Diagnostics

Inguinal hernia is typically a clinical diagnosis; however, imaging may be useful if the clinical diagnosis is unclear or to investigate an underlying cause.

• 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.

Indications

• Uncertain clinical diagnosis

• Suspected recurrent or occult inguinal hernia

• Consider preoperative imaging for complicated inguinal hernia.

Modalities

• First line: ultrasound of the groin

• Inconclusive ultrasound findings: CT or MRI abdomen and pelvis

Supportive findings

• 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.

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.

• CBC

• Blood glucose

• Serum electrolytes

• BMP

• Serum lactate

• Urinalysis

• Hydrocele

• Varicocele

• Spermatocele

• Round ligament varicosities

• Large cutaneous or subcutaneous masses in the inguinal region

  • Lipoma

  • Sebaceous cyst

  • Hematoma

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.

If these diagnoses are chronic or recurrent, they may cause inguinodynia.

• Acute appendicitis

• Diverticulosis or acute diverticulitis

• Pathology of the hip joint

• Inflammatory bowel disease

• Lumbar disk herniation

• Prostatitis

• Testicular disorders

• Urinary tract infection

• Renal colic

• Osteitis pubis

• Musculoskeletal pain

• 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 [22]

• Neuropathy