Examination of Inguinal Swelling

1.When examining an inguinal swelling,extra test are required to be done to detect hernia.
2.Thus,when examining an inguinal swelling,it is also required to include the steps used in
Examination of Lumps,and the additional steps specific to inguinal swelling.
3.In this section,the additional steps will be discussed.

Inspection-Done when the patient is standing

1.Extent-Whether is it localized to the specific site or extends into the scrotum(Inguinoscrotal
hernia)
2.Visible peristalsis-May be visualized in inguinal hernia,not in femoral hernia or other
swellings
3.Cough impulse-Ask the patient to cough will inspecting the superficial inguinal ring
-Positive if a mass bulges or any existing mass expands.Specific for hernia.

Palpation
1.Determine if it is a Hernia,and its content
i)Cough impulse-A finger is placed on the swelling,and patient coughs
-Positive if a mass can be felt bulging or expanding.Specific for hernia
*In irreducible hernias,cough impulse may be negative
ii)Reducibility-Done to determine the nature of the hernia(Reducible or irreducible hernia)
-Also to determine the content of the hernia
a)Omentocele- When reducing hernia, initially it is easy but eventually it gets
harder
-Gurgling sound is absent
-Doughy consistency
b)Enterocele- When reducing hernia, initially it is hard but eventually it gets
easier
-Gurgling sound is present
-Cystic consistency

2.Differentiate Inguinal from Femoral hernia

i)Pubic tubercle-The pubic tubercle is palpated and the swelling is inspected in relation to
the pubic tubercle
-Inguinal hernia is medial to it,femoral hernia is lateral to it.

3.Type of inguinal hernia (Direct vs indirect hernia)

i)Ring occlusion test-Done in the standing position,and the hernia is first reduced
-A thumb is pressed on the deep inguinal ring,and the patient is asked to
cough
-In indirect hernia,the swelling will not bulge.For direct hernia,the
swelling will bulge medial to the deep inguinal ring.
*For femoral hernia,this is done at the saphenous opening(4 cm below and lateral to pubic
tubercle).It will be positive.
ii)Invagination test
-Locate superficial inguinal ring from bottom of scrotum upwards
-Reduce the hernia, put finger on the ring, then ask patient to cough
-If indirect hernia, hernia bulge will hit the tip of the finger (can be blocked)
-If direct hernia, hernia bulge will hit the pulp of finger (cannot be blocked)

4.Inguinoscrotal hernia vs Scrotal swelling(Only done for inguinoscrotal hernia)

i)To get above the mass-Done in presence of inguinoscrotal extention.
-The scrotum is held with thumb in front,and other fingers
behind.The scrotum is carefully felt and palpated form bottom to top
-In isolated scrotal swelling,can get above.In inguinal hernia,mass
cannot be felt above

Percusion-Resonant if hernia consists of enterocele.Dull if hernia consist of omentocele.

Auscultation-Bowel sounds can be heard if hernia consists of enterocele
At the end of examination, describe the findings
1. Right or Left
2. Inguinal or Femoral
3. Direct or Indirect
4. Content Enterocele or Omentocele
5. How far it go?
Complicated or Uncomplicated(Irreducible,obstructed,strangulated)

Differential Diagnosis of inguinal Swelling

1.Inguinal hernia-Medial to pubic tubercle
i)Direct hernia-Deep ring occlusion test is negative
ii)Indirect hernia-Deep ring occlusion test is positive

2.Femoral Hernia-Lateral to the pubic tubercle

-Cough impulse is positive when the saphenous opening is located
-Deep occlusion test is positive if the saphenous opening is occluded

3.Spermatic cord enlargement

i)Encysted hydrocele of the cord-A cystic swelling.Fluctuation and translucency is positive
ii)Lymph varix-A condition where lymphatic vessels of the cord becomes dilated due to
obstruction caused by filariasis
-Palpation,it is cystic.Cough impuse is thrill like,rather than expansile.
iii)Diffuse lipoma-Irreducible,no impulse on coughing

4.Testis
i)Undescended testis-Usually within the inguinal canal
ii)Ectopic testis-Usually above and lateral to the superficial inguinal ring

Important landmarks
1.Pubic tubercle-2.5 cm lateral to the pubic symphysis(midline)
2.Superficial inguinal ring3.Deep inguinal ring- Midway between ASIS and pubic tubercle,2-3 cm above that point
4.Saphenous opening-3-4 cm inferiorly and laterally to pubic tubercle
5.Inguinal ligament-Runs from pubic tubercle to ASIS
-Formed by aponeurosis of external oblique,and continues as fascia lata of
the thigh

Differential Diagnosis of Femoral Hernia

1.Saphena varix-Saccular enlargement of the termination of the long saphenous
vein.Associated with varicose vein
-Schwartzs test:Percussion of the varicose vein will transmit impulse to the
saphena varix,which can be felt by the fingers

2.Enlarged lymph node-A serch for infection should be made

3.Femoral aneurysm-There will be expansile pulsation
4.Psoas abscess-Cold abscess which tracks down from Potts Disease
5.Lipoma