23. Groin Lump

Question 1

List the causes of groin lumps by considering the anatomical structures in the groin.

Answer 1

Psoas sheath – psoas abscess, psoas bursa
Femoral nerve – femoral neuroma
Femoral artery – aneurysm, pseudoaneurysm
Femoral vein – saphena varix
Lymph nodes – inguinal lymphadenopathy (infectious or malignant)
Hernial orifices – inguinal hernia, femoral hernia
Testicular apparatus – ectopic testis, undescended testis, hydrocoele of the cord
Skin/subcutis – lipoma, infected abscess, sebaceous cyst

Question 2

List the most common causes of groin lump.

Answer 2

Indirect inguinal hernia 
Direct inguinal hernia 
Inguinal lymphadenopathy
Femoral hernia 
Saphena varix

Question 3

List some important questions you should ask about the history of presenting complaint.

Answer 3

How long has the lump been there?
Is the lump always there? Does it go away when you lie down?
Has the lump changed in size?
Is the lump painful?
Have you noticed any other lumps?

Question 4

Which causes of groin lump would have been present since birth?

Answer 4

Undescended testis

Ectopic testis

Question 5

Which causes of groin lump are reducible?

Answer 5

Hernias

Saphena varix

Question 6

What can make a saphena varix increase in size?

Answer 6

Standing up for a long time

Question 7

What does a rapid increase in the size of a groin lump suggest about the underlying cause?

Answer 7

Infective process

Question 8

List some causes of painful groin lumps.

Answer 8

Strangulated hernia
Groin abscess
Infected sebaceous cyst
Infected pseudoaneurysm

Question 9

What is the difference between incarcerated hernias and strangulated hernias?

Answer 9

Incarcerated – the hernia is stuck in one place and cannot be reduced
Strangulated – the blood supply to the loop of bowel has been cut off leading to ischaemia and infarction

Question 10

Why is it important to ask the patient about any other lumps that they may have noticed?

Answer 10

The presence of inguinal lymphadenopathy in the context of more widespread lymphadenopathy may increase suspicion of a systemic disease (e.g. SLE, lymphoma, HIV)

Question 11

List some important questions you should ask if the groin lump is thought to be a hernia.

Answer 11

Has there been any abdominal pain?
Have you been straining at the stool or to pass urine? Have you been suffering from a chronic cough? Do you do a lot of heavy lifting?
Have you had any prior operations in the groin?

Question 12

What are the two main risks of hernias?

Answer 12

Bowel obstruction

Bowel strangulation

Question 13

Why is it important to ask about prior operations in the groin/abdomen?

Answer 13

Prior operations will increase the risk of incisional hernias

Question 14

List some important questions you should ask if the groin lump is thought to be caused by an infective process or malignancy.

Answer 14

Has there been any trauma or infection in the groin or lower limbs?
Have you had a fever?
Have you noticed any weight loss, night sweats or itchiness (pruritus)?
NOTE: pruritus is a feature of lymphoma

Question 15

Describe how the site of inguinal hernias differs from femoral hernias.

Answer 15

Inguinal – superior and medial to the pubic tubercle

Femoral – inferior and lateral to the pubic tubercle

Question 16

If the lump extends into the scrotum what is the most likely cause?

Answer 16

Indirect inguinal hernia

Question 17

Which causes of groin lump will cause warmth and tenderness of the skin overlying the lump?

Answer 17

Strangulated inguinal hernia – EMERGENCY
Groin abscess
Reactive lymph nodes
Infected pseudoaneurysm

Question 18

Which causes of groin lump are solid?

Answer 18

Swollen lymph nodes

Question 19

Which causes of groin lump are fluctuant?

Answer 19

Hernias 
Saphena varix 
Femoral aneurysm/pseudoaneurysm
Psoas bursa 
Hydrocoele of the cord

Question 20

What feature will you notice on palpation of a femoral aneurysm/pseudoaneurysm?

Answer 20

Transmitted pulse

Question 21

Which causes of groin lump will expand when the patient coughs?

Answer 21

Hernias

Question 22

Describe how the expansion of the lump when coughing can help distinguish direct and indirect inguinal hernias.

Answer 22

Direct – expand outwards

Indirect – expand in the direction of the inguinal canal (inferomedial)

Question 23

Describe how the direction of reducibility is different for direct and indirect inguinal hernias.

Answer 23

Direct – superolaterally and posteriorly

Indirect – along the inguinal canal

Question 24

Explain how auscultation may be useful in diagnosing a groin lump.

Answer 24

Audible bowel sounds suggest that the lump is a loop of bowel

Question 25

Outline the pathophysiology of a Direct Inguinal Hernia

Answer 25

The hernial sac protrudes through a defect in the transversalis fascia, which makes up the posterior wall of the inguinal canal

Question 26

Outline the pathophysiology of an Indirect Inguinal Hernia

Answer 26

The hernial sac protrudes through the deep inguinal ring and through the inguinal canal

Question 27

Which type of inguinal hernia has a greater risk of strangulation?

Answer 27

Indirect inguinal hernia – this is because it passes through a smaller defect in the abdominal wall

Question 28

Describe a bedside test that can be performed to distinguish direct and indirect inguinal hernias.

Answer 28

Reduce the hernia and place pressure using a finger over the deep inguinal ring
Ask the patient to cough
If the hernia reappears whilst your finger is pressed down over the deep ring, the hernia is direct
An indirect inguinal hernia will only reappear once the finger is taken off the deep inguinal ring

Question 29

What percentage of inguinal hernias are indirect?

Answer 29

75%

Question 30

What is the term used to describe coexisting direct and indirect inguinal hernias?

Answer 30

Pantaloon hernias

Question 31

Describe the origin of an Indirect Inguinal Hernia

Answer 31

Lateral to the inferior epigastric artery

Question 32

Describe the origin of an Direct Inguinal Hernia

Answer 32

Medial to the inferior epigastric artery

Question 33

Describe the conservative management of direct inguinal hernias.

Answer 33

Do nothing – losing weight may help relieve intra-abdominal pressure
Wear a truss – keeps the hernia inside the abdomen and prevents strangulation

Question 34

List some infective and neoplastic causes of inguinal lymphadenopathy.

Answer 34

Infective – HIV, TB, STI, lower limb infection

Neoplastic – lymphoma, leukaemia, metastases