How to examine the inguinal region

A thorough abdominal exam includes an examination of the genitalia. Internal reproductive organs and the rectum can be the cause of significant abdominal pain. So, it is crucial to include them in the exam. Due to the sensitivity of a genitalia exam, a chaperone must be present when the exam is performed.

The inguinal (i.e., groin) region is complex and contains a special arrangement of muscular and fascial layers, which puts it at risk for potential weakness and hernia formation. The patient’s history and pain symptoms can help guide your physical exam. Be sure to ask the patient questions that pertain to the inguinal area:

• Is the pain located in the right or left groin?
• How long have you noticed the discomfort?
• Is there swelling or a mass?
• Does standing or activity (such as lifting) cause or worsen the pain?
• Does standing or activity make the lump more prominent?
• Have you ever had a hernia repair?

Even if the patient has denied a surgical history, directly ask them if they’ve had a hernia repair. Patients often forget, so politely asking during this time is appropriate.

There are three important landmarks to identify for correct hand positioning during an inguinal exam:

1. Inguinal ligament
2. Superficial inguinal ring (also called the external ring)
3. Deep inguinal ring (also called the internal ring)

The inguinal ligament runs between the anterior superior iliac spine (ASIS) and the pubic tubercle. The superficial inguinal ring lies just above the pubic tubercle on the left and right sides, respectively. The deep inguinal ring is found about 1–2 cm superior to the halfway mark between the ASIS and the pubic tubercle.

There are two types of hernias in the inguinal region, known as direct and indirect inguinal hernias. Generally, direct inguinal hernias lay medial to the inferior epigastric vessels and are noted with a peritoneal bulge.

Indirect inguinal hernias lie lateral to the inferior epigastric vessels. Indirect hernias go through the deep inguinal ring and may extend all the way through the superficial inguinal ring into the scrotum, which gives the gross appearance of a hydrocele (e.g., a fluid-filled sac).

To differentiate a hydrocele from an indirect hernia, transilluminate (e.g., pass light through) the scrotal contents in a darkened room. This can show fluid or intestine in the bulge.

Since the inguinal region is at risk for weakness, the exam is performed to evaluate for hernias. But, it’s also important to check for masses and enlarged lymph nodes. There are five steps to examining the inguinal region:

1. Inspect and palpate with the patient supine and initiate a Valsalva maneuver.
2. Inspect and palpate with the patient standing.
3. Ask the patient to cough while palpating the inguinal region.
4. Palpate the scrota.
5. Ask the patient to cough while palpating the superficial ring.

The procedure starts with the patient supine, and then the rest of the exam is performed with the patient standing.

Step 1: Inspect and palpate with the patient supine and initiate a Valsalva maneuver

First, in a well-lit room, have the patient lie in the supine position to inspect and palpate the inguinal region in a relaxed state. Have the patient cough and lift their head slightly off the table to initiate the Valsalva maneuver. This increases the pressure in the abdomen and will make an abdominal wall mass or bulge more prominent.

Step 2: Inspect and palpate with the patient standing

Next, ask the patient to stand so that you can observe and palpate in a gravity-dependent state. Sit on a stool and inspect the region while they are standing. The increased abdominal pressure in this position may display a bulge or other findings not noticeable in the supine position.

If there is a bulge, see if it is reducible by applying upward pressure on it. If a mass is palpated, note if it is round, soft or hard, rough or smooth, and the approximate size. It is important to remember that masses in the inguinal region that are not hernias can be tumors, lipomas, or lymph nodes.

Step 3: Ask the patient to cough while palpating the inguinal region

While standing beside the patient, gently place your fingers in the groin just anterior to the inguinal fold with your fingers placed over the femoral region, superficial inguinal ring (lateral to the pubic tubercle), and deep inguinal ring (located above the midpoint of the inguinal ligament). Then, have the patient cough to evaluate for a bulge or mass.

Step 4: Palpate the scrota

Also, evaluate the scrotum on each side. Use your fingers to invert the scrotal skin. The index finger enters the inguinal canal along the course of the cord structures. The size of the superficial ring can be felt by palpating just lateral to the pubic tubercle.

Step 5: Ask the patient to cough while palpating the superficial ring

Have the patient cough while your fingers are in a position to palpate the superficial ring (lateral to the pubic tubercle). If there is a hernia, the defect in the ring is often palpable.

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