Painful Lipoma

What Is a Lipoma?

Why Does a Lipoma Become Painful?

1. Neurolipoma (Nerve Tissue Within the Lipoma)

2. Angiolipoma

3. Nerve Compression (Location-Related Pain)

• Carpal tunnel
• Tarsal tunnel
• Cubital tunnel

4. Dercum's Disease (Adiposis Dolorosa)

5. Multiple Lipomatosis (Neurolipomatosis)

6. Inflammation or Trauma

Key Clinical Points

Investigations

• Clinical exam alone is usually sufficient for superficial lipomas
• MRI is the investigation of choice for deep lipomas - shows signal identical to subcutaneous fat on all sequences. Recommended when painful or in close proximity to neurovascular structures. If MRI findings are atypical, incisional biopsy is warranted. - Schwartz's Principles of Surgery
• X-ray is usually normal

Complications of Lipoma (if long-standing)

1. Myxomatous degeneration
2. Saponification
3. Calcification
4. Infection
5. Ulceration (repeated trauma)
6. Malignant change - liposarcoma (rare; most authorities believe liposarcoma arises de novo, not from lipoma) - S. Das, p. 53

Treatment of Painful Lipoma

1. Steroid Injection

• Suitable for painful lipomas < 2.5 cm where pathologic examination is likely unnecessary
• Triamcinolone diluted with 1% lidocaine to 10 mg/mL (1-3 mL) injected into the center monthly
• Shrinks the lipoma but rarely eliminates it entirely; recurrences are frequent
• Textbook of Family Medicine 9e, p. 760

2. Liposuction

• Can be performed under local anesthesia with cannula or 16-gauge syringe
• Does not guarantee complete removal

3. Surgical Excision (definitive treatment)

• Recommended for symptomatic, painful, enlarging lipomas, or those causing dysfunction
• Small lipomas: enucleated through a small incision with blunt dissection
• Large lipomas: linear or elliptic incision with blunt/sharp dissection
• Compression dressing for 1-2 days post-op; sutures removed in 5-10 days
• Recurrence after marginal excision is rare (except intramuscular lipoma, which has a higher recurrence rate)
• All specimens should be sent for pathological examination
• Textbook of Family Medicine 9e, p. 760; Schwartz's Principles of Surgery

Summary: Types of Painful Lipoma at a Glance

Recent evidence note: A 2026 systematic review (PMID 41604515) on Dercum's disease (painful adipose tissue disorder) has been published in Annals of Plastic Surgery - if managing a patient with multiple painful fatty lesions, consulting that review for updated intervention strategies is worthwhile.

Hernia Examination

Anatomy Reference

General Principles of Hernia Examination

Patient Positioning

• Examine the patient lying down first, then standing - standing usually increases hernia size
• Some hernias are only apparent with the patient standing
• Ask the patient to cough or perform a Valsalva manoeuvre to make the hernia appear
• For divarication of recti: ask the supine patient to simply lift their head off the pillow

"If a patient describes an intermittent swelling but the surgeon finds no hernia on examination, there still may be a hernia present." - Bailey & Love's Surgery, 28th Ed

Systematic Examination Steps (S. Das)

1. Inspection

• Note site, size, shape, skin color
• Overlying skin is usually normal color
• Cellulitis over the hernia = strangulation = surgical emergency
• Inguinal hernia: look for a swelling above and medial to the pubic tubercle
• Femoral hernia: swelling below and lateral to the pubic tubercle, then turns upward

2. Site Relative to the Pubic Tubercle

3. Consistency

• Doughy/granular - omentum inside (omentocele/epiplocele)
• Elastic - bowel inside (enterocele)
• Tense and tender - strangulated hernia (most important sign)

4. Relation to Testis and Spermatic Cord (males)

• Inguinal hernia: lies in front and sides of spermatic cord; testis is incorporated within the swelling
• Femoral hernia: does not give rise to scrotal swelling; testis felt separately
• If the hernia stops just above the testis = funicular/acquired variety

Two Classical Signs of an Uncomplicated Hernia

"Two classical signs of an uncomplicated hernia are: (i) Impulse on coughing and (ii) Reducibility." - S. Das

5. Impulse on Coughing (Expansile Cough Impulse)

• Place hand gently over the swelling and ask the patient to cough
• A expansile impulse = hernia contents force out, separating the fingers
• The root of the scrotum can be held between index finger and thumb and felt for impulse on coughing

• Neck of the sac is tight - hernia is irreducible/incarcerated
• Strangulation (tense, tender)
• Adhesions blocking sac entry
• Femoral hernia (tight neck - often misdiagnosed as a lymph node)

"A swelling with a cough impulse is not necessarily a hernia. A swelling with no cough impulse may still be a hernia." - Bailey & Love

6. Reducibility

• Ask the patient to attempt reduction themselves first - they may be well-practised
• For inguinal hernia: flex and internally rotate the thigh, squeeze fundus of the sac with one hand, direct hernia through superficial inguinal ring with the other
• For femoral hernia: reduce through the saphenous opening
• Cannot be reduced = irreducible, obstructed, or strangulated hernia - treat more urgently

Special Tests to Differentiate Hernia Type

7. Zieman's Three-Finger Technique (for diagnosis when hernia is reduced or absent)

8. Invagination Test (Finger in Ring Test)

• Performed after hernia is reduced, in recumbent position
• Use the little finger (least painful): invaginate the skin from the bottom of the scrotum and push up to palpate the pubic tubercle
• Rotate and push the finger further up into the superficial inguinal ring
• Nail faces anteriorly against the spermatic cord; pulp faces posteriorly toward the ring
• Normal ring = triangular slit admitting only the tip of the finger
• Ask the patient to cough:
  • Impulse felt on tip of finger = indirect (oblique) hernia (impulse coming down the canal)
  • Impulse felt on pulp of finger = direct hernia (coming straight through posterior wall)

9. Ring Occlusion Test (Confirmatory test: Direct vs. Indirect)

• Performed standing, after hernia is reduced
• Press the thumb firmly over the deep inguinal ring (½ inch above the mid-inguinal point)
• Ask the patient to cough:

Direct vs. Indirect Inguinal Hernia: Key Differences

Femoral Hernia Examination Points

• Appears below and lateral to the pubic tubercle, lies in the upper leg
• Often rapidly becomes irreducible and loses cough impulse
• May be only 1-2 cm - easily mistaken for a lymph node
• More common in thin, elderly women
• 50% present as an emergency with very high strangulation risk
• Diagnostic error is common due to inadequate exposure
• No scrotal swelling

• Inguinal hernia
• Lymph node
• Saphena varix (also has cough impulse - distinguish by compressibility and thrill)
• Femoral artery aneurysm
• Psoas abscess
• Rupture of adductor longus with haematoma

Examination Checklist (Bailey & Love Summary)

Examination in Children

• Thick fat pad may hide a small hernia - ask the child to jump off the examining table or make it cry
• Palpate the spermatic cord at the superficial ring: thicker than the contralateral side = hernia present
• All inguinal hernias in neonates and children are indirect (congenital) - patent processus vaginalis

Investigations

• Clinical diagnosis is usually sufficient for inguinal hernia
• Ultrasound or CT if doubt exists (especially for femoral hernia)
• MRI for occult/recurrent hernias or atypical presentations