Clinical Skills - Groin Swelling

groin swelling

Swelling in the inguinal region is a very common surgical patient presentation.

A differential diagnosis of Groin swelling can be as follows; (adapted and modified from OHGP ed.3)

Position relative to skin	Groin lump DD	Position relative to the inguinal ligament
		Above	Below
IN the skin	Lipoma, Fibroma, Hemangioma and other skin lumps	yes	Yes
Deep to skin	Femoral / inguinal lymph nodes	yes	Yes
	Inguinal hernia	yes	No
	Femoral hernia	no	Yes
	Femoral artery aneurism	no	Yes
	Sphena varix of femoral vein	No	Yes

Although this post will mostly cover inguinal hernia and testicular swelling as its focus, please bear in mind that a lump is a lump - you may want to know how to examine a lump in a more general sense.

inguinal hernia

Inguinal hernia is a protuberance of peritoneal contents thru the abdominal wall where most of the time, the breach is made at the weakened musculature and the inguinal canal.

It is a very common condition, and occurs at any age. (males > Females)

Examination of patient with Groin Swelling.

After the usual cascade of events of GIEP, Exposure of the patient (which is very important particularly in examining the groin!) and etc, -the first target we would like to achieve is to find out if the swelling is a Hernia.

Now how do we know if a swelling is a hernia? - hernia, as mentioned is a protuberance of peritoneal contents - which means an increase in abdominal pressure will make it protrude! - in a more simple term, it has a “Cough Impulse”.

Here are simple steps to test for a cough impulse; (Note - patient is lying supine)

1.       Fully expose the patient (midriff to mid-thigh) and visually recognize where the swelling is. (here, ask yourself if the swelling is above / below the inguinal ligament)

2.       If not visible, ask the patient where the swelling is.

3.       If you DO see the swelling, ask the patient if the swelling can be reduced. -  most of the time, the patient will be more professional at reducing a swelling.

4.       Ask the patient to cough - and observe the swelling. - if the swelling reappears, Voila. The cough impulse is present.

5.       If you cannot see a cough impulse - you may proceed to try and feel the impulse (and, if you are being examined, you may like to proceed to show that you know how to palpate a swelling)

6.       Put your hand over the swelling gently, and ask the patient to cough - if you feel an impulse, now you have felt a cough impulse - further confirming the fact that you are now looking - and touching, a hernia.

After you have established that you have indeed a hernia, you may want to find out which of the following it is.

·         Indirect Hernia

·         Direct Hernia

·         Femoral Hernia

Here are steps to find out which of the above category the hernia fits.

1.       First, we need to distinguish between a femoral hernia from the other 2.

a.        Find the inguinal ligament - which lies from the pubic tubercle medially to the Anterior Superior Iliac Spine laterally. - you may be asked to demonstrate this so make sure you can actually do this.

b.       If the swelling lies below the inguinal ligament, it is a femoral hernia.

2.       Secondly, we will need to distinguish between Indirect and direct hernias.

a.        Look at the scrotum - some hernias present as a scrotal swelling. If the scrotum is swelling and you cannot get above the swelling (meaning the swelling most likely arises from the abdomen), it is an indirect inguinal hernia.

b.       If the swelling is a discreet swelling above the inguinal ligament, ask the patient to reduce the swelling,

c.        then place 2 fingers at the internal inguinal ring

                                                               i.      Internal inguinal ring is found 1.5cm above the femoral pulse - mid-point of inguinal ligament)

d.       Ask the patient to cough, while “blocking” the internal inguinal ring.

e.       If you DO NOT see a swelling come out, it is more likely an indirect inguinal hernia.

f.         If you DO see a swelling, the swelling is arising through structures other than the internal inguinal ring - which means it is a direct hernia.

                                                               i.      (Direct hernia protrudes from the weakening / defect in the abdominal wall - hasselbach’s triangle which is bound medially by the rectus abdominis muscle,  laterally by inferior epigastric vessels and inferiorly by inguinal ligament.

characteristics of hernias

	Indirect inguinal	Direct inguinal		Femoral
Incidence	Most common - children and young males	Less common - more in older people - more often acquired.		Least common - more female, most likely to strangulate.
Occurance	Thru internal inguinal ring - can remain in canal, exit the external ring, and pass into scrotum-  may be caused by failure of embryonic closure of the processus vaginalis.	Thru external inguinal ring. Located in region of hasselbach triangle. Rarely enter scrotum.		Thru femoral ring , femoral canal and fossa ovalis
Presentation	Soft swelling in area of internal ring - there may be pain on straining, deep ring occulusion will prevent protrusion	Bulge in area of hasselback triangle - usually painless. Easily reduced. Hernia bulge anteriorly		Right-side more common. Pain may be severe when there is strangulation.
Relation to inferior epigastric vessels	Lateral	Medial		-