The groin (inguinal region) is the transitional area between the abdomen and the legs. The groin contains blood vessels, nerves, and lymph nodes. It also contains some weak points in the abdominal wall, such as the inguinal canal (located just above the inguinal (Poupart’s) ligament, running from the anterior superior iliac crest to the pubic tubercle) and the femoral canal (located just below the inguinal ligament, medial to the femoral veins and arteries). Inguinal disorders, such as inguinal or femoral hernias, can cause abdominal symptoms. Therefore, attention should always be given to the groin during an abdominal examination. The opposite is also true: abdominal examination is important for patients with symptoms originating in the inguinal region (consider lymph node metastases, peritonitis related to a trapped inguinal hernia, or pain radiating from the groin due to aortic aneurysm). For patients with inguinal symptoms and / or disorders, attention should also be given to the history-taking and examination of the genitalia. Examination of the male genitalia is discussed below; the gynaecological examination is covered in a separate publication.
General
Hernias can cause intermittent symptoms and abnormalities. Questions during the history-taking should cover this topic explicitly.
If the groin examination is performed immediately after the abdominal examination, the patient may initially be lying on their back. Investigating the presence of hernias is preferably conducted while the patient is standing (gravity makes hernias more clearly visible). For this examination, the lower body should be completely exposed. The examination can be performed while wearing gloves (particularly if it is combined with an examination of the genitalia). For immobile or very ill patients, the examination may be performed while the patient is lying on their back.
Procedure (supine position)
- Inspect the groin and surrounding region [Figure 60].
If necessary for heavier patients, spread the inguinal folds.
Figure 60
- Have the patient perform the Valsalva manoeuvre [Figure 61].
Increases intra-abdominal pressure by blowing against the back of the hand.
Figure 61
- If there is an obvious swelling in the groin, auscultate it.
- Palpate the groin with the flat of the hand (i.e. not just with the fingertips) perpendicular to the inguinal folds and note any swellings or pain [Figure 62]. Use a rolling motion.
Palpate in a way that you can determine the presence of palpable lymph nodes. If a swelling is found, test whether it can be pushed back (reducible).
Figure 62
- Palpate the femoral artery.
If a vascular disorder is suspected, a more extensive vascular examination may be necessary (see: examination of the arteries in the abdomen). - To rule out a hernia, this procedure should be followed immediately by an examination of the inguinal canal while the patient is standing.
Focus points
- Note any skin abnormalities, swellings and pulsations.
Symmetry, scars, colour, dermatologic abnormalities. - Check whether swellings (hernias) occur or increase during the Valsalva manoeuvre.
Swellings that increase during the Valsalva manoeuvre are almost always hernias. - Check for signs of incarceration or impending incarceration.
Cases of incarcerated hernia are characterised by ileus sounds upon abdominal auscultation. - Assess the characteristics of visible swellings by palpation.
Swellings may be caused by many factors, including hernia, lymph nodes, aneurysm, testis, melanoma, and lipoma.
If abnormal lymph nodes are a possibility, then also evaluate other lymph node stations in the body, and asses the legs, genitalia, and abdomen for possible causes (e.g. infection, malignancy).
Procedure (standing position)
- Have the patient stand upright with the lower body exposed.
The patient can wear a shirt. Many patients will find it uncomfortable to stand in the middle of a room. Leaning with the back against the examination table which has been placed against a wall, may be more comfortable and also provides stability. - Sit on a low stool in front of the patient so that the groin and genitals are at eye level.
Shorter patients may be asked to stand on a small but stable stool or bench. - Perform the examination described above for the lying position if it has not already been done.
- Inspect the groin while the patient is standing.
- Have the patient perform the Valsalva manoeuvre (again).
- If ‘new’ swellings become visible, palpate and auscultate them.
- Palpate the superficial (external) inguinal ring.
In cases of visible disorders of the scrotum or pain at the level of the scrotum, it is reasonable to postpone this examination until after the examination of the scrotum. - Draw the index finger with the nail facing the examiner from the base of the scrotum in the direction of the superficial inguinal ring [Figure 63]. The right index finger is used for examination of the right inguinal canal, and the left index finger for the left inguinal canal (in other words, crosswise).
It is important to start right at the bottom of the scrotum so that sufficient skin is drawn along.
Figure 63
- Move the index finger without rotating as far as possible in the cranial direction between the skin and the abdominal muscles, slightly lateral to the midline.
- Locate the superficial inguinal ring by applying slight pressure in the direction of the abdominal cavity making a fan-shaped motion [Figure 64].
Continue until you can feel the inguinal ring (annulus inguinalis), which feels like a ring or small pit; repeatedly inserting the finger is uncomfortable for the patient. - Have the patient repeat the Valsalva manoeuvre while your finger is on the superficial inguinal ring [Figure 65].
Figure 64
Figure 65
Focus points
- Note any swellings while the patient is standing and determine their characteristics by palpation.
- Check for swellings by palpation of the superficial inguinal ring during the Valsalva manoeuvre.
Normally, only an increase in pressure is felt. In cases of inguinal hernia, a swelling will be palpable (depending on the severity, it may be palpable before or after the Valsalva manoeuvre). If a swelling is present, test whether the swelling can be pushed back into position (reducible).