How do you describe an inguinal hernia in a physical assessment?

Physical Assessment of Inguinal Hernia

When performing a physical assessment of an inguinal hernia, the examiner should systematically evaluate for a visible or palpable bulge in the inguinal region that may increase with Valsalva maneuver, and determine whether it is direct or indirect by using the inguinal occlusion test combined with Doppler localization of epigastric vessels.

Key Components of Physical Assessment

Visual Inspection

• Look for visible bulge or asymmetry in the inguinal region
• Note the location relative to anatomical landmarks:
  • Indirect hernias: lateral to the pubic tubercle, may extend into scrotum
  • Direct hernias: medial to the pubic tubercle
• Observe for changes in the bulge with position changes (standing vs. lying)

Palpation Technique

• Perform examination with patient both standing and supine
• For males:
  • Insert index finger into the scrotum and invaginate the scrotal skin to reach the external inguinal ring
  • Follow the spermatic cord upward toward the internal ring
  • Ask patient to cough or perform Valsalva maneuver to elicit hernia
• For females:
  • Palpate over the inguinal canal and pubic tubercle
  • Note that diagnosis by physical examination alone may be less accurate, often requiring imaging 1

Distinguishing Direct vs. Indirect Hernias

• Inguinal occlusion test combined with Doppler device:
  • Locate the epigastric vessels using a handheld Doppler
  • Apply pressure over the internal ring (lateral to epigastric vessels)
  • If bulge disappears with pressure, likely an indirect hernia
  • If bulge persists despite pressure, likely a direct hernia
  • This combined approach has shown 79% accuracy for direct and 93% accuracy for indirect hernias 2

Advanced Assessment Findings

Characteristics to Document

• Reducibility: Can the hernia contents be returned to the abdominal cavity?
• Tenderness: Pain on palpation may indicate inflammation or incarceration
• Size: Document dimensions of the hernia
• Content: Bowel loops, omentum, or reproductive organs (ovary in females) 3
• Skin changes: Erythema or discoloration suggesting strangulation

Signs of Complications

• Irreducibility/incarceration: Inability to reduce the hernia
• Strangulation: Severe tenderness, erythema, fever, nausea/vomiting
• Bowel obstruction: Distention, absent bowel sounds, nausea/vomiting

Special Considerations

Occult Inguinal Hernias

• Patients may present with groin pain without visible bulge
• More common in females, younger patients, and those with higher BMI
• Physical exam may reveal tenderness over the inguinal canal without obvious bulge
• Imaging studies are necessary for confirmation 4

Pediatric Considerations

• In children, indirect hernias represent more than 90% of cases
• Assess for patent processus vaginalis
• Note that incidence is higher in premature infants (13%) compared to term infants (3-5%) 1

Pitfalls to Avoid

• Failing to distinguish between direct and indirect hernias
• Overlooking systemic causes of groin swelling (heart failure, portal hypertension)
• Relying solely on physical examination in women and children without confirmatory imaging
• Missing occult hernias in patients with groin pain but no visible bulge 1

When physical examination findings are equivocal, ultrasonography is recommended as the first-line imaging modality with sensitivity of 92.7% and specificity of 81.5%. MRI may be necessary for occult hernias if clinical suspicion remains high despite negative ultrasound findings 1, 5.