Groin lump (oxford clin cases)

Question 1

What are some common differentials when someone presents with a groin lump?

Answer 1

Indirect inguinal hernia
Direct inguinal hernia 
Femoral hernia
Inguinal lymphadenopathy 
Dilation of the great saphenous vein

Question 2

What questions might you ask in the history when a patient presents with a groin lump? Explain why you ask each one

Answer 2

How long has the lump been there- many pathologies have an insidious onset, but hernias may have been precipitated by weight lifting
Has the lump changed in size or stayed the same- most groin lumps will change in size (either bigger or smaller)
Is the lump painful- a normal or incarcerated hernia is not painful but a strangulated hernia, psoas abcess etc are acutely painful
Does anything make the lump worse- hernias will be more prominent when coughing/increasing intraabdominal pressure whereas as dilations of the saphenous vein will be worse after prolonged periods of standing
Are there any other lumps- could suggest lymphadenopathy etc

Question 3

What questions should you ask in the history if you suspect someone has a hernia? Explain why you ask them

Answer 3

Has there been any abdominal pain- bowel obstruction or strangulation is a big risk for hernias
Have they been straining to defecate or struggling to urinate- makes hernia more likely
Have they had a chronic cough- makes hernia more likely
Do they have a job that involves heavy weight lifting- makes hernia more likely
Have they had any previous operations at the groin?- makes incisional hernia more likely

Question 4

What should you ask if you think the groin lump is due to infection or malignancy?

Answer 4

Is there fever
Has there been weight loss, night sweats or pruritus
Have there been any new lumps/bumps near the anus, scrotum etc
Has there been any IV drug use
Have there been any insect bites
Have there been any infected toenails
Sexual history

Question 5

Where in relation to the pubic tubercle is an inguinal hernia?

Answer 5

Superior and medial

Question 6

Where in relation to the pubic tubercle is a femoral hernia?

Answer 6

Inferior and lateral

Question 7

If a lump extends into the scrotum what is the most likely diagnosis

Answer 7

Indirect inguinal hernia

Question 8

If the lump is warm, red, or swollen what are the likely diagnoses

Answer 8

Strangulated hernia
Groin abcess
Infective pseudoaneurysm

Question 9

If the groin lump is solid what is it likely to be?

Answer 9

A lymph node

Question 10

If the groin lump is fluctuant what could it be?

Answer 10

Hernia
Pseudoaneurysm
Psoas abscess
Dilation of the great saphenous vein

Question 11

What is the medical name for dilation of the great saphenous vein?

Answer 11

Saphena varix

Question 12

If the lump is pulsatile what is the likely diagnosis?

Answer 12

If truly pulsatile it will be either a pseudo or real aneurysm of the femoral artery
Remember it could also be a transmitted pulse eg a swollen lymph node in the femoral artery

Question 13

How can you clinically confirm the diagnosis of a hernia?

Answer 13

Place your hand on where the patient says the lump is and get them to cough
A direct hernia will bulge outwards
An indirect inguinal hernia will move down the inguinal canal
Remember you can’t just look for the hernia to move as it may not be visible you have to feel with your hand

Question 14

What re the only 2 reducible groin lumps?

Answer 14

Hernias

Saphena varix

Question 15

What does saphena varix look like normally and on reduction? How is it reduced?

Answer 15

It looks like a blueish swelling
It can be reduced via minimal palpation
When reduced the blueish swelling disappears

Question 16

How are direct vs indirect hernias reduced?

Answer 16

Direct hernias reduce superiorly and posteriorly

Indirect hernias reduce along the canal eg inguinal- usually superolaterally and posteriorly

Question 17

Why should you examine the whole abdomen if you suspect hernia?

Answer 17

To ensure there are no masses eg ascites, tumor, faecal loading which are increasing intra abdominal pressure and predisposing someone to a hernia

Question 18

How can you clinically distinguish between a direct and indirect hernia? How reliable is this?

Answer 18

Place a finger over the deep inguinal ring and get the patient to cough
Direct hernia= will protrude as the patient coughs
Indirect hernia= will only protrude after the finger is removed and the patient is asked to cough
This is only about 50% reliable- you can only know for sure when surgery is performed

Question 19

Are all hernia reducible?

Answer 19

No

Question 20

What type of hernia is more common?

Answer 20

Indirect

Question 21

What type of hernia is more likely to become strangulated and why?

Answer 21

Indirect because it passes through a smaller hole

Question 22

What factors would make a diagnosis of saphena varix more likely than a hernia?

Answer 22

Blueish tinge
Disappears when the patient lies down
Easily reduced on palpation

Question 23

How does management of indirect vs direct hernia differ?

Answer 23

Indirect= must be surgically repaired as there is a higher risk of strangulation
Direct= can be conservatively managed if benefitial

Question 24

When might a hernia be conservatively managed instead of surgically

Answer 24

If it is a direct hernia not an indirect one
If there are contraindications to being under anaesthetics eg the patient is on antiplatelets that can’t be stopped
If it can be managed by lifestyle changes eg weight loss

Question 25

What else would you do if you suspect lymphadenopathy?

Answer 25

Examine the lower legs for signs of infection or malignancy and most lymphadenopathy will be due to these
Take a more detailed history- ask about sexual history, symptoms of cancer (anal cancer= bleeding as well as general weight loss, night sweats, pruritus, fever), foreign travel
Do tests- bloods, HIV screen (this doesn’t require consent), biopsy/fine needle aspiration

Question 26

What is the most common type of hernia in men vs women

Answer 26

Inguinal hernia is most common in both genders

Femoral hernia is more common in women but in women inguinal hernias are still more common than femoral

Question 27

Define hernia

Answer 27

The abnormal protrusion of contents outside the cavity that is supposed to contain it

Question 28

What is an incarcerated hernia?

Answer 28

A hernia that is stuck in its position because there are adhesions to surrounding structures

Question 29

What is an obstructed hernia?

Answer 29

A hernia that stops/reduces the flow of bowel contents through its neck. The blood supply to the bowel is intact

Question 30

What is a strangulated hernia?

Answer 30

A hernia wherein bowel has become so constricted at the neck that the blood supply has been cut off

Question 31

What are the contents of the inguinal canal in a male?

Answer 31

Ilioinguinal nerve and spermatic cord

Question 32

What are the contents of the inguinal canal in a female?

Answer 32

Ilioinguinal nerve and round ligament

Question 33

What are the 3 arteries that are in the inguinal canal?

Answer 33

Artery of vas
Cremasteric artery
Gonadal artery

Question 34

What are the 3 veins that are in the inguinal canal?

Answer 34

Testicular vein/pampiniform plexus
Cremasteric vein
Vein of vas

Question 35

What are the 3 nerves in the inguinal canal?

Answer 35

Genital branch of genitofemoral nerve
Sympathetic supply from T10 and 11
Ilioinguinal nerve

Question 36

What are the medial, inferior and superior borders of Hesselbach’s triangle?

Answer 36

Superior= inferior epigastric artery
Medial= rectus sheath
Inferior= inguinal ligament

Question 37

What is Hesselbach’s triangle used for?

Answer 37

To define whether a hernia is direct or indirect
Direct= in the triangle
Indirect= lateral to the triangle

Question 38

What is the landmark of the deep inguinal ring? How is it found?

Answer 38

The midpoint of the inguinal ligament

It is found by finding the midpoint between the anterior superior iliac spine and the pubic tubercle

Question 39

What is the order of femoral artery/vein/nerve?

Answer 39

From lateral to medial= nerve, artery, vein

Remember alphabetically V is last so it is the innermost one