Inguinal Swelling: Examination

Examination of Inguinal Swelling

Mostly examined in standing, few test require supine position

Inspection

·         Side-right/left

·         Position and extent of the swelling

·         Inguinal region/ inguinoscrotal region

·         Size (better to tell dimension in cm than comparing with objects)

·         Shape: Pyriform( Indirect) or globular(Direct)

·         Expansile impulse on cough over the swelling

·         Skin over the swelling: any scar/engorged vein/pigmentation

·         Any visible peristalsis over the swelling

·         Position of penis: any deviation

·         Testis: swelling separate from testis or all around it

Palpation

·         Temperature ,tenderness

·         To get above the swelling (inguinoscrotal swelling -not possible)

·         Position and extent of the swelling

·         Size, Shape, Surface, Margin

·         Consistency

Ø  Soft and elastic (intestine)

Ø  Doughy (omentum)

·         Relation of the swelling to pubic tubercle:

Ø  Above and medial to pubic tubercle (inguinal hernia)

Ø  Below and lateral to the pubic tubercle (femoral hernia)

·         Relation of swelling to testis: whether testis can be felt separately from the swelling or not

·         Reducibility

Ø  Spontaneously  or manual or irreducible

Ø  Which part of the swelling is easy to reduce

Ø  first part easy- omentocele

Ø  first part is difficult, last part easy –enterocele

·         Finger Invagination test

(Usually not done routinely, don’t mention if not asked specifically)

Ø  Feel the superficial inguinal ring- patulous or not

Ø  Finger in the inguinal canal with the nail pointing towards the roof àcough impulse —on pulp (Direct) or tip (Indirect)

·         Deep ring occlusion test

Ø  Reduce àocclude deep inguinal ring by the thumb àcough.

Ø  Positive- no impulse or hernial bulge (indirect)

Ø  Negative- expansile impulse or hernia bulge seen medial to the occluded deep ring (direct)

·         Zieman’s technique( Not preferred by many surgeons)

Ø  Index finger over deep inguinal ring (1/2 inch above mid inguinal point), middle superficial ring & ring finger on femoral ring (4 cms below & lateral to pubic tubercle)

·         Palpation of testis epididymis and spermatic cord

Percussion

·         Resonant note -enterocele

·         Dull note -omentocele

Auscultation

·         Bowel sound over the swelling- enterocele

§  Mention about normal side of inguinoscrotal region

§  Examination of tone of abdominal muscles—good or poor (bulging in flank- Malgaigne Bulge)

§  Per-rectal examinations- To rule out BPH (Very important)

§  Chest Examination- to look for cause of chronic cough

§  Child (Sometime invisible due to presence of thick pad of fat)

Ø  Make him cry, jolt/jump, Gornall’s test

Ø  Gornall’s test: child held from back by both hands àAbdomen pressed and child lifted upà increased intra-abdominal pressureà hernia more prominent

§  Before presenting the case, determine whether the hernia is

−        Inguinal/femoral

−        Direct/indirect

−        Complete/incomplete

−        Determine the content—intestine/omentum

−        Complicated/uncomplicated