Australian Doctor Australian Doctor 17th November 2017 | страница 22

How to Treat – Groin lumps and pain
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ing direct from indirect hernias on
ultrasound. The literature reflects
many conflicting views. 15
Sportsman’s groin
This distinct entity, also known as
Gilmore’s groin or sports hernia,
is common in soccer players, foot-
ballers and athletes. There is pain
particularly with activity. Clini-
cal assessment includes an accu-
rate description of the pain (onset,
severity and precipitating factors)
and a history of any hip or back
regarding this condition.
Other problems to consider that
are now achieving greater recog-
nition include femoral acetabular
impingement and other femoral
head conditions that may present
with groin pain.
Examination includes all related
areas including the adductor ten-
don and pubic symphysis.
Ultrasound does not show a her-
nia, but may show a slight bulge,
and may show a tear of the rectus
sheath or muscle. The treatment
includes ongoing observation and
problems. 3 There may be a weak-
ness in the posterior wall of the
inguinal canal and tenderness in the
region of the conjoint tendon.
A possible explanation, in the
author’s opinion, is inflammation
or tendinopathy at the insertion of
the rectus muscle and conjoint ten-
don into the pubic bone, somewhat
akin to adductor tendonitis.
At this point, and just proxi-
mally, the rectus sheath is quite
tight around the muscle, which
may be hypertrophied in sport-
speople. There is no real consensus
assessment, rest, anti-inflamma-
tories, physiotherapy or, in some
cases, surgery.
The type of procedure carried
out varies enormously from open
to laparoscopic, with mesh or with-
out mesh.
Groin pain without a hernia in
the absence of another diagnosis
can be a troubling problem and is
difficult to treat. As a result, it is
easy at times to grasp at the diag-
nosis of an occult hernia or state
that it is a sportsman’s groin and
mistakenly advocate surgery.
ULTRASOUND is one of the most
useful tools for investigating pain
or swelling in the groin and scro-
tum (see figure 15).
It is used for investigating pain
from musculoskeletal disorders of
the inguinal region and adductor
tendon, and plays a controversial
role in the occult hernia and Gil-
more’s groin. Other imaging such
as X-ray and scans to detect con-
ditions such as stress fractures and
bony metastases may be required.
Ultrasound may assist in differen-
tiating inguinal from femoral her-
nias and also between other groin
lumps such as nodes or abscesses.
This examination may be more
helpful when the patient’s build
makes examination and certainty
more difficult, but do not rely solely
on the ultrasound to make a diag-
nosis.
Ultrasound is valuable in the
identification and diagnoses of
nodes. Aspiration cytology or core
biopsy can be carried out with or
without ultrasound control. Core
biopsy provides a more definitive
answer while surgery may provide
the definitive answer.
The type of cells found, for
example melanoma or lymphoid
cells, may provide a guide to the
type of groin surgery required.
A melanoma will require a groin
dissection with its attendant risks
B
A
Figure 15. Ultrasound of a right direct inguinal hernia with the patient relaxed (A) and straining (B).
whereas only a smaller sample
absence of additional radiological or
operative symptoms may persist or
will guide adjuvant treatment for a
pathological findings, ask patient to
even increase. 16
lymphoma. In many patients who
return for follow up if the groin pain
Patients with groin pain and an
complain of groin pain, a ‘hernia’ is
persists.
‘ultrasound-diagnosed hernia’ may
found during surgery.
Ultrasound is the mainstay of
have other causes for their pain. Do
As discussed, some may well be a
investigating the scrotum. This
not dismiss their concerns regarding
lipoma of the cord. 15 These lipomas
method has a role in differentiating
the pain once a hernia