How is the diagnosis made?
Inguinal hernia is typically a clinical diagnosis; however, imaging may be useful if the clinical diagnosis is unclear or to investigate an underlying cause.
Describe the clinical evaluation.
Medical history should include:
Identification of typical clinical features (e.g., of uncomplicated inguinal hernia)
Onset and duration of symptoms [
Evaluation of risk factors for an acquired inguinal hernia.
Physical examination should include:
Palpation of the inguinal canal
Evaluation for signs of complicated inguinal hernia
Identification of signs of underlying etiologies, e.g., ascites, BPH
To avoid missing inguinal hernias, routinely examine the inguinal canal in patients with unexplained acute abdominal pain and/or clinical features of bowel obstruction, especially in those with verbal impairment.
What are indications, modalities and supportive findings of imaging?
Uncertain clinical diagnosis
Suspected recurrent or occult inguinal hernia
Consider preoperative imaging for complicated inguinal hernia.
First line: ultrasound of the groin
Inconclusive ultrasound findings: CT or MRI abdomen and pelvis
Visualization of the hernial sac with its contents (e.g., bowel, omentum)
Uncomplicated inguinal hernia
Visible expansile cough impulse
Direct inguinal hernia: fascial defect in the posterior wall of the inguinal canal
Indirect inguinal hernia: widening of the deep inguinal ring
Do not delay emergency surgery for imaging in unstable patients with signs of strangulated hernia or obstructed hernia.
List lab studies.
The following tests should be obtained in patients with strangulated inguinal hernia or incarcerated inguinal hernia with bowel obstruction for supportive diagnostic evidence and to assess for complications.
List other DDs.
Round ligament varicosities
Large cutaneous or subcutaneous masses in the inguinal region
A groin bulge with an expansile cough impulse above the inguinal ligament is diagnostic of an inguinal hernia. A femoral hernia typically manifests as a groin bulge below the inguinal ligament and lateral to the pubic tubercle.
List DDs specifically for groin pain.
If these diagnoses are chronic or recurrent, they may cause inguinodynia.
Diverticulosis or acute diverticulitis
Pathology of the hip joint
Inflammatory bowel disease
Lumbar disk herniation
Urinary tract infection
Sports hernia: chronic groin pain due to an injury or weakness of the posterior wall of the inguinal canal; an actual hernia may or may not be present