Examination checklist

    Groin hernia examination

    A 24-step mark sheet for examining a groin swelling — standing and lying, cough impulse, reducibility, the deep ring occlusion test, inguinal versus femoral, and the scrotum — with a model presentation and the differential of a groin lump.

    Surgery
    Abdomen and hernias
    All colleges

    Mark sheet

    24 steps · 24 marks

    #StepWellPartlyNot
    1. 1Greets the examiner and the patient, introduces self, obtains consent and offers a chaperone1½0
    2. 2Exposes from the umbilicus to the knees, examining both groins1½0
    3. 3Examines with the patient standing first1½0
    4. 4Inspects both groins and the scrotum — site, size, shape, extension into the scrotum, scars1½0
    5. 5Asks the patient to cough and looks for an expansile impulse on both sides1½0
    6. 6Asks whether the swelling is painful and palpates it gently1½0
    7. 7Identifies the pubic tubercle and states the relation of the swelling to it1½0
    8. 8Determines whether one can get above the swelling in the scrotum1½0
    9. 9Palpates a cough impulse with the hand over the swelling1½0
    10. 10Describes size, shape, consistency, tenderness, temperature1½0
    11. 11Lies the patient down and asks him to reduce the hernia himself, or reduces it gently1½0
    12. 12Notes the direction of reduction (up and laterally, or backwards and down)1½0
    13. 13Occludes the deep ring (just above the midpoint of the inguinal ligament) with two fingers and asks the patient to cough1½0
    14. 14States whether the hernia is controlled by deep ring pressure (indirect) or not (direct)1½0
    15. 15Watches where it reappears when the pressure is released1½0
    16. 16Percusses the swelling (resonant bowel or dull omentum)1½0
    17. 17Auscultates for bowel sounds1½0
    18. 18Examines the testes and cord on both sides1½0
    19. 19Tests transillumination if the swelling cannot be got above1½0
    20. 20Examines the femoral region below and lateral to the pubic tubercle1½0
    21. 21Examines the opposite groin1½0
    22. 22Examines the abdomen for a cause of raised pressure (ascites, mass, bladder) and asks to do a rectal examination1½0
    23. 23Asks about or looks for chronic cough, constipation and urinary straining1½0
    24. 24Presents a complete diagnosis — side, type, reducibility, contents, complications1½0

    Summary of findings

    I examined the groins of a 58-year-old farmer with a chaperone present. Standing, there is a 10 × 6 cm pear-shaped swelling in the right groin extending into the right hemiscrotum. It has an expansile cough impulse. It is non-tender, soft, and I cannot get above it in the scrotum. The testis is palpable separately below it. When he lies down it reduces completely upwards and laterally with gurgling. With the deep ring occluded it does not reappear on coughing, but it emerges when the pressure is released and travels down towards the scrotum. It is resonant, with bowel sounds. The left groin, the femoral canals and both testes are normal. There is no ascites, and he has no chronic cough. My diagnosis is a right indirect, complete (inguinoscrotal), reducible inguinal hernia containing bowel, without complications.

    A complete hernia diagnosis states

    1. Side — right, left, bilateral
    2. Type — indirect or direct inguinal, femoral, incisional, umbilical
    3. Extent — bubonocele, funicular, complete (inguinoscrotal)
    4. Reducibility — reducible, irreducible (incarcerated), obstructed, strangulated
    5. Contents — bowel (enterocele), omentum (epiplocele)
    6. Precipitating cause — chronic cough, prostatism, constipation, heavy lifting, ascites

    Differential diagnoses

    Groin swellingDistinguishing clue
    Indirect inguinal herniaAbove and medial to the tubercle, controlled by deep ring pressure, descends into the scrotum
    Direct inguinal herniaOlder men, broad-necked, bulges forward medial to the deep ring, rarely enters the scrotum, not controlled by deep ring pressure
    Femoral herniaWomen more often, below and lateral to the tubercle, small, often irreducible, high strangulation risk
    HydroceleCan get above it, transilluminates, testis not separately palpable
    Encysted hydrocele of the cordMoves down when the testis is pulled, transilluminates, no cough impulse
    Undescended or retractile testisEmpty hemiscrotum
    Saphena varixBelow and lateral to the tubercle, disappears on lying, fluid thrill on tapping the varicose vein, cough impulse
    Inguinal lymph nodesMultiple, firm, look for a source on the leg, perineum or anus
    Psoas abscessBelow the inguinal ligament lateral to the femoral artery, back pain, cross-fluctuation above the ligament
    Femoral artery aneurysmExpansile pulsation
    Lipoma of the cordDoes not reduce, no cough impulse

    Investigations

    • Usually clinical
    • Ultrasound of the groin for an uncertain diagnosis or suspected occult hernia (dynamic with Valsalva)
    • Preoperative: full blood count, U&E, glucose, ECG and chest X-ray in older patients; urinalysis; assess prostatism and chronic cough

    Treatment

    See Inguinoscrotal hernia and Hernias compared.

    Examiner questions

    References

    • O'Connell PR, McCaskie AW, Sayers RD, eds. Bailey & Love's Short Practice of Surgery. 28th ed. Boca Raton: CRC Press; 2023.
    • HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22:1–165.

    Updated September 18, 2026