Differential diagnoses: Presentation of groin swellings

Dr Stollery discusses the diagnosis of congenital hydrocoele, hydrocoele, inguinal hernia and inguinoscrotal hernia.

Congenital hydrocoele


  • Primary hydrocoele that communicates with the peritoneal cavity via a patent processus vaginalis
  • Soft, fluctuant swelling which transilluminates and affects 1-2% of males
  • Fluid often drains back into the abdomen at night
  • Drainage by digital pressure not usually possible
  • Testis lies within the swelling and cannot be palpated separately


  • Most resolve without surgery in the first year of life
  • Operation the same as hernia surgery, with a herniotomy and excision of the outer layer of the tunica vaginalis



  • Secondary hydrocoele which develops in later life
  • Causes include trauma, tumour, epididymo-orchitis, torsion, hernia
  • May be associated with oedema from nephrotic syndrome or heart failure
  • Non-tender cystic swelling which will usually transilluminate
  • Testis usually palpable, but lies within the fluid
  • If diagnosis is in doubt, ultrasound can be helpful


  • Once underlying causes excluded, non-communicating hydrocoeles can be managed with scrotal support
  • Therapeutic aspiration may be required for large hydrocoeles, but is not recommended except for elderly men not fit for surgery
  • Surgery usually required for symptomatic communicating hydrocoeles
  • Recurrence uncommon after surgery

Inguinal hernia


  • The most common cause of groin swelling, due to protrusion of abdominal contents through inguinal ring
  • May be bilateral, direct or indirect, congenital or acquired
  • 90% occur in males
  • Strangulation may occur, requiring urgent intervention
  • May be associated with pain or aching
  • Swelling increases in size with gravity or when abdominal pressure increases


  • Laparoscopic repair now routine
  • Some cases may require more traditional open surgery
  • In those unfit for surgery, conservative management with a truss can be helpful
  • Recurrence uncommon with laparoscopic mesh repair

Inguinoscrotal hernia


  • Groin swelling which extends into the scrotum
  • May be very large
  • Unable to get above the swelling on examination
  • Does not transilluminate and testis palpable separately
  • Swelling usually reducible when patient lying flat and pressure applied
  • Cough reflex usually palpable


  • Management as for inguinal hernia
  • Dr Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary.

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