Teaching: Inguinoscrotal Examination

[Plabforum]

Where you are?
You are an FY2 working in Surgery Department.

Who the Student is:
Sammy Wilson, a 5th year medical student in clinical rotation in your department wanted to seek help regarding learning about inguinoscrotal examination.

What you must do:
Talk to him and teach him inguinoscrotal examination.

Special Note:
Do not ask him to repeat the steps of examination.

APPROACH

Smile

1. Introduction/ ID check:
2. build rapport:
3. Main concern: ( Always copy from the notes ).

• I can see that you are coming to learn about hernia, how much do you know about it?
• What do you want me to explain about it?
  The Medical student can ask you to teach the anatomy or the examination only sometimes so ask and understand your task properly at the start.

4. Assess knowledge (4 W):

• So before we start could you tell me❓
  – What do you know about it in particular?
  – What exactly do you want to know about it?
  Anatomy of ingunoscrotal region.
  How to perform Inguinoscrotal Examination?
  Types of Inguinal hernias?
  – Why do you want to know about it any reasons in particular?
  – Do you know Why and When we do it? (Brainstorming for colleague).
  Inguinoscrotal Examination is Part of Abdominal Examination.
  We perform Inguinoscrotal Examination when someone is presenting with Inguinal hernia.

5. Teach:

• Do you know what is hernia?
  Hernia is a swelling that occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall.
• Do you know the causes of hernia?
  Increased intra abdominal pressure in cases if chronic cough or chronic constipation.

Explain the Anatomy:

• Always remember the most important structure is Pubic Tubercle.
• If you draw imaginary line between Pubic Tubercle and Anterior Superior Iliac Spine (ASIS), this line is called the inguinal ligament.
• Superficial ring → 1⁄2 inch on top of pubic tubercle.
• Deep ring → 1⁄2 inch on top of mid point of inguinal ligament.
• Inguinal canal → mid-way between ASIS and symphysis pubis.

Types of inguinal hernia:

• There are 2 types of inguinal hernia (different entrance but same exit).
• Direct → enters through wall weakness in inguinal canal, then passes through Hassel Bach’s triangle → exits from superficial ring.

• Indirect → enters from deep ring and passes into the inguinal canal → exits from superficial ring.

Steps of Examination: ( Remember two words, COUGH, AND RED FLAGS ).

1. Before you do any examination: you need to do PPCCE ( explain them to the student).
   – You have to ensure patient privacy.
   – Explain examination to the patient and Take consent.
   – Tell the patient about the adequate exposure, from mid-chest to mid-thigh, because you need to examine abdomen, testicles, scrotum and mid-thigh due to there might be a femoral hernia.
   – You need to check his genital area to see if this swelling is coming from abdomen (inguinal) or from scrotum (femoral).

2. How to examine hernia:

• Position:
  – Ideally, I should examine the patient in standing position, but for the purpose of the exam, I‘ll examine the patient while lying down. (As the mannequin used can be a lying down).

• Inspection
  – If you can see swelling, comment on: “Site, Size, Shape, Skin on top, Unilateral/bilateral”.
  – If you cannot see swelling, ask the patient to cough: if the swelling comes out, comment as before.
  – Ask the pt to lie down and reduce the hernia and locate the deep inguinal ring. Then ask pt to cough.
  If hernia comes out from superficial ring → Direct.
  If feel impulse below your finger → Indirect.

• Palpation
  – Temperature: by back of your hand – Touch it and compare with anything above.
  – Tenderness: Touch it and look at pt’s face.
  – Deep palpation:

  1. Site – Inguinal → above and medial pubic tubercle.
     Femoral → below and lateral pubic tubercle
     Testicular (if your fingers cannot touch each other).
  2. Consistency → touch the swelling and see if it is
     Doughy → omentum or fat.
     Elastic (like tube) → Intestine.
     Very tender → strangulation (the pt will have
     constipation and vomiting in this case).
  3. cough impulse: (ask pt to cough twice)
     In inspection → If there is no swelling.
     In palpation → While you are touching the swelling, ask Pt to cough:
     a) Feel impulse → Good (no strangulation)
     b) No impulse → may be strangulation.
     c) If I am palpating + there is no swelling → ask pt to cough + do Zieman’s test.
  4. Zieman’s test (3 fingers test):
     Indication: done when there is no apparent hernia by palpation.
     Steps: Block deep ring by your index finger, Block superficial ring with your middle finger, Block saphenous opening with your ring finger. Ask pt to cough.
     Results – Impulse felt under index → indirect.
     Impulse felt under middle finger → direct.
     Impulse felt under ring finger → femoral.

• Percussion
  – Looking for the content.
  – Resonant → Intestine.
  – Not resonant → Omentum.

• Auscultation ● Looking for the content.
  – Peristaltic sound → intestine.
  – No sound → Omentum.

After the Examination:
– Make sure you cover the pt. Ideally, I should cover the pt.
– Ideally I should examine the abdomen, scrotum, testicles and L.Ns of the abdomen.

Management:

• Explain hernia and its risk factors.
• we should do some investigations:
  To see its content as US.
  To check for check for risk factors (as CXR for cough if present).

Treatment:

• Surgery: Elective repair → if hernia is reducible.
• Emergency urgent laparotomy → if strangulated.
• Open or laparoscopic repair → if irreducible.

Tell the student to always watch out for the RED FLAGS and to escalate to seniors and the surgical team if he finds any of them as this is a Surgical Emergency.