From the Guidelines
The workup for inguinal hernia pain should begin with a thorough history and physical examination, focusing on the groin area to identify any visible or palpable bulge that increases with Valsalva maneuver, and patients with suspected intestinal strangulation should undergo emergency hernia repair immediately 1.
Key Components of Workup
- Physical examination should include assessment while the patient is both standing and supine, with digital examination of the inguinal canal.
- Imaging studies are not routinely required but may include ultrasound as the first-line imaging modality due to its accessibility, lack of radiation, and high sensitivity for hernias.
- CT scan may be considered in complex cases or when other pathologies are suspected, and can help identify signs of bowel strangulation, such as reduced wall enhancement 1.
- Laboratory tests are generally not necessary unless complications like strangulation are suspected, in which case complete blood count and basic metabolic panel may be ordered to assess for signs of infection or bowel compromise.
Pain Management and Definitive Treatment
- Pain management during workup may include NSAIDs like ibuprofen 400-600mg every 6 hours or acetaminophen 500-1000mg every 6 hours.
- Definitive treatment is typically surgical repair, and patients should be referred to a surgeon for evaluation, especially if the hernia is symptomatic, enlarging, or shows signs of incarceration or strangulation (severe pain, nausea, vomiting, or irreducibility), which constitute surgical emergencies 1.
Role of Laparoscopy
- Diagnostic laparoscopy may be a useful tool with the target of assessing bowel viability after spontaneous reduction of strangulated groin hernias, and can help prevent unnecessary laparotomy 1.
- Laparoscopic repair of incarcerated hernias can be performed in the absence of strangulation and suspicion of the need of bowel resection, and has been shown to have acceptable results and lower wound infection rates compared to open repair 1.
From the Research
Diagnosis of Inguinal Hernia
- The diagnosis of inguinal hernia is usually made through history and physical examination, which are usually sufficient to make the diagnosis 2.
- Physical examination involves feeling for a bulge or impulse while the patient coughs or strains 2.
- Imaging is rarely warranted, but ultrasonography or magnetic resonance imaging can help diagnose a hernia in an athlete without a palpable impulse or bulge on physical examination 2, 3.
- Ultrasonography is also helpful when a recurrent hernia, surgical complication after repair, or other cause of groin pain is suspected 2, 4.
Role of Ultrasonography
- Ultrasonography has emerged as the most convenient imaging tool for diagnosing inguinal hernia due to its advantages, such as portability and absence of radiation 3.
- Ultrasonography is an accurate method for evaluating inguinal hernias, with high sensitivity making it particularly suitable for ruling out an inguinal hernia when the findings are negative 5.
- The diagnostic value of ultrasonography for inguinal hernias can influence the decision for or against surgery 5.
Management of Inguinal Hernia
- Symptomatic groin hernias should be treated surgically 4, 6.
- Asymptomatic or minimally symptomatic male inguinal hernia patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low 4, 6.
- Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics, and local/national resources 6.
- Mesh repair is recommended as the first choice, either by an open procedure or a laparo-endoscopic repair technique 6.