Differentials
Undescended testis
SIGNS / SYMPTOMS
Presence of a groin mass, usually in children. Underdeveloped hemiscrotum with absent testis on the affected side.
INVESTIGATIONS
Groin ultrasound scan can detect an undescended testis from an inguinal hernia. Other tests such as CT scan of the mass and MRI scan, are equally sensitive.
Lymphadenopathy
SIGNS / SYMPTOMS
An enlarged lymph node may be associated with a history of trauma, infection or malignancy. It is firm, tender, non-reducible, most often mimicking femoral hernia.
INVESTIGATIONS
Groin ultrasound scan can usually differentiate between lymphadenopathy and inguinal hernia.
Femoral hernia
SIGNS / SYMPTOMS
Femoral hernias are more common in slender, often older females, and are more prone to strangulation. It can be difficult to differentiate between an incarcerated femoral hernia and lymphadenitis.
INVESTIGATIONS
Femoral hernia is located below the inguinal ligament, lateral and inferior to the pubic tubercle. An inguinal hernia bulge lies more cephalad, in the line of the inguinal ligament between the anterior iliac spine and pubis.
Femoral aneurysm
SIGNS / SYMPTOMS
Presents as a pulsatile mass in the groin. Inguinal hernia should not pulsate.
INVESTIGATIONS
Femoral artery aneurysm may be distinguished from normal transmitted femoral pulsation by Duplex ultrasound scan.
Psoas abscess
SIGNS / SYMPTOMS
May present with back pain and fever. Recent history of foreign travel or contact with someone with chronic cough, weight loss, and night sweats are not uncommon.
INVESTIGATIONS
MRI or CT scan will show an abscess as an inflammatory mass within the psoas muscle.
Saphena varix
SIGNS / SYMPTOMS
Dilated great saphenous vein close to the saphenofemoral junction because of incompetent saphenofemoral valve. Often, there are signs elsewhere of varicosity. Typically, it is soft, compressible and, like inguinal hernia, it disappears on lying supine. Vulvar varicosity in women can present in similar fashion, mimicking a hernia.
INVESTIGATIONS
Duplex ultrasound scan will show blood flow.
Hydrocele
SIGNS / SYMPTOMS
Primary hydrocele surrounds the testicle and is not in communication with the peritoneal cavity. Although rare in children, it is common in middle to old age. Testis and epididymis are not easily defined. The absence of a mass at the external ring above the swelling is the key differentiating feature.
INVESTIGATIONS
Investigation is usually not required, but can be easily confirmed by ultrasound.
Hydrocele will often transilluminate with bright light.
Encysted hydrocele of the spermatic cord
SIGNS / SYMPTOMS
This is a rare form of hydrocele in which the hydrocele that is separated from the peritoneal cavity and testis is associated with the spermatic cord. Its presence may be confirmed clinically by pulling down on the testicle and seeing the lump follow.
INVESTIGATIONS
Investigation is usually not required, but can be easily confirmed by ultrasound.
Lipoma of the spermatic cord
SIGNS / SYMPTOMS
Lipoma of the cord is common and, if large, may be difficult to distinguish clinically from hernia. Clinically, it does not change in size with body position and does not enlarge with Valsalva manoeuvre.
INVESTIGATIONS
Ultrasound shows an echogenic solid mass, often misinterpreted as a fat-containing hernia. CT shows fat in the inguinal canal.
Spermatocele
SIGNS / SYMPTOMS
Cyst attached to the head of the epididymis. Smooth and able to get above it on examination.
INVESTIGATIONS
Investigation is usually not required.
Spermatocele will often transilluminate with bright light.
Hydrocele of canal of Nuck
SIGNS / SYMPTOMS
In females, if the processus vaginalis remains patent, it extends into the labium majus and is known as the canal of Nuck. When it contains fluid, it presents as an inguinal mass. It may easily be confused with inguinal hernia. In symptomatic patients, the surgical treatment is the same.
INVESTIGATIONS
Ultrasound shows a well-defined, cystic, hypoechogenic mass.
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