Definition
Any swelling in the inguinal area or upper medial thigh.
Key Points
- The groin crease does not mark the inguinal ligament and is an unreliable landmark.
- Inguinal hernias are common, always start above and medial to the pubic tubercle, may be medial or lateral to it and usually emphasize the groin crease on that side.
- Femoral hernias always start below and lateral to the pubic tubercle, usually flatten the skin crease on that side and are often irreducible.
- Femoral hernias are more common in women, are high risk and need urgent attention.
- Masses in the groin and scrotum together are inguinal hernias.
- Inguinal lymphadenopathy may be isolated or may be part of systemic lymphadenopathy. A cause should always be sought.
Important Diagnostic Features
The types, causes and features are listed below.
Inguinal Hernia
- Direct inguinal hernia: not controlled by pressure over internal ring, characteristically causes a ‘forward’ bulge in the groin, does not descend into the scrotum.
- Indirect inguinal hernia: controlled by pressure over internal ring, ‘slides’ through the inguinal canal, often descends into the scrotum.
- Undescended testis: often mass at the external ring or inguinal canal, associated with hypoplastic hemi-scrotum, frequently associated with indirect inguinal hernia.
- Spermatic cord: ‘cordal’ hydrocele, does not have a cough impulse, may be possible to define upper edge, fluctuates and transilluminates.
- Lipoma: soft, fleshy, does not transilluminate or fluctuate.
Femoral Hernia
- Femoral hernia: elderly women (mostly), may be tender and non-expansile, not reducible, groin crease often lost, high risk of strangulation and obstruction.
- Saphena varix: expansile, cough impulse, thrill on percussion of distal saphenous vein.
- Lymphadenopathy: hard, discrete nodules, often multiple or an indistinct mass.
- Femoral artery aneurysm: expansile, pulsatile, thrill and bruit may be present.
- Psoas abscess (rare): soft, fluctuant and compressible, lateral to the femoral artery, may be ‘cold’ abscesses caused by TB.
- Femoral neuroma (very rare): hard, smooth, moves laterally but not vertically, pressure may cause pain in the distribution of the femoral nerve.
- Hydrocele of femoral sac (very very rare).
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