csp groin lump

Clinical Examinationof Groin Lump

Division of Digestive Surgery

Medical School, Padjadjaran University

Division of Digestive Surgery

Medical School, Padjadjaran University

Specific learning objectives :

At the end of training session, student will be able to :– perform history taking of groin lump

correctly. (P5)– perform physical examination on groin

lump correctly. (P5)

Definition : Groin lump

• A lump which arises from the groin/inguinal region and it may be due to various diseases or disorders

Causes of groin lump:

• Inguinal hernias: Direct, Indirect

• Femoral hernia

• Vaginal hydrocele

• Hydrocele of testis/cord / canal of Nuck

• Ectopic testicle

• Lipoma of the cord

Causes of groin lump:

• Lymphadenitis

• Lymphadenopathy

• Abscess

• Hematoma

• Varicocele

• Seroma

Causes of groin lump:

• Testicular mass

• Testicular torsion

• Epididymitis

• Femoral aneurysm or pseudoaneurysm

• Cyst

Anatomy of the inguinal region

Types of Inguinal Hernia :

Femoral Hernia

Clinical Grading

Reduction pain Obstructiontoxic

Grade

• reponible + - - -

• irreponible - - - -

• incarceration - colic + -

• strangulation - steady + ++ increase

leucocytosis

History taking:

• Introduction:

– Greet the patient, and develop a warm and helpful environment

– Introduce yourself to the patient

History taking:

• Patient Identity– Ask the patient politely concerning

his/her:• Name• Age

– Record the gender:• Male• Female:

– Number of children– parity

History taking:

• Chief complaint:– Ask the patient regarding why the

patient comes to you. – Lump on the groin:

• Location: unilateral/bilateral• Onset: acute (< 2 weeks), chronic (>2

weeks).• Size of the lump at present

History taking:

The nature of the lump:

• Intermittent?– If yes, what are the aggravating factors? Or

relieving factors?– Is the lump reducible?– Feeling discomfort?

• Persistent?– If yes, determine the lump progression– Accompanying pain: continuous? Intermittent?

Colicky abdominal pain?

History taking:

Other related symptoms:

• Ask the patient concerning related/concomitant symptoms of :– Gastro-intestinal function:

• Nausea.• Vomiting• Bowel habit: obstipation?

History taking:

• Urinary function:

– Micturition: amount of urine,– Lower urinary tract symptoms:

obstructive and irritative symptoms.

History taking:

Fever:

• Onset of fever: before or after the appearance of the lump?

• Type of fever: – Continuous?– Intermittent?

• Accompanying night sweating?

History taking:

• Previous history of :– Previous similar lump

– Previous hernia surgery

– Previous major illness: incl. fever, chronic coughing, injury, jaundice.

Physical Examination: Preparation

• Check all the equipment required and have a good light:– Examination couch– Stethoscope– Explain the procedure and its goals to

the patient.– Wash your hands with antiseptic soap.– Dry and warm your hands with tissue

towels and put on hand gloves.

General Examination:

• General appearance:

– Consciousness– Mood: distressed? Anxious?– Immobile– Colour: Pallor? Flushing?

• If the patient’s general condition looks normal, the patient is asked to stand up in front of you.

• Ask the patient politely to expose his/her inguinal region.

• If there is no lump, you ask the patient to perform Valsava manoeuvre:

• Ask the patient’s head to turn one side. Ask the patient to cover his/her mouth with one of hands, and blow air through the mouth. While doing this, allow the patient to strain and watch for any visible lump from both inguinal and femoral regions, and scrotal regions for male patients.

Groin Examination

X

• Position• Temperature• Pain• Size• Shape• Tensile strength• Composition (solid, gas, liquid)• Changes with cough

If there is a lump on the inguinal or femoral region,

a. Inspect the lump and determine:– The colour of the lump: Redness?– The shape and location of the lump– Skin edema

b. Palpate the lump, determine :– Sign of local tenderness– The content

• Try to reduce the lump manually by using your fingers, starting from the external ring or the most lower part of the lump, going up to internal ring (Anatomical landmark: Anterior Superior Iliac Spine, pubic tubercle).

• If it fails, do not continue. The success procedure is indicated when the lump disappears with or without gurgle sounds.

• Put your right index finger above the inguinal canal or place your right/left fingers on the external ring and the opposite fingers on the internal ring or on top of any noticeable lump.

• Ask the patient to repeat the valsava manoeuvre, watch if there is lump coming out from the rings.

• Determine the position of the lump in relation with inguinal ligament:

Finger test

Differential Diagnosis

• Indirect inguinal hernia (no lump, if the fingers compression released, the lump will reappear).

• Direct inguinal hernia (Round Lump above inguinal ligament)

• Femoral hernia (Lump below the inguinal ligament/pubic tubercle).

• If a scrotal lump presents, grasp the swelling between fingers and thumb, and ascertain whether it is possible to get above the swelling.

• Determine its continuity with the inguinal canal.

• Using flash light, determine whether there is any trans-illumination.

• Ask the patient to lie down on the couch in supine position.

• Examine the vital signs:– Temperature– Pulse rate– Blood Pressure– Respiratory rate

• Perform other systems examination, including cardio-pulmonary system.

• Ask the patient politely to expose his/her abdomen and inguinal region.

Abdominal Examination:

Inspection :

• Inspect the movement:– Respiratory movement– Visible bowel peristaltis

• Is there any abdominal distention?

Abdominal Examination:

Palpation:• Using the palmar surface of your fingers,

gently palpate the abdomen. • While palpating, look to the face

expression of the patient, and look for any signs of :– Tenderness– Rebound tenderness– Muscle guarding– Rigidity– Hernial orifices

Abdominal Examination:

Percussion:• Place the palmar aspect of your left hand

on the abdomen, and gently percuss its dorsal aspect with the tip of the middle finger of the right hand, moving all around the abdominal region:– Is it tymphanitic?– Is it Dull ?– Is there any shifting dullness?– Site of liver dullness ? and is it disappeared ?

Abdominal Examination:

Auscultation

• Using stethoscope, and place it gently on the abdomen, listen to the bowel sounds and bruit at least for a minute:– Normal– Absent?– High pitched and hyperactive?– Metallic sound?

Groin Examination:

• Perform the groin examination as you perform on standing position.

• Auscultation on top of a hernia may allow the detection of bowel sounds, which can be useful information if you are unsure as to the nature of an inguinal bulge.

Digital Rectal Examination

• In old male patient with the suspicion of lower urinary tract symptoms, perform digital rectal examination to look for signs of enlarged prostate gland.

Write up

• Write up all significant findings in the medical record.

• Conclude your diagnosis and differential diagnosis, and order any necessary special investigations

Demonstration:Video