Groin Exam

History
A lump in the right place that comes and goes in a predictable way is a hernia.
In children, this is certain, in adults this is mostly always true.
You could almost operate on the basis of this history.

Inspection
Comment on general factors (patient comfort, scars, abdo swellings).
Look for scars
- they can be very subtle.
Compare both sides.
Do a cough test, look for protrusions.
Compare with patient supine, coughing, standing
Beware that thin patients have a normal bulge on coughing -> must be compared with the slow rising and falling of a hernia.

Palpation
Display the landmarks
Pubic symphysis and ASIS.
Pubic tubercle is 3 cm lateral to the symphysis.
Deduce the internal ring
- At midpoint of inguinal ligament, from pubic tubercle to ASIS, slightly downward curve.
Detect a hernia
A large bulge hardly needs palpation, the subtle hernia is often missed.
Get them to cough, with your fingers in the zone.
Is cough impulse slow rising?
Is there any squelch under your finger?

Define the hernia
Pressure the internal ring -> reducing hernia first if necessary.
Does this control the hernia? Direct?
Are there definitely 2 testicles in the scrotum??
Femoral hernia = lateral and below the pubic tubercle.
- also tends to smooth out the groin crease, whereas the inguinal hernia accentuates it.

Scrotal Swellings
Use palpation and transillumination
1. can I get above it?
--> no = groin swelling
--> yes = scrotal
2. Reducible?
--> yes = hernia
--> no = scrotal
3. Can I palpate testicle separately?
--> epididymal cysts are posterior
--> most hydrocoeles are anterior
4. Transillumination?
--> cysts, hydrocoeles and spermatocoeles transilluminate