PatientPlus=20 articles are written for doctors and so the language can be technical. = However,=20 some people find that they add depth to the articles found in the other = sections=20 of this website which are written for non-medical people.

Lumps in the groin and scrotum

History and examination is as for = all other lumps and a = review of=20 these points is recommended. In addition there are a few other features = to=20 consider.

The ability to reduce a lump may be deduced from the history by = asking if=20 anything makes it change size. The patient may have reduced it himself = or noted=20 that it is bigger if he has been on his feet all day, especially if = doing=20 anything strenuous and it is small in the morning after lying in bed all = night.

Note the anatomical location of the lump with regard to such = landmarks as the=20 inguinal ligament, the pubic tubercle and the femoral artery. As usual, = this is=20 more difficult in obese patients. When examining male patients for lumps = in the=20 groin, check that the testes are normal and in situ.

Differential diagnosis: A systematic = approach=20 should make it possible to be fairly accurate about diagnosis but some = cases can=20 be difficult. The list for lumps in the scrotum is different for lumps = in the=20 groin with the exception of inguinal hernia that can produce a very = large lump=20 in the scrotum. Most of the list below have their own articles and the = reader is=20 referred to this for greater detail.

Inguinal Lumps	Scrotal Lumps
Inguinal lymph nodes=20 Hernia, direct, indirect or femoral=20 Arterial=20 aneurysm of the femoral artery=20 Psoas abscess=20 Undescended and=20 maldescended testes	Indirect Inguinal Hernia=20 Hydrocoele=20 Testicular=20 tumours=20 Epididymal=20 cyst=20 Varicocele=20 Spermatocoele=20 Haematoma Acute = painful=20 testis suggests=20 Epididymo-orchitis=20 (eg Mumps)=20 Torsion of the=20 testis

Inguinal Lumps

Scrotal Lumps

Inguinal lymph nodes=20
Hernia, direct, indirect or femoral=20
Arterial=20 aneurysm of the femoral artery=20
Psoas abscess=20
Undescended and=20 maldescended testes

Indirect Inguinal Hernia=20
Hydrocoele=20
Testicular=20 tumours=20
Epididymal=20 cyst=20
Varicocele=20
Spermatocoele=20
Haematoma

Acute = painful=20 testis suggests=20

Epididymo-orchitis=20 (eg Mumps)=20
Torsion of the=20 testis

Investigations: Ultrasound = represents a=20 valuable, convenient and non-invasive method for obtaining images, = especially=20 within the scrotum. It has made diagnosis much easier and more reliable. = Such=20 techniques as herniography are rarely required, especially from primary = care.=20 Blood tests may be necessary if malignancy of the testis or other organs = is=20 suspected.

Ultrasound can be very useful in the diagnosis of the acutely painful = testis=20 but 15% of testicular malignancies are detected when performing = ultrasound for=20 an acute condition.²

Inguinal lymph nodes: Nodes are = often palpable=20 along the line of the inguinal ligament on both sides. They are a common = and=20 normal finding in men and even more common in women. Nodes are small, = shotty,=20 mobile and tend to come and go with time. If they are large and fixed = this is=20 abnormal. They may be a reaction to infection in the genital area or the = lower=20 limb or they may represent malignancy, including lymphoproliferative=20 diseases.
If the nodes are few, small and mobile in an otherwise = healthy=20 person then reassurance is reasonable. Otherwise look for signs of = infection in=20 the regions that are drained. Check for other nodes in the axilla and=20 supraclavicular regions and check for splenomegaly. A = spleen has=20 to be at least twice its normal size to be palpable. If the problem = seems to be=20 infection, treat it and review to ascertain that the nodes are = shrinking. In=20 young people remember infectious = mononucleosis.=20 If there is suggestion of malignancy, with large, fixed nodes, refer for = biopsy.=20 If nodes are found elsewhere the differential diagnosis is as for generalised=20 lymphadenopathy. Remember that a single node may really be a = hernia.

Hernias These are very common = problems. Not=20 all lumps are hernias but:

25% of men and 2% of women will have a hernia at some time in = their lives.=20 80,000 inguinal = hernias are repaired each year in the UK=20
90% of hernia repairs ar performed on men=20
75% of all hernias are in the groin. About two third are indirect = inguinal=20 hernia and one third direct inguinal hernia=20
Only 4% of hernias are femoral and most are in women=20
Inguinal hernia is more common in men, femoral hernia = is more=20 common in women but in women, inguinal hernia is more common than = femoral=20 hernia=20
Obturator hernia tends to present as intestinal = obstruction=20 rather than a lump and so will not be considered further=20
Indirect inguinal hernia often appears in the first year of life = but may=20 present at any age. Direct inguinal hernia is a condition of old age = as the=20 fascia thins and the muscles of the abdominal wall grow weak. =

Fig.1. Anatomy of inguinal and femoral = hernia

Inguinal hernia may present = suddenly after=20 some injudicious lifting or straining or gradually. At first they are = usually=20 easy to reduce and the patient may not have an obvious lump on = presentation.=20 Examine the patient both lying and standing. Check for a cough = impulse. If the=20 patient has a variable lump that is sometimes there and sometimes not, = a=20 hernia is very likely. Feel up through the scrotum to the inguinal = orifice and=20 check for a cough impulse. Be aware that this examination is rather = unpleasant=20 for the patient. If nothing is found do not simply send the patient = away with=20 reassurance but note that a hernia is likely and invite the patient to = attend=20 again.
An indirect inguinal hernia may present as a large lump in = the=20 scrotum and it may look like a hydrocoele. It will not = transilluminate. Try to=20 reduce it with the patient lying back with head supported on a pillow = and=20 abdomen relaxed.
Direct inguinal hernias are almost invariably in = old men.=20 They do not extend into the scrotum. They appear to come more directly = through=20 the abdominal wall than do indirect hernias but this can be = misleading. They=20 are less likely to strangulate.
In a young person, repair of any = hernia is=20 recommended. In an old and frail person at high risk for surgery a = truss may=20 suffice but if strangulation occurs the risk of emergency surgery is = much=20 greater than that for elective surgery. Failure to reduce and, = especially=20 tenderness are causes for concern and require immediate = referral.
Baby=20 girls with inguinal hernia should be checked for karyotype XY as = testicular=20 feminisation, often called complete androgen insensitivity = syndrome=20 (CAIS) often presents thus.¹=20
Femoral hernia: In older women = the=20 incidence of femoral hernia approaches that of inguinal hernia. The = lump is=20 lateral and inferior to the pubic tubercle. Check for reducablilty and = any=20 tenderness. Referral for repair should be made as there is high risk = of=20 strangulation.

Aneurysm of the femoral artery is = uncommon and=20 almost exclusively confined to drug abusers who inject into their groin. = They=20 intend the femoral vein but their aim and knowledge of anatomy is so = poor that=20 they often hit the femoral artery instead. This can damage the wall of = the=20 artery, often with infection as well as trauma. Aneurysm and thrombosis = may=20 result and even loss of the leg. Drug abusers should be most strongly = advised=20 not to inject into the groin.

Psoas abscess: This occurs with Pott's syndrome = that is tuberculosis of = the spine.=20 It is largely of historical interest in this country but in developing=20 countries, even at 2% of all cases of tuberculosis it represent = significant=20 numbers. A psoas abscess comes from a tuberculosis abscess of the lumbar = vertebra that tracks from the spine inside the sheath of the psoas = muscle. Other=20 causes include extension of renal sepsis and posterior perforation of = the bowel.=20 There is a tender swelling below the inguinal ligament that may resemble = a=20 femoral hernia or inguinal lymph node.

Hydrocoele (see separate = article) may=20 present at any age but especially in the neonate and the older man. The = scrotum=20 is enlarged, often quite markedly so. The fluid in the sac will = transilluminate.=20 Try to feel for the testis and see if it seems normal. There may be a=20 simultaneous inguinal hernia. It is quite easy to aspirate a hydrocoele = to=20 confirm the diagnosis and to confirm the correct anatomy of the scrotal = contents=20 but it will usually fill again. In infants a hydrocoele will probably = resolve=20 spontaneously but in the older group this is unlikely. There are a = number of=20 surgical approaches. Ultrasound examination may be useful to confirm the = diagnosis and to exclude other pathology.

Testicular tumours (see separate = article) are=20 usually teratomas below about 30 years old and seminomas over 40. A = normal=20 testis is fairly sensitive. Epididymo-orchitis is very sensitive but = malignancy=20 is often associated with loss of normal sensitivity. This is not = invariable and=20 pain may be the presenting feature. There is far more detail in the = article on=20 the subject.

Undescended and maldescended testes = (see separate = article) may=20 present as a lump in the groin and be mistaken for an inguinal hernia. = This is=20 one reason to check for the presence of the testis in the scrotum. = Diagnosis=20 should be made at an early age with orchidopexy if required.

Varicocele is a congenital = urological=20 malformation. It is a dilatation of the pampiniform plexus or = spermatic=20 venous plexus that presents a mass of dilated, tortuous veins and is = often=20 tender. It is usually on the left side. There may be testicular atrophy = and=20 problems of male=20 infertility.

Epididymal cysts: The epididymis is = behind the=20 testis. Cysts are usually at the head of the epididymis. They may be = quite large=20 and the man may even believe himself to be the proud possessor of a = third testis=20 with the endowment of a pawnbroker's sign. Epididymal cysts usually=20 transilluminate. Ultrasound may confirm any diagnostic uncertainty. A=20 conservative approach is fine for small cysts but larger ones may be at = risk of=20 torsion and so should be treated surgically.

Spermatocoele is a small painless = mass,=20 usually no more than 1cm in diameter, behind or just above the testis. = It=20 usually follows vasectomy, often = by many=20 years. It is of no significance and reassurance is required. It may be = difficult=20 to be certain of the diagnosis, especially if it seems to be a hard, = painless=20 lump on the testis like a seminoma. A stitch abscess or reaction may = also occur=20 after vasectomy.

Haematoma may follow trauma, = including the=20 surgical trauma of vasectomy. It may be difficult to be sure of the = diagnosis as=20 it may present as a hard, painless lump on a testis. Such lumps are = usually=20 malignant or a gumma of advanced syphilis = although the=20 latter is rarely seen nowadays. If ultrasound does not confirm the = diagnosis,=20 exploration may be required.

References:

Deeb=20 A, Hughes IA; Inguinal hernia in female infants: a cue to check = the sex=20 chromosomes?;BJU Int. 2005 Aug;96(3):401-3.[abstract]=20
Wittenberg=20 AF, Tobias T, Rzeszotarski M, et al; Sonography of the Acute = Scrotum: The=20 Four T's of Testicular Imaging.;Curr Probl Diagn Radiol. 2006=20 Jan-Feb;35(1):12-21.[abstract]

Internet:

Manthey = D=20 Hernias; eMedicine; October 2004=20
http://www.sur= gical-tutor.org.uk/default-home.htm=20 Revision Notes: groin=20 hernias and their complications and scrotal=20 pain and swellings.

Acknowledgements EMIS is grateful = to the=20 Mentor authoring team for writing this article. The final copy has = passed peer=20 review of the independent Mentor GP authoring team. =A9EMIS = 2006.

Last issued 05 Jul = 2006

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