Masses and pain in the groin: a review of imaging findings

Thinking beyond hernia: a review of non-hernia groin lumps

With increasing reliance on imaging, a large number of patients presenting with a groin lump are being referred to radiology to confirm the diagnosis of hernia, usually with an ultrasound in the first instance (occasionally MRI or CT). However, when imaging of the groin was performed, we have encountered many different kinds of non-hernia lesions in our practice. Such lesions can be categorized based on their tissue of origin and pathology. A specific diagnosis can often be reached using ultrasonography, MRI or a combination of imaging modalities. This review article will help general, musculoskeletal and abdominal radiologists to understand the anatomy of the groin, diagnose and characterise soft tissue lesions that may present as a groin lump, provide guidance for further imaging and insight into imaging features which may need specific investigations like core biopsy, tertiary referral and review at multidisciplinary meetings.

Synovial chondromatosis of the hip, a case report and literature review

A case of giant synovial chondromatosis of the hip with extra-articular localisation in the ileopectineal bursa is presented and the literature concerning this condition is reviewed. Synovial chondromatosis is a rare condition of unknown aetiology. A literature search was performed to identify studies describing outcome after surgical treatment of synovial chondromatosis of the hip. Thirteen studies including two hundred-ninety patients could be included. Mean follow-up was fifty-six months. Seven out of two hundred-ninety developed a complication after surgical resection of the lesion. Recurrence rate of synovial chondromatosis is about 19%. Malignant transformation of synovial chondromatosis to chondrosarcoma is extremely rare. No wound infections were reported and avascular necrosis of the femoral head occurred in one patient who was treated with dislocation of the hip during surgery. After resection of synovial chondromatosis excellent functional outcome can be expected.

Lipoma of the fossa femoralis mimicking a femoral hernia. Report of 2 cases

INTRODUCTION

Lipoma of the femoral fossa is uncommon. Often asymptomatic, femoral lipoma may growth within the circumscribed space of the femoral fossa causing pain and discomfort. A worsening pain caused by a lipomatous mass in the femoral area is a clinical feature that can mislead the diagnosis, resembling the more common condition of femoral hernia.

METHODS

Two cases of symptomatic lipomas of the femoral fossa mimicking an incarcerated femoral hernia are presented. In both, Caucasian female, patients clinical examination and ultrasound of the femoral region revealed a painful neoplasm suspected for incarcerated femoral hernia.

RESULTS

Intraoperatively, a mass of encapsulated fat arising from the bottom of the fossa femoralis was found. No visceral protrusion through the femoral ring could be documented. The neoplasms were removed in toto. Histology of the excised specimens evidenced the diagnosis of femoral lipomas suffering by chronic compressive damages. In a midterm postoperative follow up, both patients were symptom- free.

DISCUSION

A correct preoperative diagnosis of femoral lipoma is challenging, even following an accurate diagnostic pathway. The cases highlighted herewith seem to confirm that lipoma of the femoral fossa can be mistaken with a femoral hernia.

CONCLUSIONS

The clinical and histological features evidenced could result helpful in the differentiation of a lipomatous mass of the femoral fossa from a genuine femoral hernia.

Assessment of Diagnostic Value of Sonography for Cryptorchidism

Cryptorchidism refers to the condition in which the testicle is not positioned in the base of the scrotum. The most important goal of diagnosing and managing the undescended testis is to place the testis in the scrotum to maximize its potential for spermatogenesis. This article provides a comprehensive concept of cryptorchidism, its diagnosis, and complications. This prospective study was performed to assess the value of sonography in the diagnosis of undescended testes. This prospective study was performed to evaluate 124 cases of cryptorchidism. In the authors’ survey, the sensitivity of sonography for determining cryptorchidism was 91%. The most common site of undescended testis was the inguinal canal, and the right undescended testis was localized more than the left undescended testis. The results were compatible with other studies. It was concluded that sonography is the safest, most noninvasive, and most valuable method of detection for undescended testes.

Pelvic osteomyelitis presenting as groin and medial thigh pain: a resident's case problem

STUDY DESIGN

Resident's case problem.

BACKGROUND

Groin pain represents a diagnostic challenge and requires a diagnostic process that rules out life-threatening illness or disease processes. Osteomyelitis is a potential fatal disease process that requires accurate diagnosis and medical management. Osteomyelitis presents a problem for the outpatient physical therapist, as the described physical findings for the diagnosis of osteomyelitis are nonspecific.

DIAGNOSIS

A 67-year-old man with groin and bilateral medial thigh pain was referred for physical therapy care to address right adductor weakness and generalized deconditioning. He had undergone extensive treatment for bladder cancer, with a recent radical cystoprostatectomy and cutaneous urinary diversion with an Indiana pouch. Postsurgical magnetic resonance imaging indicated normal findings, and the patient was currently being managed by an orthopaedic surgeon, who diagnosed the patient as having obturator nerve palsy. The physical therapist's examination produced findings inconsistent with this diagnosis. Subsequently, nuclear medicine studies revealed pubic symphysitis/osteomyelitis with secondary myositis, predominantly affecting the right adductor muscles.

DISCUSSION

Osteomyelitis represents a difficult problem for the outpatient physical therapist. Careful consideration of red-flag symptoms and inconclusive physical testing indicate the need for further medical work-up. In this case, appropriate medical management led to improvement in patient function, highlighting the need for early diagnosis.

LEVEL OF EVIDENCE

Differential diagnosis, level 4.

Large Retroperitoneal Liposarcoma Diagnosed upon Radiological Evaluation of Mild Right-Sided Inguinal Hernia

While inguinal hernia is common in the primary care office, the differential diagnosis is extensive and includes infectious, inflammatory and neoplastic processes. Varicocele is another frequent, generally benign condition which occasionally reflects serious disease entities. Left-sided or bilateral varicoceles account for the overwhelming majority of varicoceles because the left gonadal vein drains into the left renal vein in contrast to the right gonadal vein, which drains directly into the inferior vena cava, thus making left-sided or bilateral venous congestion more likely. Presence of an uncommon unilateral right-sided varicocele thus warrants further radiological workup, in particular CT abdomen and pelvis, to evaluate for retroperitoneal pathology. We describe a case in which appropriate use of a variety of imaging modalities including testicular ultrasound and CT led to an important diagnosis of a large, well-differentiated liposarcoma in the right retroperitoneum of a patient with a right-sided groin mass.

The inguinal canal: anatomy and imaging features of common and uncommon masses

A variety of benign and malignant masses can be found in the inguinal canal (IC). Benign causes of masses in the IC include spermatic cord lipoma, hematoma, abscess, neurofibroma, varicocele, desmoid tumor, air, bowel contrast material, hydrocele, and prostheses. Primary neoplasms of the IC include liposarcoma, Burkitt lymphoma, testicular carcinoma, and sarcoma. Metastases to the IC can occur from alveolar rhabdomyosarcoma, monophasic sarcoma, prostate cancer, Wilms tumor, carcinoid tumor, melanoma, or pancreatic cancer. In patients with a known malignancy and peritoneal carcinomatosis, the diagnosis of metastases can be suggested when a mass is detected in the IC. When peritoneal disease is not evident, a mass in the IC is indicative of stage IV disease and may significantly alter clinical and surgical treatment of the patient. A combination of the clinical history, symptoms, laboratory values, and radiologic features aids the radiologist in accurately diagnosing mass lesions of the IC. Supplemental material available at radiographics.rsnajnls.org/cgi/content/full/28/3/819/DC1.

Sonography of various cystic masses of the female groin

OBJECTIVE

The purpose of this presentation is to review the pathologic spectrum of cystic masses that may involve the female groin region, with a correlation of the lesions with their sonographic appearance.

METHODS

We reviewed the sonographic findings of palpable groin masses showing a cystic pattern in female patients. The groin region is best depicted with a high-frequency (7.5- to 12-MHz) linear array transducer. Color Doppler sonography and an extended field of view are helpful in the differential diagnosis of variable groin masses.

RESULTS

There are various cystic masses involving the female groin, such as round ligament cysts, varicosities of the round ligament, inguinal herniation of the ovary, cystic lymphangiomas, epidermal inclusion cysts, abscesses, and pseudoaneurysms.

CONCLUSIONS

Sonography with color Doppler imaging is helpful for the differential diagnosis of the pathologic spectrum of cystic masses involving the female groin.

Sonographic findings of groin masses

OBJECTIVE

The groin contents consist of the spermatic cord and its fascial coverings and vascular, nervous, and muscular structures. Abnormalities in the groin region are variable. The purpose of this image presentation is to describe the sonographic findings of the various kinds of groin lesions.

METHODS

We retrospectively reviewed the sonographic findings of various kinds of groin lesions. All sonographic examinations were performed with high-frequency (5- to 15-MHz) linear array transducers.

RESULTS

The most common abnormality in the groin was a hernia, which contains bowel loops, omental fat, and peritoneal fluid. The most common benign tumor of the inguinal region was a lipoma. Other benign tumors of the groin included leiomyomas, dermoid cysts, epidermoid cysts, and lymphangiomas. The most common primary malignant tumors in the inguinal region were sarcomas such as rhabdomyosarcoma and liposarcoma. Secondary malignant tumors of the inguinal regions were metastatic lymphomas and metastatic carcinomas of the lung, breast, ovary, and gastrointestinal tract. Hematomas and inflammation may occur in the inguinal region.

CONCLUSIONS

Although there was substantial overlap of sonographic findings in the various inguinal masses, clinical history and certain sonographic details can assist in making the correct diagnosis.

Endoscopic evaluation and treatment of groin pain in the athlete

BACKGROUND

Chronic groin pain in athletes forms a major diagnostic and therapeutic challenge.

HYPOTHESIS

Evaluate and treat undiagnosed groin pain in the athlete by endoscopy.

STUDY DESIGN

Prospective cohort study.

METHODS

Athletes who were referred to the Ikazia Hospital with undiagnosed chronic groin pain between January 1998 and August 2001 were included. Radiography, bone scintigraphy, and ultrasonography were performed. In 14 athletes, groin pain remained undiagnosed. Ten patients complained of unilateral, 4 of bilateral groin pain. Patients underwent a transabdominal or extraperitoneal diagnostic endoscopy.

RESULTS

All patients were operated ambulatory without significant difficulties. Pathology found by endoscopy was hernia inguinalis (n = 9), hernia femoralis (n = 4), preperitoneal lipoma (n = 3), and hernia obturatoria (n = 1). Only once was there no pathology. In 17 groins, a Prolene mesh was placed preperitoneally. Thirteen patients (93%) returned to full activity within 3 months of surgery. One year after surgery, one patient had minor symptoms and one patient had persistent symptoms. All other patients had no complaints.

CONCLUSIONS

An occult hernia should be high on the list of differential diagnoses in undiagnosed chronic groin pain in athletes. Operative treatment can return the patient to his sport within 3 months.

Inguinal hernias: MRI and ultrasound

This article presents an overview of the key anatomic structures of the groin region as seen on gross anatomy and the appearance of these structures on ultrasound and magnetic resonance imaging (MRI). An overview of the sonographic and MRI techniques used in preoperative diagnosis of inguinal hernias is provided, and their value is discussed. Finally, the role of ultrasound and MRI after surgical inguinal hernia repair is addressed.

Imaging of groin masses: inguinal anatomy and pathologic conditions revisited

The groin region is subdivided into two distinct anatomic areas: the inguinal canal and the femoral triangle. A series of cross-sectional imaging cases illustrate that a good understanding of the local anatomic characteristics of the groin allows confident characterization of groin pathologic conditions. Such conditions can be classified into five major groups: congenital abnormalities, noncongenital hernias, vascular conditions, infectious or inflammatory processes, and neoplasms. Congenital entities include hernias, cysts, undescended testis, and retractile testes. Ultrasound (US) is useful in depicting these conditions. In the second group, noncongenital hernias, US allows visualization of bowel loops in peristalsis within the hernia. Herniography, computed tomography (CT), and magnetic resonance (MR) imaging are also helpful in diagnosis. Among vascular conditions, false aneurysms may be detected from the turbulent flow through the tract at Doppler US. The characteristic venous flow of varicoceles is best diagnosed with US during the Valsalva maneuver. Infectious or inflammatory conditions include, among others, hematomas, which appear hyperattenuating at CT and have variable appearances, depending on the age of the blood products, at MR imaging. The origins of neoplasms may be assessed at CT and MR imaging, although appearances of solid tumors are relatively nonspecific.

Ultrasound of the adult hip

The adult hip is a new and challenging site for evaluation with ultrasound (US). Clinically, diseases involving the hip region may be difficult to diagnose without the help of imaging. The hip region is a crossroad for numerous vascular, nervous, and muscular structures that pass between the trunk and the lower extremity. Thus, inflammatory processes and neoplasms may spread to and from the hip, buttock, thigh, pelvis, and retroperitoneum, and trauma may also effect the adjacent areas of the trunk and thigh. Because it is a crossroad, many conditions that are not specific to the hip occur in this area, including inguinal lymphadenopathy, pathology from the abdomen or the genitalia (intestinal hernia, inflammation, and infection), and even referred pain from spinal disorders. The goals of US imaging are the detection and localization of these pathological processes, the differentiation of intra-articular andextra-articular pathology, and the performance of diagnostic and therapeutic interventional procedures. This article reviews the hip anatomy, followed up by a discussion of the US evaluation and differential diagnosis of common pathology occurring in the hip area. This includes joint effusion, arthritis, loose bodies, bursitis, pseudoaneurysm, muscle and tendon diseases, as well as tumor and tumor-like lesions such as hematoma, abscess, and lymphadenopathy.