Reasoning GP · Algorithm · 1-page summary
Groin pain in adults
For: adults with groin pain or a groin lump in primary care. Not for: children (paediatric surgical pathways; limping child algorithm for hip pain).
Core rule: examine standing and lying, both inguinal and femoral regions, and the testes in every male; an irreducible, painful groin lump is a surgical emergency, and a lump below and lateral to the pubic tubercle is a femoral hernia until proven otherwise.
0Stop — call 999 now
- Strangulated hernia — irreducible, firm, tender lump with vomiting, distension, obstruction, peritonism, skin discolouration or systemic toxicity → 999 if unstable or severely unwell, otherwise Same-day immediate ED/surgical. No repeated reduction, no imaging first.
- Acute testicular or scrotal pain (torsion) → Same-day immediate ED/urology; 999 if severe pain, collapse or no immediate transfer. Ultrasound must not delay.
- Acute limb ischaemia — painful, pale, cold limb, absent pulses, sensory loss or weakness → 999 / immediate vascular or ED. Do not delay for outpatient imaging.
1Triage — the hernia, by type
| Finding | Action |
|---|---|
| Strangulation features | Block 0 → 999 / ED |
| Recently irreducible | No strangulation → Same-day surgical |
| Femoral, or a woman | Suspected femoral, even if reducible; groin hernia in a non-pregnant woman → Urgent surgery |
| Symptomatic inguinal | Pain, dragging → Routine elective repair |
| Minimal symptoms, man | Reducible inguinal → discuss watchful waiting or elective repair |
2Screen — serious causes
- Pain + collapse, hypotension or pulsatile abdominal mass (ruptured AAA) → 999
- Cannot weight-bear after trauma (hip fracture) → Same-day ED, X-ray pelvis and hip. A normal X-ray does not exclude it.
- Fever + groin swelling (abscess) → Same-day review; surgical/acute if drainage or severe infection.
- Unexplained, progressive, hard/fixed or generalised nodes, esp. with fever, night sweats, weight loss, itch, splenomegaly or abnormal FBC → consider Urgent suspected cancer referral (NG12).
- Hip pain on steroids, alcohol excess, sickle cell (AVN) → Urgent MRI and orthopaedics.
- Sudden severe hip pain with known malignancy (pathological fracture) → Same-day immediate ED.
3Assess
☐ Lump: reducible, cough impulse, tender, relation to pubic tubercle, pulsatile, transilluminates ☐ Testes/scrotum (males) ☐ Abdomen ☐ Femoral pulses both sides, limb temperature ☐ Hip range, FABER/FADIR ☐ Adductor squeeze ☐ Nodes: feet, legs, skin, genitalia, perineum, anal region ☐ Unexplained nodes: FBC + film, CRP or ESR, targeted HIV, EBV, renal/liver, LDH
Not routine: USS for a clinically clear hernia; X-ray for typical hip OA.
4Classify — only if blocks 0–2 are negative
- Inguinal hernia — above and medial to pubic tubercle, cough impulse, reduces lying; clinical diagnosis.
- Femoral hernia — below and lateral, mostly women; may be a small tender lump mistaken for a node.
- Hip OA — anterior groin pain, age 45+, activity-related, no or ≤30 min morning stiffness, reduced internal rotation; clinical diagnosis.
- Adductor-related / athletic groin — medial pain with sport, adductor origin tenderness, pain on resisted adduction.
- Inguinal nodes — local until shown otherwise; find the source. Women: cyclical pain → endometriosis; discharge, cervical motion tenderness → pelvic infection.
- Uncertain — USS for an equivocal lump or node; MRI only with a specific indication.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Reducible hernia: stay active by symptoms; treat constipation and chronic cough; truss gives temporary relief only.
- Hip OA: tailored exercise is core; weight-management support; topical NSAID may be considered. Not routinely paracetamol or weak opioids; no strong opioids.
- Adductor pain: relative rest, early physiotherapy-led rehabilitation; NSAIDs only after renal, GI and CV assessment.
- Lymphadenitis: treat an identified skin/soft-tissue source per local guideline. No empirical antibiotics for unexplained nodes; STI risk → sexual health.
6Refer routinely and review
- Physiotherapy: adductor strain, hip OA exercise, meralgia.
- Orthopaedics: consider for joint replacement if hip OA substantially affects quality of life despite non-surgical care; FAI/labral tear.
- Specialist MSK ± MRI: athletic groin pain persisting despite rehabilitation.
- Gynaecology: endometriosis, ovarian pathology. Review at 6 weeks: nodes, hip OA, post-repair.
7Never reassure by
- "A gland" — a firm, tender lump below the ligament in a woman may be a femoral hernia.
- A reducible femoral hernia — it still needs urgent surgical referral, not watchful waiting.
- Groin pain in a male without examining the testes.
- A normal X-ray in suspected occult hip fracture or early AVN.
- A normal blood count, or node size under 1 cm — lymphoma is not excluded.
- Repeated empirical antibiotics for persistent nodes.
8Safety-net — say it, then document it (written for every hernia)
999 / A&E “If your hernia will not go back and is painful or tender, or you vomit, your tummy swells or you feel very unwell, go to A&E now (999 if severely unwell). Go to A&E now for sudden testicular pain (999 if you collapse or cannot get there). Call 999 for a cold, pale leg, or collapse with sudden severe tummy/back/groin pain.”
Same day: “Contact us today if a hernia becomes firm and won’t go back, if you get a fever with a painful groin swelling, or a groin gland grows quickly.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 feature; testes and pulses examined
Lump located against the pubic tubercle, standing and lying
Femoral or female hernia referred urgently
Nodes: source found, or bloods and review booked
Written strangulation safety-net and review date documented
Summary of the full Reasoning GP groin pain algorithm, which holds the history, examination tests, post-repair care, rehabilitation and evidence. Sources: HerniaSurge groin hernia guidelines, RCS England/British Hernia Society commissioning guide, NICE NG226 (osteoarthritis), NICE NG12 (suspected cancer, updated April 2026), NICE CG173 (neuropathic pain), EAU guidelines. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.