Examination of the Groin

Introduction

  • Introduce yourself to the patient
  • Wash your hands
  • Explain the examination to the patient
    • Reassure them that you will stop immediately if it becomes too painful at any point
  • Ensure verbal consent is adequately obtained
    • Offer the patient a chaperone if required

Always work through a structured approach as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by any examiner.


Observation

Examine them standing first and ask them to lower their underwear

  • Assess the patient from in front and from the side, on both sides, checking for:
    • Obvious lumps
    • Asymmetry
    • Scrotal swelling
    • Scars
  • Ask the patient to cough, to accentuate any hernia

Palpation

Examination of a Lump

If there is an obvious lump, examine that side first; remember to tell the patient exactly what are you doing throughout.

Important points to note are:

  • Is there one lump or are there multiple?
    • Multiple lumps suggest lymph nodes or possibly superficial lesions
  • Consistency (hard or soft)?
  • Is there a cough impulse?
    • Remember that an incarcerated hernia will most likely not have a cough impulse (as by definition the hernia is trapped and immovable)
  • Is it reducible?
  • Is it pulsatile?
  • Can you get below it and does it extend into the scrotum?

Examination of a Hernia

If you suspect a hernia:

  • What is its relation to the pubic tubercle?
    • Above and medial = inguinal hernia
    • Below and lateral = femoral hernia*

*Look for a small “pea-sized” lump in the groin, indicative of a femoral hernia. These are difficult to find because they are small, but have high rates of obstruction thus essential to look carefully for; they are often incarcerated and so rarely have a cough impulse

Repeat the examination for the other side of the groin (around 20% of inguinal hernias are bilateral)

Ask the patient to lie down

  • Look to see if the lump reduces spontaneously at this point, indicating a hernia
Fig. 1 - A large right sided hernia.

Fig. 1 – A large right sided hernia.

An examiner may ask you about differentiating a direct from an indirect inguinal hernia clinically. This can be done by reducing the hernia, pressing over the deep ring (which is just above the mid-point of the inguinal ligament) and asking the patient to cough; theoretically if the hernia still protruded, despite occluding the deep ring, then this indicates a direct hernia.

However, this is extremely unreliable and the only definite method to differentiate them is at the time of surgery. Most importantly, it has no impact on management (the management for both is either surgery or conservative, whether it is indirect or direct makes no difference)


Completing the Examination

To finish the examination, thank the patient and state to the examiner that to complete your examination, you would like to examine the external genitalia.

Examination of the external genitalia will assess for scrotal extension of the hernia and any genital lesions which may spread to the inguinal lymph nodes. Testicular lesions will drain to the iliac nodes, so will not be palpable

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