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Clinical Examination of Inguinal Hernia and Scrotal Swellings

Valentina Lefemine MD, MRCS (Eng) Specialist Registrar in Surgery All Wales Training Programme

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Introduction
Patient standing up

Patient lying down

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Inspection
Scrotum, groin crease, groin

LOOK for: Scars (manually part the skin fold) Asymmetry Lumps/swelling in both sides Skin Changes

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Inspection
Look for swelling in both sides Cough look! (one side) Cough look! (other side)

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Palpation
Scrotum, groin Feel mass, testicle, cord structures

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Lump ( groin/ scrotum)

Describe lump:
Introduction (tenderness, site, size) Define (shape, surface, edges) Composition (consistency, fluctuance, pulsatility, compressibility, reducibility) Layer of origin (fixity, tethering) Overlying, surrounding skin

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Think!
Palpate the scrotum first (even if the
swelling is in the groin!!)

If you can feel a mass in the scrotum ask yourself:

Can I get above it? Can I feel it separate from the testis? Does it transilluminate?

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Palpation
Can you get above it?

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If, no
Hernia Infantile hydrocele (rare) Varicocele

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If, yes

Testicular mass Epididymal cyst/Spermatocoele

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Palpation
Can you feel the testicle separately?

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If, no
Hydrocele/haematocoele Testicular neoplasia Torsion Orchitis

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If, yes.
Hernia Varicocele

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Varicocele

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Palpation

Does it transilluminate?

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If, no
Testicular tumour Hernia

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If, yes
Hydrocele Epidydimal cyst

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If you think the swelling is an hernia

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Palpation

Identify landmarks: ASIS, pubic tubercle and pubic symphysis

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ntry e ring l a n i ingu p e e nt: D e m a al lig ia n i u e ing inal hern h t SIS f o u A t g n n i i n t po ee w Mid- of indirec t t t be n i poin -po d i m nt ( rtery i o Ing al p oral a n i gu Fem n i liga uina Mid PS) me l nt and

ASIS

Inguinal hernia

PT
ASIS anterior superior iliac spine PT pubic tubercle PS pubic symphysis

Femoral nerve

Femoral vein

PS
Femoral hernia

The mid-inguinal point is MEDIAL to the midpoint of the inguinal ligament

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Very important landmark

Mid-point between the ASIS to the pubic symphyis is: MID-INGUINAL POINT the femoral artery lies below this Mid-point between the ASIS to the pubic tubercle is: MID-POINT OF THE INGUINAL LIGAMENT the deep inguinal ring lies here Superficial inguinal ring (through which inguinal hernias emerge ) is above and medial to the pubic tubercle

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Type of hernias
Inguinal hernias emerge above and medial to the pubic tubercle

Femoral hernias emerge below and lateral to the pubic tubercle

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Palpation

Position yourself to the side of the patient Use flat of palpating hand on the groin

(parallel to the inguinal ligament) while the other supports the small of the back

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Hernia
Cough impulse? (not always!) Ask patient to reduce it; you try if patient unable Once reduced
Press over external ring cough
Controlled-inguinal hernia Not controlled femoral hernia

Press over deep ring cough

Controlled indirect (80%) Not controlled direct (20%)

If you cant reduce it move on!

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Offer if appropriate
Other groin Abdominal examination Per-rectal examination

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Finally

SUMMARY SENTENCE AND DIAGNOSIS

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Groin lump...what it could be?

Hernia Lymphnode Saphena varix Ectopic testis Femoral aneurysm Hydrocoele Lipoma of the cord Psoas abscess

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Thank you!