lumps, such as nodes or an abscess.
Taxis may be used in the early stages to reduce an acutely irreducible hernia( see box 3).
Inguinal hernia Test a reducible hernia to determine whether it is indirect or direct. An indirect hernia arises from lateral to the inferior epigastric artery through the deep ring and then descends obliquely medially. When reduced, it can be controlled by pressure over the deep ring.
A direct hernia protrudes medial to this through the posterior wall, known as Hesselbach’ s triangle( see figure 4). Pressure over the cont’ d page 20
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