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Groin examination

Mr Smith, a 23-year-old male, has noticed a swelling in his groin. Please examine, present your findings and a differential
diagnosis.

Click here

Actor briefing

You are Chris Smith a previously well 23-year-old. You have noticed a
swelling in your groin that came on 4 days ago after lifting weights in the
gym

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Examiner briefing

Please ask the candidate to begin their examination. Do not interrupt

unless you are unsure what they are testing.

At 7 minutes please ask them to present and ask them the set
questions

On the mark scheme:

2 points are scored if they have passed more than 90% of the marking
criteria

1 point is scored they have achieved at least 50% of the marking

criteria.

0 points are scored if less than 50% of the marking criteria is achieved

Next question <+

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Click here
On general inspection there is a 3 x 5 cm round scrotal lump on the left. Kn eel down and to the side of the patient (avoiding a compromising
There is no overlying erythema position!)

There are no scars Inspect the lump

Note its location, size, shape, colour, and contour

Look for any overlying scars

A~k the patient to cough and look closely at the superficial ring on
either side for a visible cough impulse.

On palpation you are able to get above the lump easily.

From the side palpate, first the normal side then the lump itself with
one hand on their back, the other on the lump, again checking for
pain.

Note the size, shape and the temperature

Attempt to get above the lump

If you can get above it, it is likely to b e a scrotal swelling

If you can't get above it, it is likely to be a groin swelling such as a

hernia or a varicocoele

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Click here

Differentiating the lump

You can't feel the testis separately from the lump

Palpate to assess its rela tion to the testes
The lump is not painful Test for transillumination by shining a torch from the posterior
a.~pect of the lump. /\. hydrocoele or epididymal cyst will vividly
illuminate.
It does not transilluminate
/\. varicocele feels like a bag of worms, easiest with the patient
standing

If you can't feel th e testicle separately differentials include a

testicular tu m our - semin oma, teratoma, a hydrocoele or
haematocoele, orchitis or torsion, and rarely a syphilitic gumma.

If you can feel the testes separatdy and it is not transilluminable

then epididymitis and a spermatocoele are possibilities

Next question <+

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Groin examination

Mr Smith, a 23-year-old male, has noticed a swelling in his groin. Please examine, present your findings and a differential
diagnosis.

Click here

What wou ld you do to complete your examination?

To finish my examination I wou ld perform a fu ll abdominal examination,

and a digital rectal examination.

Next question -.
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Groin examination

Mr Smith, a 23-year-old male, has noticed a swelling in his groin. Please examine, present your findings and a differential
diagnosis.

Click here

Please present your findings

Mr Smith is a 23-year-old gentleman with a left sided scrotal swelling.

On inspection, there is a 3 x 5 cm scrotal swelling on the left. I am able
to get above the lump with ease. It is not separate from the testis and
does not transilluminate. My top differential diagnosis to exclude is a
testicular neoplasm.

, Next question -+ ]
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Groin examination

Mr Smith, a 23-year-old male, has noticed a swelling in his groin. Please examine, present your findings and a differential
diagnosis.

Click here

What are the differentials for a scrotal swelling?

Common differentia ls include a hernia e.g. a inguinal or femoral hernia,

lymph nodes, varicocoele or a swelling related to the testes, such as a
hydrocoele, epididymal cyst, lipoma of the cord or testicular tumour.
Other differentials include infection such as orchitis or epididymit is,
testicular torsion, and a spermatocoele

, Next question -+ ]
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Click here

What tumour markers are there for a testicular tumour?

Beta-hCG and AFP may be elevated in nonseminomatous germ cell /

tumours, whilst placentalike alkaline phosphatase and beta-HCG can be

raised in seminomas. Tumour Primary tumour associated with it
marker

Pure seminomas do not excrete AFP. CA 27.29 Breast CA

CEA Colorectal CA
CA 19-9 Pancreatic CA
AFP Nonseminomatous germ cell tumours
Hepatocellular carcinoma
B-hCG Nonseminomatous germ cell tumours
CA- 125 Ovarian CA

Next question •

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Groin examination

Mr Smith, a 23-year-old male, has noticed a swelling in his groin. Please examine, present your findings and a differential
diagnosis.

Click here

If you were concerned the swelling was a testicular mass, what investigation
would you perform?

I wou ld request a scrotal ultrasound

If testicular cancer was confirmed a CT staging scan wou ld be required.

Next question •
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Click here

What is the management for a testicular tumour

The case would be discussed in an MDT, followed by definitive

treatment with orchidectomy and consideration of chemotherapy or
radiotherapy

Radiotherapy is not normally useful for teratomas.

The patient would require counselling and consideration of sperm

storage should he want to have children in the future

Next question <+

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Pass the MRCS Home -ta'1 ' 11, E a ~ la 1
1I [ g11at g 111 I I 0

Groin examination

Mr Smith, a 23-year-old male, has noticed a swelling in his groin. Please examine, present your findings and a differential
diagnosis.

Click here

Key Information

Wash your hands

Introduce yourself Candidate
Permission - may I examine you today please? Number
Exposure - abdomen and groin should be exposed
Reposition - Ask the patient to stand
Marking Criteria 0 1 2

Check if they are in any pain

\Vashes hand~, introduces self and role

Kneel down and to the side of the patient (avoiding a compromising

position!) Gains pennis.~ion for the examination,
exposes 1.hc patiem appropriately and
positions them appropriately
Inspect the lump
Note its location, size, shape, colour, and contour General inspection performed. Checks for
comfort I pain

Look for any overlying scars

Inspect~ the groin swelling from a kneeling
position
Ask the patient to cough and look closely at the superficial ring on either
side for a visible cough impulse.
Palpates the normal side and then the side
with the swelling.
i\ilakes an effort to get above the swelling
From the side palpate, first the normal side then the lump itself with one
Feels for a cough impulse
hand on their back, the other on the lump, again checking for pain.
Tries to reduce swell ing, or gets patient to do
so
Repeat~ the cough test 10 see if swelling
Note the size, shape and the temperature
reappears
Repeat~ cough test whil~t occluding the deep
Attempt to get above the lump ingu inal ring

Auscultates swelling
If you can get above it, it is likely to be a scrotal swelling (see below) Exam ines for transillumina1.ion with a torch
If you can't get above it, it is likely to be a groin swelling such as a
hernia or a varicocoele
Thanks the patient.
Sum1narises \\'ilh a succinct prese ntation of
Groin swelling the salient examination findings and correctly
suggests an ingu inal hernia as a likely
diagnosis
Note its relation to the pubic tubercle. An inguinal hernia is found above Mentions di!Terentials for a testicular swell ing
and medial to the pubic tubercle, whilst a femoral hernia is found below Conectly identifies tumour markers
and lateral to the pubic tubercle.
Ask the patient to cough - and feel for a cough impulse. To be positive it Suggests appropriate managemem for a
must expand rather than just move on coughing suspected testicular tumou1·

Ask the patient to reduce the lump if possible "are you able to push it
back in?" If you have to reduce it yourself, use a flat palm rather than a
finger. If reducible, ask them to cough to see if the lump reappears

Repeat this step, whilst pressing over the deep inguinal ring at the
midpoint of the inguinal ligament, found halfway between ASIS and the Overall Impression
pubic tubercle. If the swelling is controlled by pressure despite coughing
then the hernia is more likely to be an indirect inguinal hernia, passing Pass Borderline Borderline Fail
Pass Fail
through the deep inguinal ring. If not controlled it is probably a direct
inguinal hernia, herniating directly though the abdominal wall. However,
this can only be established accurately during surgery.

Auscultate the lump, listen for bowel sounds.

Scrotal swelling:

Palpate to assess its relation to the testes

Test for transillumination by shining a torch from the posterior aspect of

the lump. A hydrocoele or epididymal cyst will vividly illuminate.

A varicocele feels like a bag of worms, easiest with the patient standing

If you can't feel the testicle separately differentials include a testicular

tumour - seminoma, teratoma, a hydrocoele or haematocoele, orchitis
or torsion, and rarely a syphilitic gumma.

If you can feel the testes separately and it is not transilluminable then
epididymitis and a spermatocoele are possibilities

To fin ish my examination I would perform a full abdominal examination,

and a digital rectal examination.

Tum to the examiner, stethoscope held behind your back with both
hands, and present.

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