Groin Lump Flashcards
List the causes of groin lumps by considering the anatomical structures in the groin.
- 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
List the most common causes of groin lump.
- Indirect inguinal hernia
- Direct inguinal hernia
- Inguinal lymphadenopathy
- Femoral hernia
- Saphena varix
List some important questions you should ask about the history of presenting complaint.
- 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?
Which causes of groin lump would have been present since birth?
Undescended testis
Ectopic testis
Which causes of groin lump are reducible?
Hernias
Saphena varix
What can make a saphena varix increase in size? And what makes it disappear?
- Standing up for a long time - makes it bigger
- Lying down- makes it reduce
What does a rapid increase in the size of a groin lump suggest about the underlying cause?
Infective process
List some causes of painful groin lumps.
- Strangulated hernia
- Groin abscess
- Infected sebaceous cyst
- Infected pseudoaneurysm
What is the difference between incarcerated hernias and strangulated hernias?
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
Why is it important to ask the patient about any other lumps that they may have noticed?
The presence of inguinal lymphadenopathy in the context of more widespread lymphadenopathy may increase suspicion of a systemic disease (e.g. SLE, lymphoma, HIV)
List some important questions you should ask if the groin lump is thought to be a hernia.
- 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?
What are the two main risks of hernias?
Bowel obstruction
Bowel strangulation
List some signs and symptoms suggesting strangulation of a hernia
- Colicky abdo pain
- Absolute constipation
- Vomitting
- Red, tender + warm lump = local inflammation
- Febrile + tachycardia = systemic inflammation
Why is it important to ask about prior operations in the groin/abdomen?
Prior operations will increase the risk of incisional hernias
List some important questions you should ask if the groin lump is thought to be caused by an infective process or malignancy.
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
List some questions you might ask to find out the cause of potential lower limb infections and infectious inguinal lymphadenopathy
- Intra-venous drug use
- Insect bites
- Razor cuts
- Infected toe nails
- STIs, sexual hx –> genital rash + discharge
Describe how the site of inguinal hernias differs from femoral hernias.
Inguinal – superior and medial to the pubic tubercle
Femoral – inferior and lateral to the pubic tubercle
If the lump extends into the scrotum what is the most likely cause?
Indirect inguinal hernia
Which causes of groin lump will cause warmth and tenderness of the skin overlying the lump?
- Strangulated inguinal hernia – EMERGENCY
- Groin abscess
- Reactive lymph nodes
- Infected pseudoaneurysm
Which causes of groin lump are solid?
Swollen lymph nodes
Which causes of groin lump are fluctuant?
- Hernias
- Saphena varix
- Femoral aneurysm/pseudoaneurysm
- Psoas bursa
- Hydrocoele of the cord
What pathology causes a pulsatile lump?
- Femoral aneurysm
- May be transmitted pulse from lymph node etc.
Which causes of groin lump will expand when the patient coughs?
Hernias
Describe how the expansion of the lump when coughing can help distinguish direct and indirect inguinal hernias.
Direct – expand outwards
Indirect – expand in the direction of the inguinal canal (inferomedial)
Describe how the direction of reducibility is different for direct and indirect inguinal hernias.
Direct – superiorly and posteriorly
Indirect – along the inguinal canal (superolaterally and posteriorly)
Explain how auscultation may be useful in diagnosing a groin lump.
Audible bowel sounds suggest that the lump is a loop of bowel
Outline the pathophysiology of: Direct Inguinal Hernia Indirect Inguinal Hernia
- Direct Inguinal Hernia The hernial sac protrudes through a defect in the transversalis fascia, which makes up the posterior wall of the inguinal canal
- Indirect Inguinal Hernia The hernial sac protrudes through the deep inguinal ring and through the inguinal canal
Which type of inguinal hernia has a greater risk of strangulation?
Indirect inguinal hernia – this is because it passes through a smaller defect in the abdominal wall
Describe a bedside test that can be performed to distinguish direct and indirect inguinal hernias.
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
What percentage of inguinal hernias are indirect?
75%
What is the term used to describe coexisting direct and indirect inguinal hernias?
Pantaloon hernias
Describe the origin of: Indirect Inguinal Hernia Direct Inguinal Hernia in relation to the inferior epigastric artery
- Indirect Inguinal Hernia Lateral to the inferior epigastric artery - Direct Inguinal Hernia Medial to the inferior epigastric artery
Describe the conservative management of direct inguinal hernias.
Do nothing – losing weight may help relieve intra-abdominal pressure
Wear a truss – keeps the hernia inside the abdomen and prevents strangulation
List some infective and neoplastic causes of inguinal lymphadenopathy.
- Infective – HIV, TB, STI, lower limb infection
- Neoplastic – lymphoma, leukaemia, metastases
List the different types of hernias in order of risk of strangulation
- Femoral Hernia (always managed surgically asap due to such high risk)
- Indirect Inguinal Hernia
- Direct Inguinal Hernia
