Where is the best place to send someone with a lump in their groin?

Referral for a Groin Lump

A patient with a lump in the groin should be referred to a surgical specialist for evaluation, preferably one with expertise in inguinal pathology such as a general surgeon or urologist. 1

Diagnostic Approach to Groin Lumps

Initial Evaluation

• Groin lumps have diverse etiologies including hernias, lymphadenopathy, vascular abnormalities, and soft tissue tumors 2
• Ultrasound with Doppler is the first-line imaging modality for diagnosing groin masses, as it can differentiate between hernias and other pathologies 3, 2
• CT or MRI may be indicated for complex or suspicious masses to better characterize the lesion and determine its extent 2

Common Causes of Groin Lumps

Infectious/Inflammatory

• Lymphadenopathy due to infection (bacterial, viral) or inflammatory conditions like Kikuchi-Fujimoto disease 4
• Fournier's gangrene presenting with groin pain, swelling and systemic symptoms requires immediate surgical consultation 1

Neoplastic

• Enlarged lymph nodes may indicate primary lymphoma or metastatic disease from penile, vulvar, or other pelvic malignancies 1
• Soft tissue tumors including lipomas, sarcomas, and cystic lymphangiomas can present as groin masses 5

Urologic/Reproductive

• Scrotal compartment syndrome presents with acute scrotal pain, swelling, and requires urgent urological evaluation 3
• In women, endometriosis of the inguinal canal can mimic a hernia with pain that may not correlate with menstrual cycles 6

Vascular

• Vascular graft infections in patients with prior vascular surgery can present as painful groin swelling with or without drainage 1
• Pseudoaneurysms may present as pulsatile groin masses 1

Referral Guidelines Based on Presentation

Urgent/Emergency Referral (Same Day)

• Patients with signs of infection (erythema, fever, severe pain) should be urgently referred to emergency surgical services 1
• Suspected testicular torsion or scrotal compartment syndrome requires immediate urological consultation as delay beyond 6-8 hours significantly increases risk of testicular loss 3
• Patients with groin masses and signs of sepsis should be referred to emergency services immediately 1

Expedited Referral (Within 2 Weeks)

• Suspicious lymphadenopathy, especially in patients with risk factors for malignancy 1
• Hard, fixed, or rapidly growing masses 2
• Groin masses in patients with history of cancer 1

Routine Referral

• Asymptomatic, mobile, soft lumps consistent with lipomas or other benign conditions 2
• Stable, longstanding masses without concerning features 2

Special Considerations

For Suspected Malignancy

• Patients with suspicious groin lymphadenopathy and known or suspected vulvar cancer should be referred to gynecologic oncology 1
• Men with penile lesions and groin lymphadenopathy should be referred to urologic oncology 1

For Vascular Issues

• Patients with history of vascular surgery and groin masses should be referred to vascular surgery due to concern for graft infection or pseudoaneurysm 1

Pitfalls to Avoid

• Assuming all groin lumps are hernias - up to 20% of presumed hernias are other pathologies 2
• Delaying referral for painful, enlarging masses or those with overlying skin changes 1, 3
• Failing to consider malignancy in patients with persistent lymphadenopathy, especially those with risk factors 1