16 Sep

Inguinal hernia: How to examine and treat

What is an inguinal hernia?

Inguinal hernia is a defect occurring at the groin region. Patients often complains of a swelling over the groin region. A small hernia may reduced by itself and becomes irreducible if bigger. If it get obstructed, it may cut off the blood supply and lead to dead bowel.

How to approach an inguinal hernia?

It occurs more in men and elderly although women also get affected. It is due to the weakness of the lower abdominal muscles. Most patients will have a background diseases such as benign prostatic hyperplasia, chronic coughing and constipation. Condition such as overweight/ obesity and prolonged standing may also lead to hernias.

Symptoms and signs

Common symptoms are swelling over the inguinal that may or not be reducible. Others include:

  • pain or discomfort at the swelling
  • swelling of the scrotum (due to descent of bowel within the scrotum)
  • pain during straining, sports or bending down
  • unable to open bowel or pass flatus (may suggest obstruction and need urgent medical attention)

A physician may find a small and reducible swelling or a large and irreducible. It depends on severity of the condition and integrity of the hernia content.

Physical examination

The aim in physical examination of a hernia is to:

  • Identify whether it is a hernia
  • Type of hernia (inguinal/ femoral)
  • Classify the inguinal hernia

Identification of a hernia

Always start with inspection. We suggest to start in standing position to get the best findings. Look for:

  • location of the swelling (limited to groin or extending to scrotum)
  • skin changes
  • bowel movements within the scrotum
  • surgical scars
  • ask the patient to cough to demonstrate a visible cough impulse (first time)

An inguinal hernia is found above and medial to the pubic tubercle while a femoral hernia is below and lateral to the pubic tubercle. This is an important anatomical landmark to differentiate both hernias in a clinical setting.

Ask the patient whether he can reduce the swelling himself. DO NOT reduce for him without asking first. If you do that and patient is in pain that is ground for examination failure and dismissal. You may ask the patient to lie down at this point. Palpate gently looking for:

  • are you able to get above the swelling
  • is the swelling extend down to the scrotum
  • is both testis palpable
  • any bag of worms sensation
  • ask the patient to cough to demonstrate palpable impulse (second time)

Auscultation should focus on identify any bowel sounds or bruit within the swelling.

Special test

Deep occlusion test is perform while patient is lying down. Ask the patient to reduce the swelling. Locate the deep inguinal ring (this is the location between ASIS and pubic tubercle known as midpoint of inguinal ligament). Apply pressure to this location and ask the patient to cough for the final time (third time). If the swelling reappears, it is a direct hernia. If not, it passes through the deep ring hence an indirect hernia.

Complete your examination with examining the contralateral groin and digital rectal examination (you may just say it during the examination)

Tips:

  1. In an obvious inguinal hernia, some examiner may allow students to examine in a lying position.
  2. Practice to perform examination with asking patient to cough only 3 times. Asking more than that may irritate the patient and worse the examiners.
  3. Students confuse between the midpoint of inguinal ligament and mid inguinal point. to recap:
    1. Mid point of inguinal ligament – ASIS to pubic tubercle; location of deep inguinal ring
    2. Mid inguinal point – ASIS to pubic symphysis; location of femoral artery
  4. Hernia is bread and butter of surgery. Do not fumble. Students should able to perform well if they get this in exams.

Image courtesy from Trakarnsagna A, Chinswangwatanakul V, Methasate A, et al.  International Journal of Surgery Case Reports. 2014;5(11):868-872. doi:10.1016/j.ijscr.2014.10.042

For more reading, you can read here.

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