Groin lump (oxford clin cases) Flashcards
What are some common differentials when someone presents with a groin lump?
Indirect inguinal hernia Direct inguinal hernia Femoral hernia Inguinal lymphadenopathy Dilation of the great saphenous vein
What questions might you ask in the history when a patient presents with a groin lump? Explain why you ask each one
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
What questions should you ask in the history if you suspect someone has a hernia? Explain why you ask them
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
What should you ask if you think the groin lump is due to infection or malignancy?
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
Where in relation to the pubic tubercle is an inguinal hernia?
Superior and medial
Where in relation to the pubic tubercle is a femoral hernia?
Inferior and lateral
If a lump extends into the scrotum what is the most likely diagnosis
Indirect inguinal hernia
If the lump is warm, red, or swollen what are the likely diagnoses
Strangulated hernia
Groin abcess
Infective pseudoaneurysm
If the groin lump is solid what is it likely to be?
A lymph node
If the groin lump is fluctuant what could it be?
Hernia
Pseudoaneurysm
Psoas abscess
Dilation of the great saphenous vein
What is the medical name for dilation of the great saphenous vein?
Saphena varix
If the lump is pulsatile what is the likely diagnosis?
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
How can you clinically confirm the diagnosis of a hernia?
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
What re the only 2 reducible groin lumps?
Hernias
Saphena varix
What does saphena varix look like normally and on reduction? How is it reduced?
It looks like a blueish swelling
It can be reduced via minimal palpation
When reduced the blueish swelling disappears
How are direct vs indirect hernias reduced?
Direct hernias reduce superiorly and posteriorly
Indirect hernias reduce along the canal eg inguinal- usually superolaterally and posteriorly
Why should you examine the whole abdomen if you suspect hernia?
To ensure there are no masses eg ascites, tumor, faecal loading which are increasing intra abdominal pressure and predisposing someone to a hernia
How can you clinically distinguish between a direct and indirect hernia? How reliable is this?
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
Are all hernia reducible?
No
What type of hernia is more common?
Indirect
What type of hernia is more likely to become strangulated and why?
Indirect because it passes through a smaller hole
What factors would make a diagnosis of saphena varix more likely than a hernia?
Blueish tinge
Disappears when the patient lies down
Easily reduced on palpation
How does management of indirect vs direct hernia differ?
Indirect= must be surgically repaired as there is a higher risk of strangulation Direct= can be conservatively managed if benefitial
When might a hernia be conservatively managed instead of surgically
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
What else would you do if you suspect lymphadenopathy?
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
What is the most common type of hernia in men vs women
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
Define hernia
The abnormal protrusion of contents outside the cavity that is supposed to contain it
What is an incarcerated hernia?
A hernia that is stuck in its position because there are adhesions to surrounding structures
What is an obstructed hernia?
A hernia that stops/reduces the flow of bowel contents through its neck. The blood supply to the bowel is intact
What is a strangulated hernia?
A hernia wherein bowel has become so constricted at the neck that the blood supply has been cut off
What are the contents of the inguinal canal in a male?
Ilioinguinal nerve and spermatic cord
What are the contents of the inguinal canal in a female?
Ilioinguinal nerve and round ligament
What are the 3 arteries that are in the inguinal canal?
Artery of vas
Cremasteric artery
Gonadal artery
What are the 3 veins that are in the inguinal canal?
Testicular vein/pampiniform plexus
Cremasteric vein
Vein of vas
What are the 3 nerves in the inguinal canal?
Genital branch of genitofemoral nerve
Sympathetic supply from T10 and 11
Ilioinguinal nerve
What are the medial, inferior and superior borders of Hesselbach’s triangle?
Superior= inferior epigastric artery Medial= rectus sheath Inferior= inguinal ligament
What is Hesselbach’s triangle used for?
To define whether a hernia is direct or indirect
Direct= in the triangle
Indirect= lateral to the triangle
What is the landmark of the deep inguinal ring? How is it found?
The midpoint of the inguinal ligament
It is found by finding the midpoint between the anterior superior iliac spine and the pubic tubercle
What is the order of femoral artery/vein/nerve?
From lateral to medial= nerve, artery, vein
Remember alphabetically V is last so it is the innermost one
