PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections 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 these points is recommended. In addition there are a few other features to consider.

The ability to reduce a lump may be deduced from the history by asking if anything makes it change size. The patient may have reduced it himself or noted that it is bigger if he has been on his feet all day, especially if doing 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 inguinal ligament, the pubic tubercle and the femoral artery. As usual, this is more difficult in obese patients. When examining male patients for lumps in the groin, check that the testes are normal and in situ.

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

Inguinal Lumps | Scrotal Lumps

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

Indirect Inguinal Hernia
Hydrocoele
Testicular tumours
Epididymal cyst
Varicocele
Spermatocoele
Haematoma

Acute painful testis suggests

Epididymo-orchitis (eg Mumps)
Torsion of the testis

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

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

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

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

25% of men and 2% of women will have a hernia at some time in their lives. 80,000 inguinal hernias are repaired each year in the UK
90% of hernia repairs ar performed on men
75% of all hernias are in the groin. About two third are indirect inguinal hernia and one third direct inguinal hernia
Only 4% of hernias are femoral and most are in women
Inguinal hernia is more common in men, femoral hernia is more common in women but in women, inguinal hernia is more common than femoral hernia
Obturator hernia tends to present as intestinal obstruction rather than a lump and so will not be considered further
Indirect inguinal hernia often appears in the first year of life but may present at any age. Direct inguinal hernia is a condition of old age as the 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 some injudicious lifting or straining or gradually. At first they are usually easy to reduce and the patient may not have an obvious lump on presentation. Examine the patient both lying and standing. Check for a cough impulse. If the patient has a variable lump that is sometimes there and sometimes not, a hernia is very likely. Feel up through the scrotum to the inguinal orifice and check for a cough impulse. Be aware that this examination is rather unpleasant for the patient. If nothing is found do not simply send the patient away with reassurance but note that a hernia is likely and invite the patient to attend again.
An indirect inguinal hernia may present as a large lump in the scrotum and it may look like a hydrocoele. It will not transilluminate. Try to reduce it with the patient lying back with head supported on a pillow and abdomen relaxed.
Direct inguinal hernias are almost invariably in old men. They do not extend into the scrotum. They appear to come more directly through the abdominal wall than do indirect hernias but this can be misleading. They are less likely to strangulate.
In a young person, repair of any hernia is recommended. In an old and frail person at high risk for surgery a truss may suffice but if strangulation occurs the risk of emergency surgery is much greater than that for elective surgery. Failure to reduce and, especially tenderness are causes for concern and require immediate referral.
Baby girls with inguinal hernia should be checked for karyotype XY as testicular feminisation, often called complete androgen insensitivity syndrome (CAIS) often presents thus.1
Femoral hernia: In older women the incidence of femoral hernia approaches that of inguinal hernia. The lump is lateral and inferior to the pubic tubercle. Check for reducablilty and any tenderness. Referral for repair should be made as there is high risk of strangulation.

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

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

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

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

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

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

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

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

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

References:

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

Internet:

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

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

Last issued 05 Jul 2006

Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.

Advertise on this site

Click here to complete our survey about Patient UK for a chance to win £500 of M&S vouchers

Related pages in Patient UK

Your Experience
Please add your experience about this condition
Leaflets
Testes - Get To Know Yours

PatientPlus
Femoral Hernias
Testicular Tumours

Diagrams
Testicle (diagram)

Web links
Cancer of the Testis
Epidiymo-orchitis
Testicular Cancer

Other - Useful resources
Pictures, diagrams, photos, images, etc.
Evidence based medicine
Online textbooks and journals
Guidelines
Medline
Other good health sites

^ Top of Page

Books

Want to search some more? Use the Google Search box below to search our site (default) or to search on the internet.

Web | www.patient.co.uk

Would you like to try our advanced on-line knowledge support system designed to provide professionals with relevant up to date information about recognition and management of disease or take the Mentor Challenge?

Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.

Advertise on this site

PS - Health and Poverty

Perhaps the biggest cause of ill health throughout the world is poverty. MAKEPOVERTYHISTORY North East has a website giving details of ongoing campaigns against poverty. Help to Make Poverty History.

^ Top of Page

Comprehensive, free, up-to-date health information as provided by GPs to patients during consultations

HOME Search our site Or browse
Choose a section...

Main content sections...

Health and disease leaflets

Listen to content of leaflets

Support/self help groups

All about medicines

Patient UK Book Shop

Medical Equipment

Patient UK Pharmacy

Lifestyle/preventing illness

Tests and investigations

Directory of UK websites on...

A-Z index of health sites

Diseases

Health news

Health equipment

NHS information

Helplines

Benefits

Travel health

Carers issues

Private health

Dental health

Events/campaigns

More...

Medical Reference articles

PatientPlus

More patient resources...

Health books

Patient experience

Poems and stories

Find a doctor, therapist, etc

Glossaries/Dictionaries

More medical detail...

Clinical guidelines

Evidence based medicine

Online textbooks

Images and pictures

Medline

Book GP appointments...

EMIS Access

Other sections...

Whats new on Patient UK

Help

Disclaimer

Home page
HELP

Related to this topic : Leaflets | PatientPlus | Diagrams | Weblinks | Books | Your Experience | Other resources | Glossaries
Print / listening options : |

How can I Judge the quality of health information?

Disclaimer/Terms | Feedback | Add link | About Us | Quality Control | Licence data | Search box | Accesskeys | Content by Keyword

© EMIS and Patient Information Publications 1997-2007   Advertise on this site