Groin Lump

Question 1

What are the differentials for groin lumps

Answer 1

Hernia (direct/indirect inguinal, femoral)
Inguinal lymphadenopathy 
Saphena varix
Psoas abscess/bursa
Lipoma
Sebaceous cyst
Neuroma 
Femoral aneurysm/pseudoaneurysm
Ectopic testis 
Undescended testis
Hydrocele of cord

Question 2

What questions should be asked about a groin lump

Answer 2

How long has it been there
Is the lump always there, does it reduce when the patient lies down (hernia, saphena varix)
Has the lump gotten bigger, smaller or stayed the same size
Is the lump painful (strangulated hernia, infected sebaceous cyst, infected pseudoaneurysm, groin abscess)
Are there any other lumps (bilateral inguinal hernia, lymphadenopathy)

Question 3

What may predispose to the following: femoral artery pseudoaneurysm, direct inguinal hernia, inguinal lymphadenopathy

Answer 3

Femoral artery pseudoaneurysm: angiography
Direct inguinal hernia: heavy lifting
Inguinal lymphadenopathy: lower limb infection

Question 4

What questions should be asked about a suspected hernia

Answer 4

Any abdominal pain? (Bowel obstruction and strangulation) -> colicky pain + distension + vomiting + absolute constipation

Straining at stool, struggling to pass urine, or suffering from a chronic cough? Does the job or leisure activity involve heavy lifting? (Increases abdominal pressure + likelihood of hernia)

Any prior operations in the groin? (Predisposes to incisional hernias)

Question 5

What questions should be asked if an infective process or malignancy is suspected

Answer 5

Any trauma or infection in the lower limbs or groin? (Including IVDU, insect bites, infected toenails)
Sexual history, genital rashes, discharge
Have there been any indicators of anal, scrotal or cutaneous malignancy
Fever?
Has there been weight loss, night sweats or pruritus?

Question 6

What features should you look for on palpation of a groin lump

Answer 6

Site (where, which tissue layer, extension to scrotum?)
Size
Tenderness and warmth 
Solid or fluctuate 
Pulsatility 
Cough impulse
Reducibility

Question 7

What does the site of the groin lump suggest

Answer 7

Saphenofemoral junction = saphena varix

Neck of hernia:
Superior and medial to pubic tubercle - inguinal
Inferior and lateral to the pubic tubercle - femoral

Cutaneous and subcutaneous - lipoma

Extension to scrotum - indirect inguinal hernia

Question 8

What does tenderness and warmth on examination of a groin lump tell you

Answer 8

Strangulated hernia - red and inflamed
Reducible hernias - tender
Groin abscesses, reactive lymph noes or infected pseudoaneurysms - warm and tender to palpation + overlying erythema

Question 9

What does fluctuance of a groin lump tell you

Answer 9

Swollen lymph nodes = solid

Hernia, saphena varix, femoral aneurysm/pseudoaneurysm, Passos bursa, hydrocele = softer, may be fluctuant

Question 10

What does pulsatility of a groin lump tell you

Answer 10

Femoral aneurysm (true or pseudo)

Swollen lymph node overlying the femoral artery may transmit a pulse

Question 11

What does the cough impulse indicate for groin lumps

Answer 11

Lump expands and increases in tension during coughing
Diagnostic of hernias
Direct inguinal - expands outwards (through defect in posterior wall of inguinal canal)
Indirect inguinal - expands along the path of the inguinal canal (inferomedial direction)

Question 12

What does a reducible groin lump tell you?

Answer 12

Only hernias and saphena varices are reducible

Saphena varix - soft bluish swelling only seen when standing. Empties with minimal palpation and fills upon release

Direct inguinal hernia - reduces superiority and posteriorly
Indirect inguinal hernia - reduces superolaterally and posteriorly

Question 13

What information will auscultation of a groin lump tell you

Answer 13

Bowel sounds present - herniated bowel

Question 14

What test is used to distinguish between a direct and indirect hernia

Answer 14

Reduce the hernia and place a finger over the deep ring (midpoint of the inguinal ligament)
Ask the patient to cough
Hernia re-appears: direct inguinal
Hernia does no reappear: indirect

Question 15

72F with lump in the groin. First noticed it a lump ago, has never disappeared and does not change in size. Slightly tender
Exam - fluctuant lump, 2cm, neck is inferior and lateral to the pubic tubercle
Weak cough impulse, cannot be reduced. Not tender to palpation + no erythema

Diagnosis + management

Answer 15

Femoral hernia

Referral to surgeons for operative repair without delay

Question 16

What is the management for a strangulated hernia and why

Answer 16

Emergency surgery due to risk of bowel necrosis and perforation

Question 17

Groin lump that is noticed only when standing.
Exam - fluctuant swelling, bluish tinge, non-tender
Expansile cough impulse
Easily reduces with light palpation and reappears as soon as pressure is removed
No audible bowel sounds over the lump, non-pulsatile
Lump disappears on lying down

Diagnosis?

Answer 17

Saphena varix (non-tender, fluctuant groin lump with cough impulse, disappears when flat + bluish tinge)

Question 18

Management options for a direct inguinal hernia

Answer 18

Nothing, may help to lose weight
Truss
Surgical repair

Question 19

Firm rubbery lump, left groin crease. Relatively mobile and does not appear to be tethered. Not possible to reduce the lump
Always present and non-tender
Cause?

Answer 19

Inguinal lymphadenopathy

Question 20

What are the causes of inguinal lymphadenopathy

Answer 20

Infective: HIV | TB | STIs
Neoplastic: lymphoma | leukaemia | metastases

Question 21

Define the following: hernia, sinus, stoma, fistula

Answer 21

Hernia: Abnormal protrusion of the contents of a cavity through the wall that normally contains it

Sinus: blind-ended tract between an epithelial surface and a cavity lined with granulation tissue

Stoma: artificial opening of an internal tube that has been brought to the surface

Fistula: Abnormal communication between two epithelial surfaces e.g. hollow organs or hollow organ + exterior

Question 22

What is the difference between reducible, irreducible, incarcerated, obstructed and strangulated hernias

Answer 22

Reducible: can pushed back into the right place

Irreducible: Cannot be pushed back into the right place

Incarcerated: stuck in the abnormal position as there are adhesions between the hernial sac and surrounding structures OR adhesions mean the sac is wider than the neck

Obstructed: neck of the hernial sac obstructs passage of flow through the bowel

Strangulated: blood supply is compromised due to constriction by the neck of the hernial sack

Question 23

What is Hesselbach’s triangle

Answer 23

Distinguishes between indirect and direct hernias. Direct hernias arise within the triangle.

Borders:
Rectus sheath
Inguinal ligament
Deep inferior epigastric artery

Question 24

What is the difference between herniotomy, herniorraphy and hernioplasty

Answer 24

Herniotomy: surgical excision of a hernial sac

Herniorraphy: repair of a hernia using locally available tissues e.g. sutured repair such as the Bassini

Hernioplasty: repair of a hernia using synthetic material e.g. mesh

Question 25

What is the difference between the mid-inguinal point and the midpoint of the inguinal ligament

Answer 25

Mid inguinal: half way between ASIS and pubic symphysis - surface landmark for femoral artery

Midpoint of inguinal ligament: half way between ASIS and pubic tubercle - surface landmark for the deep inguinal ring