What is the initial approach for a patient presenting with an inguinal mass?

Initial Approach for a Patient Presenting with an Inguinal Mass

The initial approach for a patient with an inguinal mass should include a thorough clinical examination followed by ultrasound imaging to establish the diagnosis before determining appropriate management. 1

Clinical Assessment

• Perform a detailed examination of the inguinal mass, documenting:

  • Size and dimensions of the mass 1
  • Location (unilateral vs bilateral) 1
  • Mobility or fixation of the mass 1
  • Relationship to surrounding structures (skin, Cooper ligaments) 1
  • Presence of tenderness or pain 2
  • Reducibility of the mass (disappears when supine) 2
  • Presence of cough impulse 2

• Assess for associated symptoms:

  • Groin pain, which may be burning, gurgling, or aching 2
  • Heavy or dragging sensation that worsens with prolonged activity 2
  • Swelling that changes with position 3

Diagnostic Imaging

• High-frequency ultrasound (>10 MHz) is the first-line imaging modality for evaluating an inguinal mass 1

  • Helps differentiate between:
    • Inguinal hernia 2
    • Lymphadenopathy 1
    • Testicular masses 1
    • Vascular abnormalities 4
    • Soft tissue tumors 5, 6

• MRI should be considered when:

  • Ultrasound findings are inconclusive 1
  • Atypical presentation or absence of cough impulse 6
  • Suspected soft tissue tumor 5
  • Need to assess relationship to surrounding structures 4

• CT scan of abdomen and pelvis is indicated when:

  • Metastatic disease is suspected 1
  • Evaluation of pelvic or retroperitoneal lymph nodes is needed 1

Specific Diagnostic Considerations

For Suspected Hernia

• Assess for bulge or impulse while patient coughs or strains 2
• Check if the mass reduces spontaneously in supine position 3
• Consider use of a truss for temporary management if participation in activities is necessary 3

For Suspected Lymphadenopathy

• Evaluate for risk factors of penile cancer if inguinal lymphadenopathy is present:

  • History of HPV infection 1
  • HIV status 1
  • Poor hygiene 1
  • Tobacco use 1
  • Presence of penile lesions 1

• If lymphadenopathy is suspected:

  • Perform fine-needle aspiration cytology (FNAC) for palpable nodes 1
  • Consider sentinel node biopsy for high-risk patients 1

For Suspected Testicular Mass

• Perform testicular examination 1
• Check serum tumor markers (AFP, hCG, LDH) if testicular cancer is suspected 1

Management Algorithm

1. For reducible, non-tender mass with cough impulse:

   • Likely inguinal hernia - refer for surgical evaluation 2
   • Surgical repair may not be necessary for small, minimally symptomatic hernias 2

2. For non-reducible, tender mass:

   • Urgent surgical consultation to rule out incarcerated hernia 2

3. For firm, fixed lymphadenopathy:

   • Evaluate for primary malignancy (penile, anal, or other regional cancers) 1
   • Consider FNAC or excisional biopsy 1

4. For soft tissue mass without hernia characteristics:

   • MRI to characterize the mass 6
   • Surgical excision with pathological examination 6

Pitfalls to Avoid

• Do not assume all inguinal masses are hernias - up to 50% of palpable inguinal nodes may be enlarged due to inflammatory changes rather than malignancy 1

• Do not miss malignant causes - aggressive angiomyxoma and other soft tissue tumors can mimic inguinal hernias 5

• Do not delay imaging when presentation is atypical or examination findings are inconclusive 6

• Do not overlook the possibility of metastatic disease in patients with unexplained lymphadenopathy 1