A 68-year-old woman comes to the office due to a groin bulge. She first noticed it 2 months ago and says that it gets larger with prolonged standing and shrinks with lying down, but it is not painful. There has been no trauma to the area. The patient has had no fever, nausea, anorexia, weight loss, abdominal pain, or urinary symptoms. She has a history of obstructive pulmonary disease with occasional exacerbations and hypertension. The patient has smoked a pack of cigarettes daily for 45 years. Temperature is 36.9 C (98.4 F), blood pressure is 140/80 mm Hg, pulse is 78/min, and respirations are 16/min. BMI is 34 kg/m2. Oxygen saturation is 95% on room air. Cardiopulmonary examination shows mildly decreased breath sounds bilaterally. The abdomen is soft and nontender; bowel sounds are normal. There is a 2-cm groin mass below the right inguinal ligament, which is medial to the right femoral artery; no tenderness, pulsations, or overlying erythema is present. The mass is tympanitic to percussion. Which of the following is the best next step in management of this patient?
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This patient's nontender groin bulge is located below the inguinal ligament, raising strong suspicion for femoral hernia, a displacement of abdominal or pelvic contents through a widened or laxed femoral ring (medial to the femoral artery and inferior to the inguinal ligament). Risk factors include chronic cough (eg, chronic obstructive pulmonary disease), constipation, and smoking. Most cases arise in older women and present as a nonpulsatile mass in the groin. The mass generally worsens with increased abdominal pressure (eg, standing, Valsalva maneuver, coughing) and improves with decreased abdominal pressure (eg, lying down). When a bowel loop is present within the hernia, it is often tympanitic to percussion.
Because femoral hernias pass through a narrow orifice, they are associated with a substantial risk of incarceration (trapping of abdominal/pelvic contents within the hernia) and strangulation (constriction of blood flow with subsequent ischemia/necrosis). Therefore, asymptomatic femoral hernias are generally referred for elective surgical repair to prevent potentially life-threatening complications and subsequent high-risk emergency surgery, which is associated with an increased risk of morbidity (eg, bowel resection) and mortality.
In contrast, inguinal hernias (hernia above the inguinal ligament) are associated with a lower risk for incarceration and strangulation because hernia contents pass through a wider orifice. Therefore, most asymptomatic inguinal hernias can be managed with reassurance and watchful waiting. Observation can also be considered for patients with chronic (>3 months), stable femoral hernias, but is not recommended for most patients with femoral hernias due to the risk of incarceration (Choice E).
(Choice A) CT angiography can be used to diagnose femoral artery aneurysm, which is associated with a pulsatile groin bulge that does not change with alterations in abdominal pressure.
(Choices C and D) Diverticulitis usually presents with lower abdominal pain and, occasionally, a tender lower abdominal mass. Treatment of uncomplicated diverticulitis generally includes oral antibiotics; percutaneous drainage is sometimes required when diverticular abscess is present. Other infections that can develop in the groin include cutaneous abscesses or lymphangitis. This patient's mass is nontender and not associated with erythema or fever, making infection less likely.
Educational objective:
Femoral hernias (hernia located below inguinal ligament) protrude through the femoral ring and usually present with a nontender, nonpulsatile bulge in the groin that grows in size with increased abdominal pressure. Because the risk of incarceration with femoral hernias is high (due to narrow hernia orifice), patients with asymptomatic femoral hernias are referred for early elective hernia repair. In contrast, asymptomatic inguinal hernias (hernia located above inguinal ligament) can usually be managed with watchful waiting because hernia contents pass through a wider orifice.