Workup for Possible Inguinal Hernia
The workup for a possible inguinal hernia should begin with a thorough physical examination, which alone can confirm the diagnosis in the vast majority of patients with appropriate signs and symptoms, while ultrasound should be used when the diagnosis is uncertain or in female patients. 1
Initial Clinical Evaluation
Physical Examination
- Inspect the groin area for visible bulge while patient is standing
- Have patient perform Valsalva maneuver (cough or strain) to elicit hernia
- Palpate the inguinal canal and external ring for bulge or impulse
- Assess for reducibility of any palpable mass
- Evaluate for tenderness or signs of incarceration/strangulation
Key History Elements
- Duration and progression of symptoms
- Pain characteristics (timing, severity, exacerbating factors)
- History of heavy lifting or straining activities
- Previous abdominal surgeries
- Family history of hernias
- Risk factors:
- Family history
- Previous contralateral hernia
- Male gender
- Advanced age
- Abnormal collagen metabolism
- History of prostatectomy
- Low body mass index 2
Imaging Studies
Ultrasound
- Indicated when:
- Diagnosis is uncertain after physical examination
- Female patients (to avoid missing femoral hernias)
- Suspected recurrent hernia
- Evaluation of surgical complications after repair
- Suspected alternative cause of groin pain (e.g., hydrocele) 1
- Benefits:
- Non-invasive
- No radiation exposure
- Can be performed dynamically (during Valsalva)
- Can differentiate between various groin pathologies
Magnetic Resonance Imaging (MRI)
- Consider when:
- Clinical suspicion remains high despite negative ultrasound
- Complex cases requiring detailed anatomical evaluation
- Higher sensitivity (94.5%) and specificity (96.3%) compared to ultrasound (92.7% and 81.5% respectively) 3
- Particularly useful for occult hernias
Other Imaging Modalities
- Dynamic CT scan: Alternative when MRI is contraindicated
- Herniography (injecting contrast media into hernial sac): May be used in selected patients with unclear diagnosis 1
Classification and Risk Stratification
- The European Hernia Society (EHS) classification system should be used to stratify patients for tailored treatment, research, and audit 2
- Risk factors for complications (incarceration/strangulation) that require urgent attention:
- Female gender
- Femoral hernia
- History of hospitalization related to groin hernia 2
Management Decision-Making
Indications for Surgical Referral
- Symptomatic hernias should be treated surgically
- Asymptomatic or minimally symptomatic male patients may be managed with "watchful waiting" initially, though most will eventually require surgery
- All femoral hernias should be repaired promptly due to higher risk of complications
- All symptomatic hernias in women should be repaired, preferably using laparoscopic approach 2
Surgical Approach Considerations
- Laparoscopic repair is associated with:
- Open repair may be more appropriate for:
- Patients over 65 years (4.18 times more likely to have open repair)
- Patients on anticoagulants (38.8 times more likely to have open repair)
- Large inguinoscrotal hernias 5
Common Pitfalls to Avoid
- Relying solely on physical examination in women (may miss femoral hernias)
- Failing to consider alternative diagnoses (e.g., lymphadenopathy, hydrocele, varicocele)
- Delaying surgical referral for femoral hernias (higher risk of complications)
- Not recognizing signs of strangulation requiring emergency intervention
- Overlooking bilateral hernias (consider laparoscopic evaluation of contralateral side during TAPP procedure) 2
By following this systematic approach to the workup of possible inguinal hernias, clinicians can ensure accurate diagnosis and appropriate management decisions, minimizing the risk of complications and optimizing patient outcomes.