Patient details
- Name
- Mr M.J.
- Age / sex
- 64-year-old man
- Occupation
- Builder
- Marital status
- Married
- Admitted
- Emergency department, 17:10
- Clerked
- Emergency department, 17:25
- Source
- Patient himself, reliable
- Referred by
- Self-referred
Presenting complaint
“The lump in my right groin came out this morning and will not go back, and it is very painful.”
History of presenting complaint
Mr M.J. has had a swelling in the right groin for three years. It appeared on standing, coughing and lifting, and went back when he lay down or pressed on it. Over the last year it has grown and reached the upper part of the scrotum, but it was never painful. Ten hours before admission, at 07:00, while lifting a sack of cement, the swelling came out larger than usual and would not go back. It became painful at once, and the pain in the lump is now constant and severe, 8 out of 10. He tried several times to push it back and could not. About four hours later he developed cramping pain in the centre of the abdomen that comes in waves, and he has vomited four times, first food and then green fluid. His abdomen has become swollen. He has not opened his bowels today and has not passed wind since the morning. He has had no fever. He has had a morning cough with sputum for years. For the past year he has had a weak urinary stream, has to strain to pass urine, and gets up three times at night. He is not constipated. His work involves heavy lifting every day. He has no swelling in the left groin, has had no previous hernia operation, and had no pain in the testis before today.
Past medical history
Chronic bronchitis. Hypertension for eight years. No diabetes, no heart disease.
Past surgical history
No previous operations.
Drugs and allergies
Salbutamol inhaler as needed. Amlodipine 5 mg once daily. No anticoagulants or antiplatelet drugs.
No known drug allergies.
Social history
Smokes 25 cigarettes a day for 40 years (50 pack-years). No alcohol.
Last ate at 06:30 today; sips of water since, last at 15:00.
General examination
A man in obvious pain, lying still with his right hip bent. Alert and orientated. Tongue dry. Not pale, not jaundiced.
Examination of the groin and scrotum
Examined lying down, as he could not stand because of pain. Both groins and the scrotum exposed.
Inspection
A pear-shaped swelling runs from the right groin into the upper scrotum. The skin over it is of normal colour. Left groin normal. No scars.
Palpation
The swelling measures about 8 by 6 cm. It lies above and medial to the pubic tubercle. It is tense, very tender and warm, and has no cough impulse. It is not reducible; no forceful attempt was made. I cannot get above it. It does not light up with a torch. The right testis is felt separately below the swelling and is normal and not tender. Left groin: no swelling and no cough impulse. Both femoral orifices normal.
Abdominal examination
Moderately distended and drum-like on percussion. Mild tenderness throughout, with no guarding and no rebound. No scars. Bowel sounds high-pitched and frequent.
Rectal examination
Prostate smoothly enlarged. Rectum empty.
Other systems
Chest: scattered wheezes, no crackles.
Heart: first and second heart sounds normal.
Legs: calves soft.
Summary
Provisional diagnosis
Strangulated right inguinal hernia with small bowel obstruction.
Immediate plan
- Inform the senior surgeon and the anaesthetist now.
- Nil by mouth. Intravenous fluids. Nasogastric tube. Analgesia. Urinary catheter.
- Bloods: full blood count, urea, creatinine and electrolytes, lactate, group and save. ECG and chest X-ray.
- Antibiotics before surgery according to protocol.
- Consent for emergency hernia repair with possible bowel resection.
- No repeated attempts at reduction.
Differential diagnosis of a painful groin or scrotal lump
Group by where the lump arises: hernia, scrotum, lymph nodes and vessels. Use the pubic tubercle and the cough impulse to separate them.
| Diagnosis | Points to it in the history | Points to it on examination | In this patient |
|---|---|---|---|
| Hernias | |||
| Strangulated inguinal hernia | Long-standing reducible groin lump that suddenly sticks and hurts; vomiting | Above and medial to the pubic tubercle, tense, tender, no cough impulse, cannot get above it | Most likely |
| Strangulated femoral hernia | Often an older woman, often no earlier lump noticed; vomiting | Small tense lump below and lateral to the pubic tubercle | Lump is above the tubercle and reaches the scrotum |
| Scrotum | |||
| Testicular torsion | Boy or young man, sudden severe pain, vomiting, no earlier lump | Tender testis lying high and sideways; can get above it | Wrong age; testis normal |
| Epididymo-orchitis | Pain over days, burning urine or discharge, fever | Hot, tender, swollen epididymis; can get above it | Testis normal |
| Infected or bleeding hydrocele | Long-standing scrotal swelling that becomes painful; injury | Cannot feel the testis apart; lights up with a torch unless it contains blood | Testis felt separately |
| Torsion of an undescended testis | Never had a testis on that side | Tender groin lump with an empty scrotum on that side | Both testes present |
| Lymph nodes and abscess | |||
| Inguinal lymphadenitis or abscess | Wound, infection or ulcer on the leg, foot or perineum; fever | Hot, red, tender swelling below the ligament; source found on the leg | No source, no redness |
| Psoas abscess | Weeks of back pain, fever, weight loss | Soft fluctuant swelling below the ligament, hip held bent | Acute onset |
| Vessels | |||
| Saphena varix | Varicose veins; lump on standing | Soft, bluish, disappears on lying, thrill on coughing | Tense and does not disappear |
| Femoral artery aneurysm or false aneurysm | Recent needle or catheter in the groin | Pulsating, expansile lump | Not pulsatile |
Clinical signs related to this case
The signs you should look for in any patient with a groin lump. For each one, know how to elicit it and what a positive result means.
| Sign | How to elicit it, or what you see | What it means |
|---|---|---|
| Is it a hernia | ||
| Cough impulse | The swelling expands and pushes against the hand on coughing | Hernia. Lost when the hernia is strangulated. |
| Reducibility | The swelling goes back on lying or with gentle pressure | Uncomplicated hernia |
| Cannot get above it | Fingers cannot meet above the swelling at the root of the scrotum | The swelling comes down from the abdomen: hernia. If you can get above it, it arises in the scrotum. |
| Which hernia | ||
| Relation to the pubic tubercle | Feel the tubercle, then the neck of the swelling | Above and medial: inguinal. Below and lateral: femoral. |
| Deep ring occlusion test | Reduce the hernia, press over the mid-point of the inguinal ligament, ask the patient to cough | Controlled: indirect. Bulges medial to the finger: direct. Unreliable, and the surgeon decides at operation. |
| Is it strangulated | ||
| Tense, tender, irreducible, no cough impulse | The four findings together | Strangulation until proved otherwise |
| Red, warm skin over the lump | Look before you touch | Late strangulation with dead bowel |
| Fast pulse and fever | Repeat every half hour | The patient is becoming septic |
| Distension and tinkling bowel sounds | Examine the abdomen in every hernia patient | The hernia contains obstructed bowel |
| Scrotal signs | ||
| Testis felt separately | Find the testis and epididymis below or behind the swelling | The swelling is not arising from the testis |
| Transillumination | Torch held behind the swelling in a dark room | Lights up: fluid, as in a hydrocele. A hernia does not. |
| High-lying horizontal testis, absent cremasteric reflex | Testis drawn up and lying sideways; stroking the thigh does not lift it | Torsion |
| Vascular signs | ||
| Thrill on coughing that disappears on lying | Soft lump over the upper thigh vein | Saphena varix |
| Expansile pulsation | Two fingers on the lump are pushed apart with each beat | Aneurysm |
Teaching case. The patient is fictional and written to illustrate format and reasoning. Local protocols decide investigation and treatment.