Inguinal Hernia Review

Today I listened to IM Reasoning‘s podcast, EPISODE 14: COGNITIVE AUTOPSY OF A GROIN LUMP JULY 26, 2017. The speakers review a case that involved an inguinal hernia that had a bad outcome. The case caused me to do a brief review of this very basic topic.

First I reviewed Resource (1) below, Inguinal Hernias: Diagnosis and Management. Here are some excerpts:

Symptoms and Physical Findings

Hernias may be easily diagnosed with an adequate physical examination. The physical examination should begin by carefully inspecting the femoral and inguinal areas for bulges while the patient is standing. Then, the patient should be asked to strain down (i.e., Valsalva maneuver) while the physician observes for bulges. This may be accomplished by using the right hand to examine the patient’s right side and the left hand to examine the patient’s left side. The physician invaginates the loose skin of the scrotum with the index finger on the ipsilateral side of the patient, starting at a point low enough on the scrotum to reach as far as the internal inguinal ring. Starting on the scrotum, the examining finger follows the spermatic cord upward above the inguinal ligament to the triangular, slit-like opening of the external inguinal ring. The external inguinal ring is medial to and just below the pubic tubercle. The inguinal canal is gently followed laterally in its oblique course. While the examining finger is in the canal next to the internal inguinal ring, the patient strains down or coughs as the physician feels for any palpable herniation.9 The diagnosis of an inguinal hernia is confirmed if an “impulse” or bulge is felt.

If no bulge is detected with a Valsalva maneuver, a hernia is unlikely. . . .

It is more challenging to diagnose a hernia in female patients. Direct palpation with an open hand over the groin area might detect the impulse of a hernia during a Valsalva maneuver. However, further workup with diagnostic testing or referral to a surgeon is often indicated. Rarely, diagnostic laparoscopy is necessary.

Incarceration may be managed in the office setting if there is no associated pain. The standard of care is to place the patient in the Trendelenburg position while holding gentle pressure on the area for up to 15 minutes. If acute onset of groin pain occurs, the hernia may have become strangulated (i.e., the blood supply to the entrapped contents is compromised). Strangulation should be suspected in the presence of tenderness, redness, nausea, and vomiting and is a surgical emergency.10

The role of imaging in the diagnosis of occult but symptomatic inguinal hernia is apparently not settled.

Next I reviewed Resource (2) below, Role of imaging in the diagnosis of occult hernias. The authors of this article conclude:

Ultrasonography and CT cannot reliably exclude occult groin abnormalities. Patients with clinical suspicion of inguinal hernia should undergo MRI as the definitive radiologic examination.

And finally I reviewed Resource (3) below, Evaluation of hernia of the male inguinal canal:
sonographic method. The authors state:

A clear, concise method is presented, with correlated diagrams
and sonographic images, which aims to improve the ability of sonographers to easily identify inguinal herniae.


(1) Inguinal Hernias: Diagnosis and Management [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Am Fam Physician. 2013 Jun 15;87(12):844-848.

(2) Role of imaging in the diagnosis of occult hernias [PubMed Abstract] [Full Text HTML]. JAMA Surg. 2014 Oct;149(10):1077-80. doi: 10.1001/jamasurg.2014.484.

(3) Evaluation of hernia of the male inguinal canal: sonographic method [PubMed Abstract] [Full Text HTML] [Full Text PDF].  J Med Radiat Sci. 2018 Jun;65(2):163-168. doi: 10.1002/jmrs.275. Epub 2018 Apr 17.


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