Clinical examination

The groin should be examined with the patient standing erect and again with the patient lying flat. Hernias are sometimes only apparent when the patient stands up or only when the patient strains or coughs (Fig. 14.10).

When the patient is examined a rapid decision should be made as to whether the lump is a hernia or not a hernia - this is the crucial initial decision to make. A hernia has a cough impulse, changes in size when the patient strains or lies down and may be reducible. The other lumps in the groin do not change their disposition when the patient stands or lies down.

Reducing the hernia and then using one finger to hold it reduced while the patient coughs is a useful test which will enable the inguinal canal or the femoral ring to be identified, almost with certainty. Scrotal hernias must be separated from other scrotal lumps - hydrocoele, varicocoele, testicular tumours, epididymal cysts, etc. If the hernia is reducible, the diagnosis is obvious. A cough impulse is a characteristic of hernias, but not of other scrotal masses.

The advent of sophisticated radiological investigation has enabled small and occult hernias to be more easily diagnosed. The chief utility of ultrasound is to enable scrotal and other swellings to be clearly differentiated: • In the absence of a clinical hernia, do not rely on radiological examination to make the diagnosis.

Figure 14.10. An inguinal hernia in the adult is above and medial to the inguinal ligament and pubic tubercle as the hernia emerges from the superficial inguinal ring.

• Radiological assessment helps identify the origin of unusual lumps in the groin and scrotum.

• Expertise is required to interpret radiological images of the groin.

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