History-Taking for an Inguinal Mass
Begin by documenting the exact characteristics of the mass itself: size and dimensions, number of masses present, whether unilateral or bilateral, mobility versus fixation to surrounding structures (particularly skin and Cooper ligaments), and presence of associated edema of the penis, scrotum, or legs. 1, 2
Essential Mass Characteristics to Document
- Physical properties of the mass: Record the diameter, consistency (firm versus soft), whether it is reducible or non-reducible, and any associated tenderness 1, 2
- Location specificity: Note whether the mass is above or below the inguinal ligament, medial versus lateral positioning, and proximity to the pubis 1, 2
- Relationship to surrounding structures: Assess for infiltration or perforation of skin, fixation to Cooper ligaments, and involvement of adjacent tissues 1
Symptom History
- Pain characteristics: Elicit whether the patient experiences groin pain, burning, gurgling, or aching sensations, and whether symptoms worsen toward the end of the day or after prolonged activity 3
- Functional impact: Ask about heavy or dragging sensations, whether the bulge disappears when lying down, and any impact on daily activities 3, 4
- Constitutional symptoms: Screen for fatigue, weight loss, and night sweats, which suggest systemic disease or malignancy 5
- Duration and progression: Document whether the mass has been slowly enlarging, fluctuating in size, or remaining stable 5, 6
Critical Risk Factors to Assess
- Malignancy risk factors: Inquire about history of HPV infection, HIV status, poor hygiene practices, tobacco use, and presence of any penile, vulvar, or lower extremity skin lesions 2, 5
- Associated symptoms: Ask about obstructive symptoms, fecal incontinence, vaginal involvement (in women), and any history of fistula formation 1
- Previous interventions: Document any prior chemotherapy, radiation therapy, or surgical procedures in the groin or pelvic region 1
Examination of Primary Sites
- Genitourinary examination: Perform thorough inspection of the penis, vulva, and perineum for suspicious lesions, as these malignancies commonly drain to inguinal nodes 5, 7
- Lower extremity and skin examination: Examine the entire lower extremity and skin for melanoma or other cutaneous malignancies that could metastasize to inguinal nodes 5
- Digital rectal examination: This is mandatory to evaluate for anal lesions and assess perirectal nodal involvement 1
- Vaginal examination in women: Assess for vaginal/vaginal septal involvement, particularly with anteriorly placed masses 1
Common Pitfalls to Avoid
- Do not assume all inguinal masses are hernias: Up to 50% of palpable inguinal nodes in penile cancer patients are enlarged due to inflammatory changes rather than malignancy, but 20-25% of clinically node-negative patients harbor occult metastases 1, 2, 7
- Do not overlook bilateral assessment: Crossover lymphatic drainage from left to right and vice versa occurs regularly, making bilateral examination essential even when the mass appears unilateral 1
- Do not delay evaluation of persistent masses: Chronic lymphadenopathy lasting more than 4 weeks warrants prompt specialist referral, as early diagnosis of malignancy significantly improves outcomes 5