Surgery chapters
Inguinoscrotal pathologies in the adult (differential diagnosis of groin and scrotal swellings)
A clinical approach to lumps in the groin and scrotum in adults: inguinal and femoral hernias, saphena varix, lymph nodes and other groin lumps; hydrocele, epididymal cyst, varicocele, testicular tumour, epididymo-orchitis, torsion and Fournier gangrene, with the key examination questions and tests.
- In the groin, find the pubic tubercle: an inguinal hernia lies above and medial (at the neck), a femoral hernia below and lateral; femoral hernias are commoner in elderly women and strangulate easily. A cough impulse also occurs in a saphena varix and varicocele.
- In the scrotum ask three questions: can you get above it? (no → inguinoscrotal hernia), is the testis separate?, does it transilluminate?
- Hydrocele surrounds the testis and transilluminates; epididymal cyst lies above and behind a separate testis; varicocele is a "bag of worms", mostly left; a hard painless testicular lump is a tumour until proved otherwise (ultrasound, AFP/hCG, inguinal orchidectomy); sudden pain in a teenager is torsion: explore at once.
On this page
Overview
Lumps in the groin and scrotum are among the commonest surgical referrals and a favourite of clinical and MCQ exams. Most are benign (hernia, hydrocele, cyst), but three must not be missed:
- Strangulated hernia (especially femoral).
- Testicular torsion.
- Testicular cancer.
This chapter gives the examination method and the differential diagnosis. Hernia repair techniques are covered in the abdominal wall chapter, and childhood conditions in the paediatric chapters.
Applied anatomy in brief
- Inguinal ligament: from the anterior superior iliac spine to the pubic tubercle.
- Deep (internal) ring: at the mid-inguinal point, just above the femoral artery pulse, lateral to the inferior epigastric vessels.
- Superficial (external) ring: just above and lateral to the pubic tubercle.
- Hesselbach (inguinal) triangle: inferior epigastric vessels laterally, lateral edge of rectus medially, inguinal ligament (iliopubic tract) below. Direct hernias come through here.
- Femoral canal: medial compartment of the femoral sheath, below the inguinal ligament. Boundaries: inguinal ligament in front, pectineal (Cooper) ligament behind, femoral vein laterally, lacunar (Gimbernat) ligament medially (sharp, unyielding). Contains fat and the lymph node of Cloquet.
- Lymph: testis → para-aortic nodes (it descended from the abdomen); scrotal skin → superficial inguinal nodes.
A testicular tumour spreads to para-aortic nodes, while a scrotal skin cancer spreads to inguinal nodes.
Examining a groin lump
- Examine standing and lying; expose both groins and the scrotum.
- Find the pubic tubercle and relate the lump to it.
- Cough impulse: present in reducible hernias, saphena varix and varicocele. Absent in an irreducible or strangulated hernia.
- Reducibility: does it go back on lying or gentle pressure?
- Deep ring occlusion test: after reduction, press over the deep ring and ask the patient to cough. If the hernia stays reduced, it is likely indirect; if it bulges medially, likely direct. Not fully reliable even for experts.
- Examine the scrotum (two testes?), the other side (bilateral hernias are common), the abdomen, and the legs (varicose veins, nodes, lesions draining to nodes).
Differential diagnosis of a groin lump
| Lump | Key features |
|---|---|
| Indirect inguinal hernia | Commonest hernia; young or old men; above and medial to the tubercle; descends into the scrotum; controlled by deep ring pressure |
| Direct inguinal hernia | Older men, chronic straining (cough, constipation, prostatism); broad neck through Hesselbach triangle; rarely enters scrotum; low strangulation risk; may contain bladder |
| Femoral hernia | Elderly thin women (but still less common than inguinal hernia even in women); small, firm, often irreducible, below and lateral to the tubercle; cough impulse often absent; high strangulation risk; may present only as small bowel obstruction |
| Saphena varix | Dilated top of the long saphenous vein at the saphenofemoral junction; soft, disappears on lying, cough impulse with a fluid thrill, bluish; varicose veins in the leg |
| Inguinal lymph nodes | Often multiple, firm, not reducible; look for a source (leg, perineum, anal canal, scrotal skin, vulva) or lymphoma/TB |
| Femoral artery aneurysm | Expansile pulsation; vascular patient |
| Psoas abscess | Below the inguinal ligament, lateral to the femoral artery; fluctuant; back pain or spinal TB; hip held flexed |
| Lipoma of the cord | Soft, no cough impulse, along the cord; often found at hernia repair |
| Encysted hydrocele of the cord | Smooth oval lump above the testis; moves down when the testis is pulled; transilluminates |
| Hydrocele of the canal of Nuck | Female equivalent along the round ligament |
| Undescended or ectopic testis | Empty scrotum on that side |
A small, hard, irreducible lump below and lateral to the pubic tubercle in an elderly woman with vomiting is a strangulated femoral hernia, not a lymph node. Always examine the groins in unexplained small bowel obstruction.
A cough impulse does not prove a hernia (saphena varix, varicocele), and its absence does not exclude one (irreducible or femoral hernia).
Points on hernia types
| Feature | Indirect | Direct | Femoral |
|---|---|---|---|
| Origin | Congenital (patent processus vaginalis) | Acquired weakness | Acquired; wider female pelvis |
| Relation to inferior epigastric vessels | Lateral | Medial | Below the inguinal ligament |
| Neck relative to pubic tubercle | Above and medial | Above and medial | Below and lateral |
| Into scrotum | Often | Rarely | No |
| Strangulation risk | Moderate | Low | High |
- Sliding hernia: part of the sac wall is formed by a viscus (sigmoid colon on the left, caecum on the right, or bladder). Care at repair.
- Pantaloon hernia: direct and indirect sacs straddling the inferior epigastric vessels.
- Richter hernia: only part of the bowel wall trapped (often femoral); may strangulate without obstruction.
- Littre hernia: sac contains a Meckel diverticulum.
- Maydl hernia: a W-shaped loop; the strangulated part may lie inside the abdomen.
Examining a scrotal swelling
Ask three questions:
- Can I get above it? If not, it is an inguinoscrotal hernia (or extends up the cord).
- Is the testis separate from the swelling? Separate → epididymal cyst, spermatocele, epididymitis, varicocele. Not separate → hydrocele, testicular tumour, orchitis, haematocele.
- Does it transilluminate? Yes → hydrocele, epididymal cyst (and, less brightly, spermatocele). No → solid lumps, blood, pus, thick-walled sacs, hernia with bowel.
Then check tenderness, consistency, the cord and vas, the other side, inguinal and abdominal (para-aortic) masses. Scrotal ultrasound is the key test for nearly all scrotal swellings.
Differential diagnosis of a scrotal swelling
| Swelling | Get above? | Testis felt separately? | Transilluminates? | Key features |
|---|---|---|---|---|
| Inguinoscrotal hernia | No | Yes | No (unless child) | Cough impulse, reducible, bowel sounds |
| Hydrocele | Yes | No (surrounds testis) | Yes, brightly | Painless, tense or lax, fluctuant; commoner in hot countries and filarial areas |
| Epididymal cyst | Yes | Yes (above and behind) | Yes | Multiple, "bunch of grapes", middle age, often bilateral |
| Spermatocele | Yes | Yes (above the testis) | Yes | Single, lax, milky "barley-water" fluid with sperm |
| Varicocele | Yes | Yes | No | "Bag of worms", dragging ache, worse on standing, empties on lying; left in about 90% |
| Testicular tumour | Yes | No (it is the testis) | No | Hard, painless, heavy, loss of testicular sensation; young men |
| Epididymo-orchitis | Yes | Early yes, later no | No | Painful, red, fever, dysuria; elevation relieves pain |
| Torsion | Yes | No | No | Sudden severe pain, high-riding transverse testis, absent cremasteric reflex |
| Haematocele | Yes | No | No | After trauma (or aspiration); may hide tumour |
| Tuberculous epididymitis | Yes | Yes (craggy epididymis) | No | Beaded vas, painless craggy epididymis, lax secondary hydrocele, scrotal sinus posteriorly |
"Above, separate, light": the three scrotal questions.
Scrotal conditions
Hydrocele
Fluid in the tunica vaginalis.
- Primary (idiopathic): middle-aged and older men, slowly enlarging, painless; very common in hot countries; filarial (Wuchereria bancrofti) in endemic areas, sometimes chylocele.
- Secondary: to epididymo-orchitis, torsion, trauma or testicular tumour; usually small and lax.
- Congenital: patent processus vaginalis (children); fluctuates in size.
Ultrasound is essential when the testis cannot be felt, especially in a young man (a tumour can hide behind a secondary hydrocele). Do not aspirate if tumour is possible (needle-track seeding).
Treatment: leave small ones; surgery for large or troublesome ones:
- Lord's plication for thin-walled sacs (little dissection, fewer haematomas).
- Jaboulay eversion of the sac behind the testis for thick sacs.
- Aspiration (with or without sclerosant) for unfit patients; fluid re-collects.
Complications of surgery: haematoma (commonest), infection, recurrence.
A hydrocele in a young man may be secondary to a testicular tumour; get an ultrasound before any aspiration or surgery.
Epididymal cyst and spermatocele
- Cystic degeneration of the epididymis; above and behind the testis, separate from it; transilluminate.
- Excise only if symptomatic; warn young men that removal may block sperm transport on that side. Aspiration is useless (multilocular).
Varicocele
- Dilated pampiniform plexus veins.
- Left side in about 90%: the left testicular vein enters the left renal vein at a right angle, is longer, may lack valves, and can be compressed by a loaded colon or between the aorta and SMA (nutcracker).
- Dragging ache by the end of the day; scrotum hangs low; "bag of worms" with a cough impulse on standing; empties on lying. Long-standing: smaller, softer testis.
- Linked with subfertility (raised testicular temperature), though benefit of treatment is uncertain.
- Grades: I only on ultrasound or Valsalva; II palpable; III visible.
- Sudden left varicocele in an older man, not emptying on lying → left renal tumour (renal vein invasion); ultrasound or CT kidneys.
- Treatment if symptomatic: radiological embolisation first, or surgical ligation (inguinal, retroperitoneal or laparoscopic). Complications: hydrocele, recurrence.
A right-sided varicocele alone, or one that does not empty lying down, needs imaging of the abdomen for a mass compressing the veins.
Testicular tumour
- Commonest solid cancer in young men (about 20–40 years). Germ cell tumours are 90–95%.
- Seminoma: peak in the 4th decade; radiosensitive and chemosensitive.
- Non-seminomatous germ cell tumours (NSGCT): teratoma, embryonal, yolk sac, choriocarcinoma; peak in the 3rd decade.
- Risk factors: undescended testis (even after orchidopexy), previous tumour in the other testis, Klinefelter syndrome, family history.
- Presentation: painless, hard, heavy testicular lump; sometimes pain after bleeding into the tumour, or a secondary hydrocele; gynaecomastia (hCG); back pain from para-aortic nodes; cough or haemoptysis from lung metastases ("cannonball" shadows).
| Marker | Raised in |
|---|---|
| AFP | NSGCT (yolk sac elements); never in pure seminoma |
| β-hCG | Choriocarcinoma, some NSGCT, and some seminomas |
| LDH | Tumour bulk |
- Investigations: scrotal ultrasound (mandatory), tumour markers before orchidectomy, then CT chest, abdomen and pelvis for staging.
- Treatment: radical inguinal orchidectomy: cord clamped and divided at the deep ring through a groin incision. Never a scrotal incision or biopsy (it opens new lymphatic routes to inguinal nodes and risks local recurrence).
- Then surveillance, chemotherapy (BEP: bleomycin, etoposide, cisplatin) or radiotherapy (seminoma) according to stage. Prognosis is excellent; cure is usual even with spread.
- Offer sperm banking before treatment.
Any solid lump within the testis is malignant until proved otherwise.
Acute scrotum: torsion versus epididymo-orchitis
| Feature | Testicular torsion | Epididymo-orchitis |
|---|---|---|
| Age | Mainly 10–25 years | Sexually active young men; older men with UTI or catheter |
| Onset | Sudden, severe, often with vomiting; may wake from sleep or follow exercise | Gradual over a day or two |
| Urinary symptoms, fever | Usually absent | Dysuria, discharge, fever |
| Testis position | High-riding, horizontal lie | Normal |
| Cremasteric reflex | Absent | Usually present |
| Lifting the testis | Pain not relieved or worse | Pain relieved (Prehn sign) |
| Urine | Usually clear | Pyuria |
| Action | Immediate exploration | Antibiotics, rest, scrotal support |
Torsion:
- Cause: "bell-clapper" deformity (high investment of tunica vaginalis), usually bilateral.
- Salvage is near complete if untwisted within about 6 hours, falling steeply after that.
- Do not delay surgery for Doppler if the clinical picture is clear.
- Surgery: scrotal exploration, untwist, assess viability, fix with non-absorbable sutures, and fix the other testis; remove a dead testis (orchidectomy).
- Torsion of the appendix testis (hydatid of Morgagni): younger boys, localised pain at the upper pole, "blue dot sign"; explore if any doubt.
Epididymo-orchitis:
- Young men: Chlamydia trachomatis (and gonorrhoea) → doxycycline (with ceftriaxone if gonorrhoea possible), treat partners.
- Older men: urinary organisms (E. coli) from outflow obstruction or catheters → quinolone; check the urinary tract.
- At least 2 weeks of antibiotics; drain an abscess.
- Mumps orchitis: after parotitis in postpubertal males; can cause atrophy and, if bilateral, infertility.
- Tuberculous epididymitis: chronic craggy epididymis, beaded vas, cold abscess and sinus; look for renal TB; antituberculous drugs (common in Pakistan).
In a teenager, epididymo-orchitis is a diagnosis of exclusion. If torsion cannot be ruled out, explore.
Fournier gangrene
- Necrotising fasciitis of the scrotum, perineum and penis; polymicrobial (aerobes and anaerobes).
- Risk: diabetes, alcoholism, immunosuppression; perianal or urinary source, minor trauma.
- Sudden scrotal pain, swelling, fever, then black skin patches, crepitus, foul discharge, rapid septic shock. The testes are usually spared (separate blood supply).
- Treatment: resuscitation, broad-spectrum IV antibiotics, urgent and repeated radical debridement of all dead tissue; urinary or faecal diversion if needed; later skin grafts. Mortality can be very high.
Other scrotal lumps
- Sebaceous cysts of scrotal skin: common, multiple.
- Filarial elephantiasis: lymphatic obstruction (W. bancrofti); massive scrotal swelling; antifilarial drugs (diethylcarbamazine, albendazole, ivermectin); reduction surgery.
- Scrotal skin cancer (squamous): historical chimney sweeps; spreads to inguinal nodes.
Expect: relation of inguinal and femoral hernias to the pubic tubercle; femoral hernia in elderly women with high strangulation risk and the lacunar ligament as the rigid medial wall; direct versus indirect hernia and the inferior epigastric vessels; saphena varix as a lump with a cough impulse; the three questions for scrotal swellings; hydrocele (transilluminates, testis not separate), epididymal cyst (separate, behind), varicocele (bag of worms, left, renal tumour), tuberculous epididymitis with beaded vas; testicular tumour markers, para-aortic spread and inguinal orchidectomy; torsion versus epididymo-orchitis, bell-clapper deformity, 6-hour window and bilateral fixation; Fournier gangrene in diabetics.
Quick revision
- Groin: inguinal above and medial to the pubic tubercle; femoral below and lateral.
- Femoral: elderly women, small, irreducible, strangulates; always repair.
- Cough impulse without hernia: saphena varix, varicocele.
- Scrotum: get above? testis separate? transilluminates?
- Hydrocele: surrounds testis, transilluminates; ultrasound in young men.
- Epididymal cyst: separate, above and behind, bunch of grapes.
- Varicocele: left, bag of worms; new left varicocele in older man → renal tumour.
- Testicular tumour: hard painless lump; AFP/hCG; inguinal orchidectomy; para-aortic nodes.
- Torsion: sudden pain, high horizontal testis, no cremasteric reflex; explore within 6 hours; fix both.
- Fournier: diabetic, crepitus, debride urgently.
Written by The House Job from standard references (Bailey & Love).
FAQ
How do you tell an inguinal from a femoral hernia?
Relate the neck of the lump to the pubic tubercle. An inguinal hernia lies above and medial to it, while a femoral hernia lies below and lateral to it.
Which scrotal swellings transilluminate?
Hydroceles and epididymal cysts transilluminate brightly; a spermatocele does so less brightly. Solid tumours, blood, pus and hernias containing bowel do not.
Why is a testicular tumour removed through the groin?
Because the testis drains to para-aortic nodes. A scrotal incision would open new lymphatic routes to the inguinal nodes and risk local spread, so the cord is clamped and divided at the deep ring.
How is torsion told apart from epididymo-orchitis?
Torsion is sudden, in a teenager, with a high horizontal testis, absent cremasteric reflex and no urinary symptoms. If there is any doubt, the scrotum is explored straight away.
Why is a left varicocele more common?
The left testicular vein is longer and drains at a right angle into the left renal vein, often with poor valves, so pressure in it is higher.