What is the step-by-step process for a clinical examination of an inguinal hernia?

Clinical Examination of Inguinal Hernia

The clinical examination for inguinal hernia should focus on visual inspection for a bulge that increases with coughing or straining, palpation of the inguinal canal while the patient performs a Valsalva maneuver, and bilateral groin assessment to detect both obvious and occult hernias. 1

Patient Positioning and Preparation

• Examine the patient in both standing and supine positions, as hernias may be more apparent when standing due to increased intra-abdominal pressure 1
• Have the patient undress to expose both groins completely for bilateral comparison 1
• Ensure adequate lighting and a warm room to facilitate patient comfort and muscle relaxation 1

Step-by-Step Examination Process

Visual Inspection

• Look for a visible bulge in the inguinal region that extends from above the inguinal ligament and may descend into the scrotum in males or the labia in females 1
• Ask the patient to cough or strain while observing for a bulge that appears or enlarges with increased intra-abdominal pressure 1
• Observe both groins simultaneously to compare symmetry, as 64% of infants under 2 months have bilateral involvement 1
• Note any redness, warmth, or swelling over the hernia site, which may indicate strangulation requiring emergency intervention 1

Palpation Technique

• Place your examining finger at the external inguinal ring (located just above and lateral to the pubic tubercle) 1
• In males, gently invaginate the scrotal skin to follow the spermatic cord upward into the inguinal canal 1
• Ask the patient to cough or perform a Valsalva maneuver while your finger is in position to feel for an impulse or bulge pushing against your fingertip 1
• Palpate for tenderness along the inguinal canal, as patients with occult hernias are twice as likely to have tenderness even without a visible bulge 2
• The "silk sign" or "silk glove sign" is pathognomonic: scrotal contents retract inward on coughing as herniated contents are forced back through the inguinal canal 1

Testicular Examination in Males

• Palpate both testes to ensure they are present in the scrotum and not involved in the hernia 1
• Distinguish between a hernia and a hydrocele by transillumination if needed 1
• Assess for testicular descent and position, as undescended testes may be confused with inguinal masses 1

Bilateral Assessment

• Always examine both groins, even if the patient reports unilateral symptoms, as contralateral patent processus vaginalis occurs in 64% of infants younger than 2 months 1
• Failing to examine both sides is a common pitfall that can miss bilateral disease 1

Assessment for Complications

• Evaluate for signs of incarceration or strangulation: irreducibility, severe tenderness, erythema, or systemic symptoms like fever or tachycardia 1
• Check for signs of bowel obstruction: nausea, vomiting, abdominal distension, or absence of flatus 1
• Assess for systemic inflammatory response syndrome (SIRS), which commonly indicates strangulated obstruction 1, 3
• Attempt gentle reduction if the hernia is incarcerated but not strangulated; never force reduction if there is concern for strangulation 1

Special Considerations for Occult Hernias

• In patients with chronic groin pain but no visible bulge, maintain high suspicion for occult hernia, particularly in females, younger patients, and those with higher BMI 2
• Tenderness over the inguinal canal on palpation is twice as common in occult hernias and should prompt further investigation 2
• These patients often have prolonged preoperative pain and higher opioid use, with 83% symptom resolution after repair 2

Advanced Diagnostic Maneuvers

• The inguinal occlusion test combined with handheld Doppler to locate epigastric vessels can differentiate direct (79% accuracy) from indirect hernias (93% accuracy), which is useful for surgical planning 4
• This technique is more accurate than physical examination alone, which has only 35% accuracy for direct hernias 4

Common Pitfalls to Avoid

• Missing femoral hernias, which have a higher risk of strangulation and are located below and lateral to the pubic tubercle 1
• Failing to assess for complications requiring urgent intervention, as delayed treatment beyond 24 hours significantly increases mortality 1, 5
• Dismissing groin pain without a bulge as non-hernia pathology, when 44% of hernia repairs may be for occult hernias 2
• Not examining the contralateral side, missing bilateral disease in up to 64% of young infants 1