Question 3 : Tender groin and palpable mass

Question 3 : 
A 30 year old man presents with a tender groin and palpable mass
• List the DD (5 marks)
• Describe the E Physician sonographic approach to this problem (10 marks)

Differential diagnosis:

  1. Inguinal hernia direct or indirect
  2. Femoral hernia
  3. Lymph node
  4. Varicocoele
  5. Hydrocoele
  6. Femoral artery aneurysm
  7. Tumour  of spermatic cord or testes
  8. Cryptorchid
  9. Lipoma – most common tumour of inguinal canal
  10. Metastases in lymph nodes or bone
  11. Seroma if patient presents post inguinal surgical procedure
  12. Hip joint inflammation such as iliopectineal  bursitis
  13. Abscess if post surgical procedure

ED Physician approach using ultrasound

  • Obtain consent from patient to examine using ultrasound.
  • Patient best examined supine in private area with towel over penis and towel covering contralateral leg. When examining inguinal area, penis held under towel away laterally from area by patient . When examining scrotum, penis held under towel against lower abdomen. Scrotum  best examined with towel between legs and legs crossed.
  • If examining for hernias may have to stand patient up.
  • Start with examining the inguinal area including the femoral canal and overlying nodes. Proceed to examine the hip-joint and the iliac fossa if adjacent to the mass. Continue by careful examination of scrotum. Identify mass clinically by palpation and insonate over area. If unable to identify mass then ask patient to demonstrate it.
  • Use linear probe for groin.If patient obese switch to curvilinear probe
  • Use linear probe to examine the scrotum and it’s contents

Potential findings

1. Hernia : Direct, indirect or femoral

Abdominal Wall Hernias Moises Dominguez http://step2.medbullets.com/gastrointestinal/121738/abdominal-wall-hernias

Technique :

  • Identify inferior epigastric artery, the lateral margin of the rectus abdominus and the inguinal ligament ( Hesselbach triangle).A direct inguinal hernia will lie medial to the epigastric vessels within the triangle. Look for tissue of variable echogenicity  (fat and bowel. +/- peristalsis) moving medial to the epigastric artery
  • Lateral to the epigastric vessels  and superior to the inguinal ligament is the location of the deep inguinal ring. This is the origin of an indirect inguinal hernia.
  • Distal to the inguinal ligament and medial to the femoral vasculature is the femoral canal which is the origin of a femoral hernia
  • Ask patient to perform a Valsalva manoeuvre, the femoral vein distal to the inguinal ligament should distend . Watch for protrusion of hernia

2. Nodes

  • May be superficial ( superficial to the femoral vessels) or deep (deep and medial to the inguinal vessels
  • Normal node should be < 5mm
  • Look at shape

Normal node

  • oval
  • hyperechoic hilum
  • uniform thickness of the hypoechoic cortex
  • Hilar pattern of blood flow on colour or power Doppler

Hyperplastic lymph node

  • Features of normal lymph node but may be enlarged

Neoplastic 2 to lymphoma or metastases

  • Round or asymmetric shape
  • Non uniform cortical thickness
  • Loss of normal echogenic hilum
  • Peripheral or mixed pattern of blood flow

3. Varicocoele

  • Irregular, usually nontender type lump palpable in the spermatic cord superior to the left testicle.
  • Multiple hypoechoic serpiginous tubular structures of varying sizes
  • Best seen superiorly and lateral to testes
  • with a valsalva mannoevre get retrograte filling

4. Hydrocoele

  • Hypoechoic unless contains cholesterol crystals
  • may be infected – pyocoele
  • may be associated with tumour.

5. Tumours

Lipoma is the most common tumour in the inguinal canal .

  • May be hypo or isoechoic to testes

Sarcoma – most common tumour of the spermatic cord . On ultrasound

  • Non specific heterogenous appearance
  • Areas of necrosis and haemorrhage
  • Increased flow on Colour Doppler

Adenomatoid tumour – most common tumour of all extra testicular tumours

  • Non specific ultrasound appearance
  • Arises from the tail of the epididymis
  • Well defined
  • Oval +/- cystic structure

Testicular tumours Germ cell/non germ tumours

  • Well defined and hypoechoic compared with normal testicular tissue
  • Can be heterogeneous with calcification or cystic changes
  • Can be lobulated or multilobulated
  • Increased vascularity of a lesion is not specific to testicular tumours
  • Mixed germ tumours are usually more heterogeneous on US : areas of calcification/cystic change/haemorrhage/necrosis
  • US appearance of testicular lymphomas are similar to germ cell tumours especially seminomas : Hypoechoic with increased Doppler flow
  • Leukaemias: testicular involvement in 64% of patients with leukaemia. US appearance very variable : unilateral/bilateral/diffuse /focal/low high reflectivity/increased Doppler flow – difficult to distinguish from inflammation

6. Seroma

  • Fluid filled space

7. Ilieopectineal  bursitis

  • Cystic mass can be observed in contact with the joint capsule
  • Found lateral to the femoral vessels.
  • May have associated joint effusion
  • Use colour Doppler to  rule out the presence of an aneurysm.

8. Cryptorchid

  • Lack of a testis in the scrotal sac
  • The undescended testis is a homogeneously hypoechoic ovoid structure, similar to the contralateral testis, with an echogenic mediastinum testis
  • May be high up in the scrotum or within the inguinal canal (39%)
  • Inconclusive in evaluation of the atrophic testis (41%), where it is difficult to differentiate from a lymph nodes

9. Abscess  post surgery

  • Spherical or oblong anechoic or hypoechoic collection containing hyperchoic debris.

 

References

  1. AJR : Ultrasound of the Groin: Techniques, Pathology, and PitfallsJon A. Jacobson1 Viviane Khoury2 Catherine J. Brandon1
  2. Abdominal Wall Hernias Moises Dominguez http://step2.medbullets.com/gastrointestinal/121738/abdominal-wall-hernias
  3. AJR June 2013, Volume 200, Number 6 FOCUS ON: Genitourinary Imaging
    Review Testicular Cancer: What the Radiologist Needs to Know Evgeniy I. Kreydin1, Glen W. Barrisford1, Adam S. Feldman1 and Mark A. Preston1
  4. Sci ELO Iliopectineal bursitis: case report Eduardo Amaral Gomes1  Leonardo Mourão Cerqueira2

 

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