What is the approach to diagnose inguinal (in the groin area) hernia?

Diagnostic Approach to Inguinal Hernia

The diagnosis of inguinal hernia primarily relies on a detailed physical examination of the groin area, with ultrasonography being the first-line imaging modality when the diagnosis is uncertain, particularly in women, children, and cases of suspected recurrent hernias. 1

Clinical Assessment

Physical Examination

• Inspect and palpate the groin area while the patient is standing and supine
• Look for:
  • Visible bulge or asymmetry in the groin area
  • Palpable impulse during coughing or Valsalva maneuver
  • Tenderness over the inguinal canal (twice as likely in occult hernias) 2
• Record the morphology, size, and location of any lesion 3
• Note that patients with occult hernias may have groin pain without a visible bulge 2

History Taking

• Assess for common symptoms:
  • Groin pain (may be severe)
  • Burning, gurgling, or aching sensation in the groin
  • Heavy or dragging sensation that worsens by end of day or after activity
  • Pain distribution pattern and quality 1
  • Exacerbating and relieving factors 1
• Note that symptoms may be present for a longer duration in patients with occult hernias 2

Imaging Studies

Ultrasonography

• First-line imaging when diagnosis is uncertain after physical examination
  • Sensitivity: 92.7%, Specificity: 81.5% 1
• Particularly useful for:
  • Female patients (where physical examination is less reliable) 4
  • Suspected recurrent hernias 5, 4
  • Evaluation of complications 1
  • Differentiating hernia from hydrocele or other groin masses 5

Magnetic Resonance Imaging (MRI)

• Higher sensitivity and specificity than ultrasonography 4
• Indicated when:
  • Clinical suspicion remains high despite negative ultrasound findings 4
  • Uncertainty regarding corporal invasion 3
  • Athletes without palpable impulse or bulge 5

Other Diagnostic Considerations

• Perform inguinal ultrasound before dynamic sentinel node biopsy if planned 3
• Herniography (injecting contrast media into the hernial sac) may be used in selected patients 4

Types of Inguinal Hernias

Classification

• Indirect inguinal hernias: Result from patent processus vaginalis (>90% in boys) 1
  • Higher frequency on the right side (60% of cases) 1
• Direct inguinal hernias: Protrusion through a weakness in the posterior wall of the inguinal canal

Common Pitfalls to Avoid

• Failing to distinguish between direct and indirect inguinal hernias 1
• Relying solely on physical examination in women and children, which can lead to missed diagnoses 1
• Overlooking occult hernias, especially in:
  • Female patients (who are more likely to have occult hernias) 2
  • Younger patients with higher BMI 2
  • Patients with groin pain but no visible bulge 2
• Dismissing groin pain without bulge, which may lead to prolonged suffering and increased opioid use 2

Special Considerations

• Obtain a pretreatment biopsy when malignancy is suspected or when nonsurgical treatment is planned 3
• Consider that 83% of patients with occult hernias experience symptom resolution after repair 2
• Be aware that laparoscopic repair is associated with shorter recovery time, less pain, and lower recurrence rates than open repair in many cases 4

Remember that although most hernias are repaired, surgical intervention is not always necessary for small, minimally symptomatic hernias 5. However, watchful waiting is not recommended for patients with symptomatic hernias or for nonpregnant women 4.