What is the evaluation and management approach for a patient with suspected inguinal hernia?

Evaluation for Possible Inguinal Hernia

History and physical examination are sufficient to diagnose inguinal hernia in the vast majority of patients, with imaging reserved for specific clinical scenarios. 1, 2

Clinical Assessment

Key History Elements

• Groin pain is the most common presenting symptom, which may be burning, gurgling, or aching in character 1
• Pain often worsens toward the end of the day and after prolonged activity 1
• Patients may report a heavy or dragging sensation in the groin 1
• Visible bulge that may disappear when lying down 1
• Assess for symptoms beyond the groin: genital pain, urinary symptoms, abdominal pain, and increased peristalsis can all be associated with inguinal hernias 3

Physical Examination Technique

• Palpate for a bulge or impulse while the patient coughs or strains 1, 2
• Examine both groins bilaterally, as contralateral hernias are common (64% in infants under 2 months, 25-50% in children with patent processus vaginalis) 4
• In males, palpate the testis to ensure it is present in the scrotum and not involved in the hernia 4
• Do not miss femoral hernias, which have a higher risk of strangulation and are more common in women 4, 5

Critical Red Flags for Complications

Immediately assess for signs of incarceration or strangulation, as these require emergency intervention:

• Irreducibility of the hernia 4
• Tenderness, erythema, or warmth over the hernia site 4, 6
• Systemic symptoms: fever, tachycardia, leukocytosis (SIRS criteria) 7
• Abdominal wall rigidity 7
• Laboratory markers: elevated lactate, CPK, and D-dimer levels are predictive of bowel strangulation 7

Diagnostic Imaging

When Imaging is Indicated

Imaging is rarely warranted in straightforward cases but should be obtained in specific scenarios 1:

• Ultrasonography is the first-line imaging modality when:

  • Physical examination is equivocal or negative despite high clinical suspicion 1, 2
  • Evaluating women with suspected groin hernias (diagnosis is more difficult on physical exam) 2
  • Assessing for recurrent hernia or suspected hydrocele 1
  • Evaluating surgical complications 1

• MRI has higher sensitivity and specificity than ultrasound and should be used:

  • For diagnosing occult hernias in athletes without palpable bulge or impulse 1, 2
  • When ultrasound is negative but clinical suspicion remains high 2

• CT scan with contrast is indicated in emergency settings:

  • To assess for complications like bowel obstruction or strangulation 4
  • CT has 56% sensitivity and 94% specificity for reduced wall enhancement predicting bowel strangulation 4

Management Approach

Non-Emergent Cases

• Watchful waiting is a reasonable option for men with asymptomatic or minimally symptomatic inguinal hernias, as the risk of hernia-related emergencies is low 2, 5
• Watchful waiting is not recommended in symptomatic patients or non-pregnant women 2, 5
• Patients should be counseled that the majority will eventually require surgery 5

Emergency Cases

Patients with suspected intestinal strangulation should undergo emergency hernia repair immediately 7, 4

Critical timing considerations:

• Delayed treatment beyond 24 hours is associated with significantly higher mortality rates 7, 8
• Symptomatic periods lasting longer than 8 hours significantly affect morbidity rates 7
• Time from onset to surgery is the most important prognostic factor 7

Surgical Referral

• All infant inguinal hernias require urgent surgical referral for repair within 1-2 weeks of diagnosis to prevent bowel incarceration and gonadal infarction 4
• Symptomatic adult hernias should be referred for surgical evaluation 5

Common Pitfalls to Avoid

• Failing to examine both sides for hernias can result in missing contralateral hernias 4
• Missing femoral hernias, particularly in women, which have higher strangulation risk 4, 5
• Not assessing for complications requiring urgent intervention (incarceration, strangulation) 4
• Delaying evaluation when any signs of strangulation are present can lead to severe complications and increased mortality 4, 8
• Assuming that physical features of the hernia (size, ease of reduction) predict incarceration risk—they do not consistently correlate 4, 6