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deep ring does not control a direct
hernia.
Large indirect hernias push medi-
ally and distend the deep ring and
can simulate a direct hernia. Clini-
cal examination and ultrasound
are unreliable in differentiating the
types.
With safer surgical techniques
and the use of mesh reinforcement,
the differentiation between direct
and indirect hernias is not as rel-
evant. Either type of hernia may
strangulate.
How to Treat – Groin lumps and pain
Femoral hernia
Femoral hernias are far more
commonly irreducible and prone
to strangulation because of the
tighter, rigid, narrow femoral
canal and ring through which they
emerge. They comprise just 2-5%
of all hernias. 8 On inspection, a
swelling may be obvious but is eas-
ily missed, particularly in a stout or
elderly, frail and confused patient.
Exclude a femoral hernia in any
patient with abdominal symptoms.
Some patients may develop
shock in cases of strangulated her-
nias. They need urgent resuscita-
tion before anaesthesia to avoid
fatalities.
The lump is lateral to the pubic
tubercle and below the inguinal
ligament (see figures 5 and 6).
However, as the hernia enlarges
and is constrained by the overly-
ing fascia of Scarpa, it may ride up
over the inguinal ligament. In thin
patients, the inguinal ligament can
be palpated and the hernia made
out below.
A finger in the external ring can
usually exclude an inguinal her-
nia, thus confirming a femoral
hernia. However, large irreducible
or strangulated hernias can still
cause confusion because the swell-
ing makes the surface markings
less clear. It can be difficult to dis-
tinguish a femoral hernia from an
enlarged inguinal lymph node or an
abscess.
A femoral hernia often consists
mainly of fat and may have some
of the signs of a lipoma. In the
author’s experience an ultrasound
may help but may not be conclu-
sive.
Lymph node enlargement
A node may enlarge from drain-
ing an infection (sometimes an
ingrowing toenail) or as part of a
generalised infection (see figure 7).
The node may be metastatic from
a melanoma of the leg or a squa-
mous cell carcinoma of the anus
or vulva. A local or generalised
neoplastic process such as a lym-
phoma may also produce enlarged
groin nodes. It is not always easy to
determine whether nodes are ‘reac-
tive’ or pathological.
Histopathology allows definitive
diagnosis, via aspiration cytology
(see figures 8, 9), core biopsy or
surgical removal of the node.
Abscess
An abscess can be almost impos-
sible to differentiate from a stran-
gulated femoral hernia. In both
conditions, patients may experi-
ence pain, erythema, heat and ten-
derness.
Seek a possible source of infection
and do not forget to examine the
foreskin.
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17 November 2017
Figure 5. Right femoral hernia in a female, with surface markings.
Figure 4. Hesselbach’s triangle.
Sexually transmitted diseases
such as chlamydia or lymphogran-
uloma venereum may be a cause.
Ask men about dysuria, discharge
from the penis, testicular pain,
swelling or fever. If untreated, chla-
mydia in men may spread to the
testicles, causing epididymitis.
Lipomas
Lipomas are generally clinically
obvious but may cause confusion
when they occur over the site of
a hernia. This is because hernias
often have a fatty component and
can feel just like a lipoma. A sepa-
rate entity is a lipoma of the cord in
the inguinal canal. An irreducible
femoral hernia can feel just like a
lipoma but is not as mobile.
Condition of scrotum and testes
The testis is oval and situated ante-
rior to the epididymis, with its long
axis vertical. The epididymis can
be palpated posterolateral to the
testis as a longitudinal, ribbon-like
structure. It is less tender than the
testis on palpation. The spermatic
cord can be palpated as a number
of vertical strands from which the
epididymis hangs. The vas deferens
can be readily identified as a cord-
like, firm structure with a smooth
surface that slips readily between
the fingers.
The structures usually dis-
play constant relations and basic
shapes, which is helpful for ana-
tomical localisation of the origin
of a swelling. The testis may, how-
ever, be undescended or anteverted,
reversing the clinical signs with the
epididymis situated anteriorly.
Abnormalities in position and size
can occur, either as a congenital or
acquired process. For example, an
undescended testis is often small.
Swellings of the cord
A varicocele is an abnormally
dilated plexus of veins that may
cause aching (see figures 10, 11). It
is detected by examining the patient
while they are standing. The swell-
ing is compressible ‘like a bag of
worms’ and disappears when the
patient is recumbent. Varicoceles
can, in rare cases, be the result of
a carcino