FLOW CHART Lumps in the Groin and Scrotum

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9. LUMPS IN THE GROIN AND SCROTUM

INTRODUcrlON

Swellings in these areas are common. They account for

about one in ten of outpatient presentations and are

therefore frequently found in finals examinations.

The majority of lumps in these areas are hernias. A

hernia is a protrusion of a viscus or part of a viscus

through an abnormal opening in the walls of its con-

taining cavity. It usually has three components: the sac,

the coverings of the sac and the contents of the sac.

.. .

Hernias may be:

a. reducible

b. irreducible

c. obstructed

d. strangulated

An irreducible hernia is said to be obstructed if

intestinal obstruction complicates the hernia. The term

is not commonly used. If the blood supply to the hernia

is compromised (implying impending gangrene and

perforation) then the hernia is said to be strangulated.

./



/.


9.1 LUMP IN GROIN

Locale the lump anatomically

Pubic tubercle

Pubic symphysis

INTERNAUDEEP

INGUINAL RING

Midinguinal point

with femoral artery

beneath it EXTERNALJSUPERFICIAL

INGUINAL RING

Midpoint of the

" ' " ' " : : : : : : . 0 . ' " ' " . ]

Anterior superior

iliac spine

'FEMORAL CANAL

Testis cannot be

coaxed into scrotum

I

No testicle in scrotum

~

FEMORAL CANAUTRIANGLE

Below and lateral to the pubic tubercle

Testis maybe

coaxed into scrotum

I- ,-

RETRACTILE UNDESCENDED,TESTIS TESTIS

No treatment if Relocation

testis goes to in scrotum

bottom of scrotum Orchidopexy inIf not relocate neonate belore

via inguinal incision 1 year old

OBSTRUCTED

I

ISee p. 46

History of hernia

Irreduere lump

IRREDUCIBLE

INGUINAL HERNIA

~Pain Bowel obstruction

Tenderness

Bowel obstruction

ISTRANGULATED

I

Testicle in scrotum

Unilocular

Sofllump

Traction on the testis

causes the lump 10

move downwards andbecome less mobile

Transitluminales

I

Excision if symptomatic

ENCYSTED HYDROCELE

OFTHECORD

Seep.46

SUPERFICIAL INGUINAL RING

Above and medial 10 Ihe pubic lubercle

Cont rol led b y Not con tro ll ed b y

pressure over pressure over

in tem r ring in,em r ring

INDIRECT DIRECT

I-,--~I

~------------TransmitS cough impulse No cough impulse

I .[FiEDUCIBL!' I~GUINAL HERNIA I

~.



9. LUMPS INTHEGROIN AND SCROTUM

9.2 LUMP IN FEMORAL CANAlJTRlANGLE

Spherical lump with

a narrow neck

I . FEMORAL HERNIASAPHENA VARIX

High saphenous ligation

Vascular lump:

Compressible

Blue

FillS slowly

Palpable thrill on coughing

Reduces when patient lies down

: : ! : . Varicose veins

I

------;/ ~----Rarer differe";lial diagnoSiS

PsoasabscesQ

Lymphadenopathy

Due to:

Local infection

Regional malignancy

or as part of ageneralized lymphadenopathy

II LYMPH NODE

Reducible (rarely)

IIrreducible lump

I

.~

j

II

REDUCIBLE

FEMORAL HERNIA

IRREDUCIBLE

FEMORAL HERNIA

~ rUctiOn

Pain Bowelobst

Tendemess IBowelObf'ruction C-rt'D ' I

STRANG1ULATED OBSTj

ISee p. 46




9.3 SCROTAL LUMPS (1)

Cannot 'get above it'

I

INFANTILE f'YDROCELE

Ugation of patent processus vaginalis

OCELE

cision

--------------------Can 'get above if

IConfined to scrotum

ULTR

-TUMOUR HYDR

Orchidectomy through Ex

inguinal incision

Staging, then deep X-ray therapy

and/or chemotherapy

Not confined 10scrotum

May be reducible

ITestis and swelling separately palpable I INGUINAL HERNIA

Testis and swelling not separately palpabte bm ~

/r -- - Controlled by Not controlled by

Does not transilluminate Transilluminates pressure over pressure over

~ I i nt er na rr ing i nl er na tr ing

HYDROCELE I ITestis is heavy and irregular r - - - - - - - - - - _ INDIRECT DIRECT

Theremaybea ~secondary hydrocele present

due to the tumour Usually middle-aged palient YOu~palient

I Due t~a palenlprocessus See p. 46Tunica albuginea and

ASOUND processus vaginalis

1 distended up to but not

through the external inguinal ring

I

Excision

HAEMATOCELE

Hisloryol:

- trauma

- drainage of hydrocele

I



9. LUMPS IN THE GROIN AND SCROTUM.

9.4 SCROTAL LUMPS (2)

Transilluminates

~

Tense lump

Situated behind testis

Size very variable

May be multiple

EPIDIDYMAL CYST.

Excision

(This may render

the patient infertile)

Unilocular

Soft lump

Traction on the testis

causes the lump

to move downwards

and become less mobile

ENCYSTED HYDROCELE

OFTHECORD

Excision if symptomatic

Epididymis affected

IFirm, craggy

epididymis

ITUBERCULOUS

EPIDIDYMITIS

Antituberculous

therapy

Does nol transilluminate

'Bag of worms'

Especially marked when standing

IVARICOCELE

Excision i f symptomatic

Post-vasectomy

May be tender

ISPERM GRANULOMA

Excision i f symptomatic

TREATMENT OF HERNIAS

Operation is the treatment of choice and may be per-

formed using general, local, epidural orspinal analgesia.

All childhood hernias are indirect and a herniotomy

is performed. This'operation is the ligation of the sac. In

the adult with an indirect hernia the posterior wall of

the inguinal canal 'is repaired in addition - herni-

orrhaphy. If the hernia is direct and there is therefore no

indirect sac, herniorrhaphy alone is performed.

A reducible hernia in an adult should ideally be

repaired by herniorrhaphy. Any enlarging hernia, with

time, may become irreducible. This in itself is not an

indication for urgent surgery, but if symptoms of ob-

struction or ischaemia accompany it then immediate

surgical intervention is required.

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FLOW CHART Lumps in the Groin and Scrotum