Hernias and other groin problems

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32

Hernias and other groin problems

Introduction

This chapter describes the clinical presentation and diagnosis of lumps and swellings in the groin along with specific conditions causing these problems. Other hernias of the anterior abdominal wall (ventral hernias) are considered at the end of the chapter.

Groin lumps and swellings account for about 10% of general surgical outpatient referrals. In both sexes, the most common lumps in the groin are hernias, mainly inguinal but also femoral. Both are caused by abdominal contents protruding through an abdominal wall defect. The normal testicular descent is from the abdomen to the scrotum via the inguinal canal, and this area remains vulnerable throughout life; inguinal hernias are much more common in males. If large, an inguinal hernia may present as a scrotal rather than a groin lump, but it is obvious that it arises in the groin. In the female, the uterine round ligament pursues a similar course; this explains inguinal hernias in females. The femoral canal, below the inguinal ligament, is another potential weakness and may give rise to a femoral hernia, particularly in women.

Enlarged lymph nodes due to infection or malignancy also cause groin lumps or swellings. Less common are vascular abnormalities such as a saphena varix or a femoral artery aneurysm. Very rarely nowadays, a psoas abscess may track down beneath the inguinal ligament to present in the groin. This used to be a common complication of spinal tuberculosis but is now more often a result of infection tracking down from a perforation in the left colon.

The anatomy of the groin provides a good starting point for understanding surgical problems in this area and is explained in Figure 32.1.

Lumps in the groin

Clinical examination

Groin and scrotum must be examined to discover the anatomical origin of the swelling. Lumps in the groin are examined as lumps elsewhere but there are some special points to note:

Consistency and reducibility

Hernias are usually soft and ‘squishy’ but the most reliable diagnostic sign is if the lump reduces when the patient lies flat or can be reduced by gentle manipulation by patient or clinician. Most inguinal hernias are at least partly reducible, although longstanding hernias gradually become irreducible because of adhesions within the sac. These are said to be incarcerated, i.e. chronically irreducible. In contrast, femoral hernias are nearly always irreducible and have no cough impulse as the femoral canal is so narrow (see Table 32.1).

Table 32.1

Summary of groin lumps and swellings and their clinical features

Disorder Anatomical/developmental basis Clinical features
a. Inguinal hernia
 Direct		 Simple bulging of abdominal contents resulting from inadequate support by weak or ruptured posterior wall of inguinal canal (transversalis fascia) Discomfort; lump usually disappears on lying down; risk of incarceration if large but low risk of strangulation
 Indirect Passage of abdominal contents, often including bowel, through inguinal canal towards scrotum or labium majus Potential for incarceration and strangulation; much more common in men
b. Femoral hernia Abdominal contents, often including bowel, migrate into femoral canal Rarely has a cough impulse; rarely reducible; high rate of strangulation; more common in women
c. Inguinal lymphadenopathy Inguinal nodes drain lower limb, abdominal wall below umbilicus, anal canal, scrotal skin, penis (but not testes, which drain to para-aortic and para-iliac nodes) Enlarged nodes indicate infection, lymphoma or metastases from primary lesion in drainage area
d. Saphena varix Dilatation of long saphenous vein superficial to deep fascia before it enters the femoral vein Can be mistaken for femoral hernia but empties on pressure and disappears on lying down, unlike femoral hernia; varicose veins present in the leg
e. Femoral artery aneurysm Dilatation of common femoral artery just below inguinal ligament Found in patients over 65 years, mostly male; classic clinical sign is expansile pulsation; could be mistaken for femoral hernia
f. Psoas abscess Classically, a tuberculous abscess of lumbar vertebra tracking down inside sheath of psoas muscle; occasionally a pyogenic abscess originating within the abdomen presents via the same route TB presents as swelling or ‘cold abscess’ below inguinal ligament; rare nowadays but may be confused with lymph nodes; pyogenic abscess typically ‘hot’; rarely may be due to abscess from renal stones

A strangulated inguinal hernia can be readily diagnosed by finding an irreducible hernia in the correct anatomical position; the lump is tender and often red. Conversely, strangulated femoral hernias are usually very small and unimpressive, often no more than the size of a grape, yet have serious consequences. Strangulated hernias, particularly femoral hernias, sometimes present with abdominal pain or signs of obstruction but without localised pain in the groin. This emphasises the importance of examining the hernial orifices in every patient with an acute abdomen.

Enlarged inguinal lymph nodes vary in consistency, number and size depending on the pathological cause; they are of course not reducible. A saphena varix is very soft and disappears completely on palpation or if the patient lies down, refilling when pressure is released or if the patient stands. The leg on that side nearly always has obvious varicose veins. A saphena varix also exhibits a cough impulse. Femoral artery aneurysms, however, are firm but pulsatile. These vascular conditions must be diagnosed correctly as injudicious operation could be catastrophic!

Relationship to the inguinal ligament

The site of the lump in relation to the inguinal ligament needs to be identified. The ligament is not visible but stretches between two palpable bony prominences, the anterior superior iliac spine laterally and the pubic tubercle medially (see Fig. 32.1a). The pubic tubercle is higher than might be imagined from the skin contour, lying 2–3 cm above the groin crease. The iliac spine is easy to locate but the pubic tubercle can be difficult, especially in obese patients. It is best found by palpating along the upper border of the pubic symphysis, outwards from the midline (care is needed in the male as the spermatic cord can be tender where it crosses the pubic tubercle).

As shown in Figure 32.2, inguinal hernias always originate above the inguinal ligament, whereas femoral hernias, saphena varices and femoral artery aneurysms always arise below it. Enlarged inguinal lymph nodes are usually situated below the inguinal ligament.

Direct and indirect inguinal hernias (Fig. 32.3)

Distinguishing between direct and indirect inguinal hernias may be clinically difficult but it is a useful exercise in eliciting clinical signs and frequently comes up in student examinations! By definition, an indirect inguinal hernia is one in which the hernial sac lies within the spermatic cord, leaving the abdomen via the deep (internal) inguinal ring to pass along the inguinal canal, exiting through the superficial (external) ring. Thus, if the hernia can be completely reduced, finger pressure over the deep ring will prevent it reappearing on coughing (the deep ring is midway between the pubic symphysis and the pubic tubercle, 2.5 cm above the femoral pulse; see Fig. 32.1a). In contrast, a direct inguinal hernia leaves the abdomen through a weakness or split in the transversalis fascia, the posterior wall of the inguinal canal, emerging directly through the superficial ring and cannot be controlled by digital pressure over the deep ring. In practice, this test is often unreliable. The patient’s age is perhaps the most useful indicator of the likely type of inguinal hernia, with indirect hernias most frequent under the age of 50 and direct hernias more common after that age.

Inguinal hernia

Inguinal hernia is one of the most common conditions seen in general surgical clinics. In a typical district general hospital, inguinal hernias account for about 7% of surgical outpatient consultations and about 12% of operating theatre time.

As shown in Figure 32.4, inguinal hernias in males are by far the most common type of groin hernia. Inguinal hernias occur eight times more often in males because of the abdominal wall deficiency caused by testicular descent. Femoral hernias are rare in males, comprising only 2.5% of groin hernias. Even in females, inguinal hernias are the most frequent (twice as common as femorals). Femoral hernias are twice as common in females as in males.

Inguinal hernias occur at any age. In childhood they always have a developmental origin and are common in premature infants. In males, hernias appear most often before the age of 5 or after middle age. A smaller peak occurs in the late teens and early twenties. Hernias in these young men probably result from a congenital predisposition, exacerbated by work or sport. Most inguinal hernias should be repaired early to reduce the long-term risk of strangulation and the need for emergency operation. The exception is small, easily reducible painless direct hernias in elderly men or those with substantial co-morbidity.

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