Scrotal contents: palpate from anteriorly. If a lump is present, determine if you can get above it.
Lump/inguinal area (both sides):palpate from laterally, with one hand on the patient’s back, using the other to feel the lump/inguinal ligament region
Describe lump (SSSCCCTTT): Site, Size, Shape, Consistency, Contours, Colour, Tenderness, Temperature (Transillumination not required here)
Feel cough impulse (on each side separately):compress lump/inguinal area firmly. Ask the patient to turn their head to the opposite direction and cough. If the swelling becomes tense and expands, there is a positive cough impulse.
Locate the deep inguinal ring (midway between ASIS and pubic tubercle)
Press firmly on the lump and, starting inferiorly, try to lift it up and compress it towards the deep inguinal ring
Once it is reduced, slide your fingers up and maintain pressure over the deep inguinal ring
Ask patient to cough
If the hernia reappears, it is a direct hernia; if not, it is an indirect hernia
Release and watch hernia reappear if it has not already done so (indirect will slide down obliquely; direct will project forwards)
NB: If you cannot reduce the hernia, try again with patient lying supine.
Percussion and auscultation
Percuss and auscultate lump:this may reveal if bowel is present in a hernia
Thank patient and restore clothing
‘To complete my examination, I would perform a full abdominal examination.’
Summarise and suggest further investigations you would consider after a full history