This is particularly important to consider in females with a painful inguinal mass since the presence of an ovary within a hernia sac places it at risk for torsion The ability to reduce the mass with gentle pressure confirms this diagnosis, but failure to reduce the mass cannot rule it out and may even suggest an incarcerated or strangulated hernia warranting surgical consultation When a painless mass is irreducible, an enlarged lymph node may be a possible cause or it may also be an acutely incarcerated hernia that has not yet become painful (particularly involving an ovary) Reduction can be attempted for painless masses to help both diagnose and treat the underlying pathology In general, painless inguinal masses are usually not emergent The finding of penile or vaginal lesions, such as those of herpes or syphilis, evidence of soft tissue infection localized to the perineum, or insect bites, eczema, or infected wounds on the legs or lower abdomen, may identify the source of inguinal adenopathy or adenitis With equivocal physical findings, ancillary tests may be helpful to establish the diagnosis Laboratory tests should be used judiciously and on a case-by-case basis; for example, complete blood count and inflammatory markers can help differentiate between infectious and oncologic processes and reflect severity of illness Various microbiologic assays may be used to make definitive diagnoses and direct treatment Ultrasonography can also be useful when the physical examination is indeterminate and is considered the imaging modality of choice for suspected inguinal abnormalities Sonographic images can identify evidence of soft tissue infectious changes (i.e., cellulitis) as distinct from drainable fluid collections (i.e., abscess) Ultrasound can differentiate between such fluid collections and lymph nodes, which is important in planning procedures or consultation with surgical specialists This modality can also characterize tumors and identify hernias Bedside ultrasound may be useful for directing procedures and to locate important neighboring structures (i.e., blood vessels) ( Fig 39.2 ) Suggested Readings and Key References Lymphadenopathy and Lymphadenitis American Academy of Pediatrics; Kimberline DW, Brady MT, Jackson MA, et al., eds Red Book: 2018 Report of the Committee on Infectious Diseases 31st ed Itasca, IL: American Academy of Pediatrics; 2018 Nelson CA, Moore AR, Perea AE, et al Cat scratch disease: U.S clinicians’ experience and knowledge Zoonoses Public Health 2018;65(1):67–73 Patton ME, Workowski KA Skin and mucous membrane infections and inguinal lymphadenopathy In: Long S, Prober C, Fischer M, eds Pediatric Infectious