Groin Lump

Question 1

Give the Ddx list for groin lumps based upon the anatomical strictures in the groin region

Answer 1

• Psoas sheath - psoas abscess or bursa
• Femoral nerve - neuroma
• Femoral artery - femoral aneurysm or pseudoaneurysm
• Femoral vein / long saphenous vein - saphena varix (dialted great saphenous vein due to incompetence at the saphenofemoral junction)
• Lymph nodes - lymphadenopathy (infectious or malignant in aetiology)
• Hernial orifices - inguinal hernia, femoral hernia
• Testicular apparatus - ectopic testis, undescended testis, hydrocele of cord
• Skin / subcutis - lipoma, infected abscess (e.g. from IVDU), sebaceous cyst

Question 2

What questions could you ask to help characterise the scrotal mass?

Answer 2

1) How long has it been there?
2) IS the lump always there? Does it reduce when the pateint lies down?
3) Has the lump gotten bigger or smaller or stayed the same size?
4) Is the lump painful?
5) Are there any other lumps?

Question 3

When might the following causes of groin lumps occur and what might precipitate them?…

1) Inguinal hernia
2) Ectopic / undescended testes
3) Lymphadenopathy
4) Femoral artery pseudoaneurysm

Answer 3

1) Precipitated by heavy lifting
2) Congenital - so often corrected after birth and therefore uncommonly present in adults

3)

Precipitated by lower limb infections or also typically present in conjunction with more widespread lymphadenopathy e.g. in lymphoma, primary HIV infection, SLE (systemic lupus erythematosus)

4)

Often following angiography - the pseudoaneurysm is a collection of blood outside the vessel lumen

5)

Question 4

What types of lumps can be made to increase in size and which can be reduced by lying down?

Answer 4

• Hernias can enlargen following increases in intra-abdominal pressure e.g. following coughing or straining for stool
• Saphena varices can enlargen after long periods of standing up due to the incompetence of the saphenofemoral junction and the subsequent retrograde flow and pooling of blood as you stand
• Saphena varices can therefore also reduce when lying down as blood drains via venous return much better

Question 5

1) Most causes of groin lumps can increase in size progressively, except for which types?
2) A rapid increase in size of scrotal lump suggests what?

Answer 5

1)

• All except for ectopic testes / undescended testes

2)

• Infective aetiology e.g. in lymphadenopathy or abscesses such as psoas abscess or skin abscesses

Question 6

Why is it important to ask if there have been any other lumps in a history for groin lumps?

Answer 6

• Because in lymphadenopathy, it often occurs in conjunction with more widespread lymphadenopathy e.g. in lymphoma, primary HIV infection and SLE (systemic lupus erythematosus)

Question 7

Which groin lumps are painful?

Answer 7

• Reducible and incarcerated hernias may or may not be painful
• Strangulated hernias are always acutely painful
• Groin abscesses (skin or psoas)
• Infected sebaceous cysts
• Infected pseudoaneurysm

Question 8

Suppose you have started to take the history and it is suggestive of hernias as the cause of the groin lumps, what further questions must you ask which might elude the risk factors for hernias - and what are they / how do these questions elude to these?

Answer 8

1) PAIN - Has there been any abdominal pain? - BO or bowel strangulation could cause abdominal pain and are risk factors for hernias
2) STRAIN - Has the patient been straining stool, struggling to pass urine, or suffering from a chronic cough? Does their job or leisure activity involve heavy lifting? - increases in intra-abdominal pressure are risk factors for hernias
3) PSH - Has the patient had prior operations in the groin area? - past surgeries increase the likelihood of incisional hernias

Question 9

Suppose you have begun to take the history and it is looking to be suggestive of an infective / malignant aetiology of the groin lump, what further questions should you ask?

Answer 9

• Has there been any trauma or infection in the lower limbs or groin? (including drug use, insect bites sexual infections etc)
• Has there been any indicators of anal, scrotal or cutaneous malignancy? (E.g. new or changing lumps and bumps in the area. Inguinal lymphadenopathy could represent metastatic spread from anal cancer, scrotal cancer or melanoma)
• Does he have a fever? - make infective pathologies such as psoas abscess or lymphadenopathy more likely. Fever could also be due to lymphoma
• Has there been any weight loss, night sweats or pruritis? These are general features of malignancy, and pruritis is a symptom of lymphoma