Groin, scrotum and abdominal wall problems

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Chapter 8 Groin, scrotum and abdominal wall problems

Alan Saunder, Caroline Dowling, Ken Farrell, Mark Frydenberg

8.1 Introduction

History

Groin or scrotal lumps are the most common symptoms of inguinoscrotal pathology. Pain is a variable, sometimes the sole, symptom. Severe persistent pain and local tenderness suggest ischaemia (from torsion or strangulation) or inflammation under tension. Local pain is not, however, a constant symptom of strangulation, which can be silent with few local manifestations, especially in femoral hernia.

Many patients present with a groin lump following a lifting strain at work. Risk factors for hernia, apart from manual exertion, include chronic cough and obstructive airways disease, chronic bladder neck obstruction, constipation and abdominal distension from ascites (Box 8.1). Larger hernias are usually of longer standing and may produce a confluent inguinoscrotal lump. Benign scrotal lumps are common and must be differentiated from hernias and malignancies.

Box 8.1

Risk factors for inguinal hernia

Lifting strain at work

Chronic bronchitis with cough

Chronic urinary obstruction

Constipation

Abdominal distension from ascites

Poor nutrition and old age (direct hernia)

Physical examination

Both sides must always be examined and contrasted. Multiple and bilateral lesions are very common, so no step in the local examination should be omitted. Inguinal and femoral hernial orifices and, in males, the cord, testis and epididymis, must be checked on both sides. Finally the femoral vessels and inguinal lymph node areas are examined.

Examination: patient standing

The examination conveniently starts with the patient standing and unclothed below the waist so that any hernias are made more prominent. In anxious, apprehensive or modest individuals it may be helpful in gaining the patient’s confidence to begin the examination while the patient is supine. Examination with the patient standing must not be omitted, however, as some hernias are only diagnosable in this position and swellings of venous origin disappear completely on lying down.

The region is inspected with the examiner sitting facing the patient, who is then asked to cough or to perform a Valsalva manoeuvre. Any lumps are noted, as are their position in relation to skin creases, bony prominences and other landmarks (Fig 8.1). Lumps are provisionally catalogued as inguinal, scrotal or inguinoscrotal. Any expansile impulse is observed and its direction noted.

image

Figure 8.1 Surgical anatomy of the groin

A: anterior superior iliac spine; B: external ring; C: femoral canal; D: femoral artery and vein; E: internal ring; F: inguinal ligament; G: abdominal crease

Two conditions of venous origin become immediately obvious on standing and can only be diagnosed in this position (Fig 8.2).

image

Figure 8.2 Examination: patient standing

A: saphena varix; B: varicocele

They should be checked first by considering the question: Is a varicocele or saphena varix present?

Varicoceles are usually easy to identify. They present as tortuous, soft, subcutaneous worm-like vascular swellings of the scrotal neck and upper scrotum that are prominent on standing, are usually left-sided and subside rapidly on lying down. They are separate from the testis and epididymis and may extend up along the cord. A venous thrill is sometimes palpable on coughing, but the soft vascular thrill is easily distinguishable from the cough impulse of an indirect inguinal hernia and is never truly expansile. It is usually also recognisable by its prominence during a Valsalva manoeuvre.

Saphena varix is slightly more difficult to distinguish from a femoral hernia. It presents as a groin lump appearing over the saphenous opening on standing and disappearing immediately on lying down. It is usually associated with obvious visible or palpable varicosity of the long saphenous vein, may show a bluish colouration visible through the skin if large and gives a venous thrill on coughing that travels downwards along the saphenous vein.

Its continuity with the long saphenous vein is additionally demonstrated by percussion over the saphenous vein in the thigh or at the knee, which transmits an impulse to a finger held over the groin lump above (Fig 8.3).

image

Figure 8.3 Saphena varix

Percussion over the saphenous vein in the thigh produces a transmitted impulse in the varix above.

Eight subsequent questions should be answered from inspection and palpation.

1 Is a hernia present? (Box 8.2)

An inguinoscrotal lump with an expansile impulse from above is an indirect (oblique) inguinal hernia.

Box 8.2

Typical features of a hernia

image Occurs at a site of weakness or an anatomical defect in the wall of a body cavity
image Usually reducible with pressure or on lying down
image Expansile cough impulse

A lump confined to the groin with an expansile impulse on coughing (bubonocele) is an inguinal or femoral hernia (once saphena varix has been excluded). The lump’s relationship to the pubic tubercle is noted, initially by inspection. Inguinal bubonoceles are predominantly medial to and mostly above the tubercle, just above the scrotal neck or extending into the labium major.

Femoral hernias are lateral or inferior to the tubercle and thus are more at the base and inner angle of the femoral triangle.

If the patient can reduce the lump, they are asked to do so and the origin of the lump is further defined. An inguinoscrotal lump that is not easily reducible is confirmed as arising either from the region of the external (superficial) inguinal ring and inguinal canal or from the femoral canal.

2 Is the hernia inguinal or femoral?

Differentiation is almost always possible by identifying whether the hernial sac emerges from the external inguinal ring above and medial to the pubic tubercle (inguinal hernia) or from the femoral canal and its opening into the thigh just above the saphenous vein, below and lateral to pubic tubercle (femoral hernia) (Fig 8.4).

image

Figure 8.4 Inguinal or femoral hernia?

A: femoral hernia is sited below and lateral to the pubic tubercle (B); C: inguinal hernia appears at the external ring above and medial to the pubic tubercle

Three-finger palpation during coughing is a simple (and rather simplistic) guide to localising hernias. The examiner’s hand (of the same side as that being examined) is placed on the inguinal region with the index finger over the inguinal canal and the middle finger pulp over the external ring. These feel the obliquely or forwardly directed impulses of indirect and direct inguinal hernia respectively. The ring finger lies over the femoral canal and saphenous opening to detect a femoral hernia. The technique is suitable for males and females. With practice, the inverted V-shaped deficit in the muscle aponeurosis comprising the external inguinal ring can be identified accurately beneath the skin of the groin by the sensitive finger pulp.

More precisely, the external inguinal ring can be examined in males by invaginating the scrotum. This procedure is uncomfortable for the patient and must be performed gently and with consideration. If the hernia is not easily reducible while standing, this part of the examination is best reserved until the patient lies down. The examiner’s index finger of the same side as that being examined is placed at the lowest point of the scrotum and gently invaginates the scrotum upwards towards the ring. When sufficient slack has been invaginated so that the examining finger is in front of the pubis, the finger is pronated so that its pulp comes to lie over the external inguinal ring, with enough free play so that the finger can be gently moved without undue discomfort. It is then easy to palpate the pubic crest and the pubic tubercle at its lateral edge and to define precisely the superior and inferior crura of the external ring and the ring itself. Asking the patient to cough or to lift the head and shoulders from the couch tenses the margins of the ring and makes them easier to define. The superficial inguinal ring normally will not admit the index finger tip: if it is enlarged enough to admit the finger into the inguinal canal, an inguinal hernia is almost certainly present. The finding of an enlarged external ring in the absence of a lump is helpful in confirming the diagnosis when the patient’s history of hernia is unequivocal, but no lump is palpable or elicitable on examination. Usually the expansile impulse of the protruding sac when the patient coughs or strains is unmistakable and diagnosis of an inguinal hernia (or its exclusion) can be made with certainty. Separation of inguinal from femoral hernias is facilitated by contrasting an empty and normal inguinal ring with the femoral hernial sac emerging below and lateral to the finger.

The scrotal examination can be done in detail with the patient still standing; often it is best deferred until the patient lies down. It is important in defining scrotal masses to ascertain that one can get above the lump on palpation. A common diagnostic difficulty is when a scrotal lump coexists with an inguinoscrotal hernia. Separation of the two lumps is facilitated by lying the patient down and reducing the hernia prior to examining the scrotum.

Examination: patient supine

When the patient lies down, hernial and other lumps often spontaneously reduce. Manual reduction of hernias is also easier in this position for the patient and clinician, and the examination is much less uncomfortable for the patient.

The hernial orifices are re-examined with the patient lying down and preferably with all hernias reduced. Both external rings and both femoral canals and saphenous openings are rechecked. In the male, no matter how obese, the external inguinal ring can be examined by the sensitive finger tip through the invaginated scrotum. Both rings can be precisely calibrated and any impulse on coughing detected. In the female the external ring is not so precisely palpable. In thinner females the external ring can be palpated accurately beneath the subcutaneous fat above the pubis and only in the very obese female does palpation of the external ring pose any difficulty. The femoral canals and saphenous openings lie more deeply. They are less amenable to precise palpation and their margins cannot be accurately defined. Definition of the external inguinal ring is thus the crucial point in the differentiation of inguinal and femoral groin hernias. Reducible hernias can be separated with confidence by establishing whether they emerge from the external ring or saphenous opening. Irreducible hernias require their sacs to be traced deeply to answer the same question. Large hernias extending into the scrotum must be indirect inguinal hernias. Large femoral hernias may extend upwards above the inguinal ligament but emerge from the saphenous opening and thus lie more laterally in their inguinal extent. Direct inguinal hernias are usually reducible, but funicular direct hernias may be irreducible. The type of hernia should thus be ascertainable without difficulty in all but the very obese female.

3 Is the hernia reducible?

Groin hernias may be reducible or irreducible. Irreducibility can be due to adhesions between the contents and sac wall, the sac wall and its surrounds or to difficulties caused by a large sac and narrow neck. Irreducible hernias are more prone to complications such as strangulation.

4 Is the hernia strangulated?

Strangulation (impairment of the blood supply of the hernial contents) is a serious complication requiring urgent surgery and is more likely to occur in irreducible hernias with narrow necks. Strangulation usually is attended by symptoms of persisting pain and irreducibility over the hernia. Abdominal pain, distension, vomiting and constipation due to bowel obstruction will also be present if the sac contents include the bowel. Strangulation may, however, give no local symptoms referable to the herni, hence the importance of checking hernial orifices in all patients presenting with symptoms of bowel obstruction (Ch 7.8).

The signs of strangulation are therefore of even greater importance than the symptoms: a strangulated hernia is tense, tender, irreducible and shows no cough impulse. Irreducibility and absence of cough impulse each have causes other than strangulation; the cough impulse depends on free transfer of intra-abdominal pressure through the hernial neck and sac to the examining finger. Small hernias in large sacs (common with femoral hernias) or adhesions between sac and contents can cause the cough impulse to disappear, but the combination of these signs with a tense and tender swelling must be considered due to strangulation and is a surgical emergency.

5 Is a scrotal lump present?

The scrotum and its contents are examined in order, starting with the skin and not omitting the skin posteriorly. The skin may evidence sebaceous cysts or occasionally show thickening, sinuses or ulcers with inflammatory lesions such as filariasis and tuberculosis.

6 Can one get above the scrotal lump?

If the answer to this question is yes, then scrotal-only diagnoses should be considered. Otherwise, the swelling is considered inguinoscrotal and the most common cause is an indirect inguinal hernia.

The body of the testis, the tunica vaginalis, the epididymis and the cord back to the inguinal ring are systematically examined to determine the origins of the scrotal lump (Fig 8.5).

image

Figure 8.5 Scrotal examination

A: sequential examination of 1: testis; 2: tunica vaginalis; 3: epididymis; 4: cord; 5: superficial inguinal ring; B: palpation of epididymis

7 Is the lump arising from the testis or epididymis?

If the testis and epididymis are palpable, lumps in either of these structures can be further defined. Either may be diffusely enlarged or the site of a discrete lump and either may be associated with an acute or chronic history of swelling with or without pain.

An acutely painful swelling of the testis and epididymis suggests torsion or acute epididymo-orchitis — very often the two cannot be distinguished clinically from each other. Sometimes a testicular neoplasm can mimic an acute inflammatory swelling and present as a painful acute swelling. Occasionally, a small (<2 cm) localised tender, tense, painful acute lump on the superior pole of the testis will be recognisable as a torsion of the appendix of the testis (hydatid of Morgagni). A painlessly enlarged testis, whether a diffuse or discrete enlargement, very strongly suggests a neoplasm. A chronic haematocele presents as a testicular lump that cannot be distinguished clinically from a neoplasm.

Discrete lesions of the epididymis are very common. Most are epididymal cysts and will be tensely or softly fluctuant and brilliantly transilluminable. Loculated cysts give a Chinese lantern effect.

Chronic solid swellings of the epididymis are usually chronic nonspecific epididymitis or less commonly due to specific infections such as tuberculosis. It may be difficult to differentiate solid discrete epididymal lumps from testicular neoplasms other than by operation. Rarely a benign epididymal tumour can be present, an adenomatoid tumour.

8 Does the lump arise from the coverings or from appendages?

Hydroceles are accumulations of liquid in the tunica vaginalis testis. When large and tense they surround the testis and epididymis from three sides, giving rise to oval or egg-shaped, fluctuant, transilluminable lumps filling the scrotum and obscuring the testis and epididymis. The site of the testis can sometimes be identified by transillumination as a dark shadow posteriorly. With smaller and less tense hydroceles the underlying testis can be palpated through the fluid. Assessment of the underlying testis and epididymis is of great importance as some hydroceles are secondary to testicular pathology (neoplasm or inflammation). In most cases, however, the testis is impalpable due to the extent of overlying fluid.

Encysted hydroceles of cord, or of the canal of Nuck in the female, give classic physical signs: a cystic spherical lump in the upper scrotum or inguinal region along the course of the cord, separate from the testis below and inguinal canal above. The lump moves freely from side to side, but longitudinal traction demonstrates its tethering to the cord and testis. A rare additional cause of a lump in the line of the cord is a lipoma or, more rarely, a liposarcoma of the cord, which is usually easily distinguishable on ultrasound as an echogenic focus as opposed to a hypoechoic fluid-filled cyst.

Differentiation of scrotal lumps can be seen to rely to a considerable extent on demonstration of the cystic nature of the lump by transillumination and fluctuation. Many solid lumps will require operation for ultimate diagnosis.

Finally, the vascular structures in both groins are checked: femoral artery, femoral and long saphenous veins and the lymph nodes.

Femoral artery aneurysm will present as a pulsatile swelling in the position of the artery over the mid-inguinal point. Venous swellings have already been mentioned.

Lymph node swellings are common. They are usually easy to diagnose from their position and consistency and the presence of a focal lesion in the drainage area. A solitary node over the lower part of the femoral canal (gland of Cloquet) can be difficult to distinguish from an irreducible or strangulated femoral hernia. Absence of tenderness is suggestive of lymph node swelling and the draining lymph node areas should be very carefully rechecked, particularly the genitalia, toes and feet, perineum and anal canal.

General examination

This includes assessment of risk factors for hernia, abdominal and chest examination in patients with suspected testicular neoplasm and examination of other lymph node areas when lymph node swellings are found.

8.2 Inguinoscrotal lumps

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