What are the treatment options for a male patient with bulging and pain in the right groin area, potentially indicating an inguinal hernia?

Treatment of Male Patient with Right Groin Bulging and Pain

For a male patient presenting with bulging and pain in the right groin, surgical repair with mesh is the definitive treatment, with laparoscopic approaches (TAPP or TEP) offering advantages of reduced postoperative pain, lower wound infection rates, and faster return to normal activities compared to open repair. 1

Initial Assessment and Diagnosis

The presentation of bulging and pain in the right groin is highly consistent with an inguinal hernia, which affects males in 94% of cases. 2 The diagnosis is typically made through history and physical examination alone, without requiring imaging in most cases. 3

Key examination findings to assess:

• Palpable bulge or impulse during coughing or straining 3
• Tenderness over the inguinal canal (present in twice as many patients with hernias) 4
• Whether the bulge disappears when the patient lies prone 3
• Groin pain that may be burning, gurgling, or aching in nature, often worsening toward end of day 3, 5

Important caveat: Even without a visible bulge, occult inguinal hernias can cause significant groin pain and represent 44% of all inguinal hernia repairs. 4 These patients are more likely to have prolonged pain and increased opioid use if diagnosis is delayed. 4

Urgency Determination

Critical decision point: Determine if the hernia is reducible or incarcerated/strangulated, as this dictates urgency. 1

• Reducible hernia: Elective repair can be scheduled 1
• Incarcerated/strangulated hernia: Emergency surgical repair is mandatory to prevent bowel necrosis, with delayed diagnosis beyond 24 hours associated with significantly higher mortality rates 1, 6

Warning signs of strangulation requiring immediate surgery:

• Systemic inflammatory response syndrome (SIRS) 1
• Elevated lactate, CPK, and D-dimer levels 1
• Obvious peritonitis 1
• Symptoms lasting longer than 8 hours 6

Surgical Approach Selection

For uncomplicated, reducible inguinal hernias (the most likely scenario):

Mesh repair is strongly recommended as the standard approach due to significantly lower recurrence rates (0% with mesh vs 19% with tissue repair) without increased infection risk. 1

Laparoscopic vs Open Repair

Laparoscopic repair (TAPP or TEP) is preferred when feasible and offers multiple advantages:

• Significantly lower postoperative pain requiring less pain medication 1, 2
• Significantly lower wound infection rates (p<0.018) 1
• Faster return to normal activities (p<0.001) 1, 2
• Ability to identify occult contralateral hernias present in 11.2-50% of cases 1
• No increase in recurrence rates compared to open repair (p<0.815) 1
• Shorter hospitalization (p<0.005) 2

Open repair may be preferred when:

• Patient has significant comorbidities limiting ability to tolerate general anesthesia 1
• Local anesthesia is desired (possible with open approach) 1
• Laparoscopic expertise is not available 1

Both TAPP and TEP demonstrate comparable outcomes with low complication rates, though TAPP may be easier in recurrent cases. 1

Special Considerations for Emergency Presentation

If the hernia is incarcerated without strangulation:

• Prosthetic repair with synthetic mesh is recommended (Grade 1A) 1
• Laparoscopic approach is appropriate when no suspicion of bowel necrosis exists 1
• Hernioscopy (laparoscopy through hernia sac) can assess bowel viability, decreasing hospital stay and preventing unnecessary laparotomies 1

If strangulation is suspected or confirmed:

• Open preperitoneal approach is preferable when bowel resection may be needed 1
• General anesthesia is required 1
• For small defects (<3 cm) with bowel necrosis, primary repair is recommended 1
• Synthetic mesh can still be used even with intestinal strangulation if there is no gross enteric spillage 1

Postoperative Monitoring

Monitor for these complications:

• Wound infection 1
• Chronic pain 1
• Recurrence 1
• Testicular complications in males 1

Common Pitfalls to Avoid

Do not delay repair once diagnosis is made. Delaying surgical repair increases risk of incarceration and strangulation, which significantly increases morbidity and mortality. 1, 6, 7 Mortality rates are substantially higher when treatment is delayed beyond 24 hours. 1

Do not dismiss groin pain without a palpable bulge. Occult inguinal hernias cause significant suffering and 83% symptom resolution can be achieved with repair. 4 These patients often have prolonged pain and increased opioid use when diagnosis is delayed. 4

Do not overlook contralateral hernias. Consider laparoscopic approach to identify occult contralateral hernias present in up to 50% of cases. 1