What is the most important examination to perform in a patient presenting with sudden lower abdominal and groin pain, an abdominal exam, groin exam, or general exam?

Most Important Examination for Sudden Lower Abdominal and Groin Pain

In a patient presenting with sudden lower abdominal and groin pain, the groin examination is most critical, as it can identify life-threatening conditions such as incarcerated inguinal hernia, testicular torsion (in males), or ovarian torsion (in females), while also ruling out musculoskeletal causes that may not require urgent intervention. 1, 2

Systematic Examination Approach

Groin Examination (Primary Focus)

The groin examination must be performed first and thoroughly because:

• Palpation for inguinal hernia is essential, as symptomatic hernias can cause severe groin pain and may present with a bulge that disappears when prone; examination involves feeling for a bulge or impulse while the patient coughs or strains 1
• Direct palpation at the medial border of the anterior superior iliac spine can identify groin tenderness associated with adductor-related pain or referred pain from sacroiliac joint dysfunction 2, 3
• Assessment of testicular position, size, and cremasteric reflex (in males) is mandatory to rule out testicular torsion, which requires emergency surgical intervention within 6 hours 2
• Evaluation for femoral hernia is critical, particularly in females, as these have higher rates of incarceration and strangulation 1

Abdominal Examination (Secondary but Essential)

After the groin examination, a focused abdominal examination must assess for:

• Peritoneal signs including guarding, rebound tenderness, and rigidity, which indicate perforation, ischemia, or acute surgical abdomen requiring immediate intervention 4
• Lower abdominal tenderness to identify potential gynecologic emergencies (pelvic inflammatory disease, ovarian torsion, ectopic pregnancy) or appendicitis 5, 4
• Abdominal distension, which has a positive likelihood ratio of 16.8 for bowel obstruction 4
• Digital rectal examination if there is suspicion of anorectal pathology, retained foreign body, or to assess for masses and tenderness 6, 7

General Examination (Tertiary Assessment)

The general examination provides critical context:

• Vital signs assessment is mandatory to identify hemodynamic instability (tachycardia, hypotension, fever) suggesting bowel ischemia, perforation, or sepsis 4
• Assessment for shock requires immediate intervention and should not delay surgical consultation 4

Clinical Algorithm for Examination Sequence

1. Immediate vital signs check for hemodynamic stability 4
2. Groin examination with direct palpation, hernia assessment, and testicular/ovarian evaluation 1, 2
3. Abdominal examination for peritoneal signs and localized tenderness 5, 4
4. Digital rectal examination if indicated by history or findings 6, 7

Critical Pitfalls to Avoid

• Never assume musculoskeletal groin pain without ruling out hernia, as incarcerated hernias can present with severe pain and require emergency surgery 1
• Do not skip testicular examination in males with groin and lower abdominal pain, as testicular torsion can present with referred abdominal pain 2
• Avoid relying solely on laboratory values in elderly patients, as serious infections may present with normal white blood cell counts 4
• Always perform pregnancy testing in women of reproductive age before proceeding with imaging, even in perimenopausal women 4

When Imaging is Required

After physical examination, imaging should be obtained if:

• CT abdomen/pelvis with IV contrast is indicated for diffuse or nonlocalized pain, changing diagnosis in 49% of cases and management in 42% of patients 6, 4
• Ultrasonography is preferred for suspected inguinal hernia when physical examination is equivocal, or for evaluating pelvic pathology in women 1, 2
• Plain radiography may identify bowel obstruction, perforation, or foreign bodies but has limited diagnostic value for most causes of abdominal pain 6