What is the likely diagnosis and treatment for a 22-year-old with pain and bulging in the right groin area?

Right Groin Pain with Bulging in a 22-Year-Old: Inguinal Hernia

The most likely diagnosis is an inguinal hernia, and surgical mesh repair is the recommended treatment for this symptomatic 22-year-old patient. 1, 2, 3

Diagnosis

Clinical Presentation

• Inguinal hernias typically present with groin swelling accompanied by pain or a dragging sensation, which matches this patient's presentation 1
• The bulging may disappear when lying down (prone position) and worsen with physical activity or straining 2
• Patients often describe a burning, gurgling, or aching sensation in the groin, with a heavy or dragging sensation that worsens toward the end of the day 2
• In young males aged 20-60, inguinal hernia is the most common cause of groin pain with visible bulging 4

Physical Examination

• Examination should involve palpating for a bulge or impulse while the patient coughs or performs a Valsalva maneuver 2
• The history and physical examination are usually sufficient to make the diagnosis in the vast majority of patients 2, 3
• Check for tenderness over the inguinal canal, which is present in many hernia cases 5

Imaging (If Needed)

• Imaging is rarely warranted when clinical findings are clear 2
• Ultrasonography may be indicated if the diagnosis is uncertain, if there is no palpable impulse or bulge despite symptoms, or to differentiate from other causes of groin swelling 1, 2
• MRI can help diagnose occult hernias in athletes without palpable findings 2

Important Differential Diagnoses to Exclude

• Hip-related pain (femoroacetabular impingement syndrome, acetabular dysplasia) - but these typically lack visible bulging 4
• Perianal/perirectal abscess - presents with pain, swelling, and systemic symptoms, more common in males aged 20-60, but located more posteriorly 4
• Adductor-related, iliopsoas-related, or pubic-related groin pain - these do not present with bulging 4

Treatment Recommendation

Surgical Repair is Indicated

• Symptomatic inguinal hernias should be treated surgically 3
• Surgical repair is advised because of the danger of incarceration and strangulation 1
• At age 22, watchful waiting is not appropriate as this strategy is only considered for asymptomatic or minimally symptomatic patients, and even then most will eventually require surgery 3

Surgical Technique Selection

• Mesh repair is recommended as first choice, either by open procedure (Lichtenstein) or laparoscopic repair 3
• For a young, active 22-year-old, laparoscopic techniques offer faster recovery times, lower chronic pain risk, and quicker return to normal activities 3
• The Lichtenstein open mesh repair under local anesthesia is also highly effective and well-evaluated 3
• Both anterior and posterior approach options should be available, with technique selection based on surgeon expertise and patient factors 3

Specific Considerations for This Patient

• Young age is a risk factor for chronic postoperative inguinal pain (CPIP), so nerve recognition during open surgery is important 3
• Day surgery is appropriate for the majority of groin hernia repairs 3
• The patient should be counseled that they can resume normal activities without restrictions as soon as comfortable postoperatively 3

Expected Outcomes

• Following initial herniorrhaphy, complication and recurrence rates are generally low 1
• Overall chronic pain incidence is 10-12%, with debilitating pain affecting daily activities ranging from 0.5-6% 3
• Laparoscopic repair allows faster return to work and normal activities 1, 3

Common Pitfalls to Avoid

• Do not dismiss groin pain without a clearly palpable bulge - occult inguinal hernias can cause significant pain and may require imaging for diagnosis 5
• Do not delay surgical referral in symptomatic patients, as prolonged conservative management increases patient suffering and may lead to complications 5
• Ensure proper mesh fixation technique is used based on hernia type to minimize recurrence risk 3