What is the recommended examination and management approach for an adult male patient presenting with symptoms of an inguinal hernia?

Inguinal Hernia Examination and Management in Adult Males

For adult males presenting with suspected inguinal hernia, diagnosis is primarily clinical through physical examination demonstrating a groin bulge that increases with coughing or straining, and surgical mesh repair is recommended for symptomatic hernias, while watchful waiting is acceptable only for asymptomatic or minimally symptomatic cases. 1, 2, 3

Physical Examination Technique

The examination should focus on specific maneuvers and findings:

• Inspect both groins while the patient stands and coughs or performs a Valsalva maneuver, looking for a visible bulge in the inguinal region that may extend into the scrotum 1, 4
• Palpate for an impulse by placing fingers over the external inguinal ring while the patient coughs—a palpable impulse indicates hernia 2, 4
• Examine both sides bilaterally even if symptoms are unilateral, as bilateral hernias are common and require different surgical planning 1, 3
• Assess below the inguinal ligament to exclude femoral hernia, which has higher strangulation risk and requires urgent intervention 1, 5
• Evaluate for reducibility by attempting gentle reduction with the patient supine—irreducibility suggests incarceration 1

Critical Red Flags Requiring Emergency Intervention

Immediately assess for complications that necessitate urgent surgery:

• Irreducibility of the hernia mass 1
• Tenderness, erythema, or warmth over the hernia site 1, 6
• Systemic symptoms including fever, tachycardia, leukocytosis, or signs of systemic inflammatory response syndrome (SIRS) 1, 6
• Abdominal wall rigidity indicating peritonitis 1
• Symptomatic duration >8 hours significantly increases morbidity risk 1, 6

Patients with any signs of strangulation require emergency hernia repair immediately, as delayed treatment beyond 24 hours is associated with significantly higher mortality rates. 1, 6

Diagnostic Imaging—When and What to Order

Clinical examination alone is sufficient in the vast majority of male patients with typical presentation 2, 4, 3:

• Ultrasonography is first-line imaging when diagnosis is uncertain, for recurrent hernias, or suspected complications, with sensitivity of 92-97% 5, 2, 4
• CT scanning with contrast should be obtained in emergency settings when strangulation is suspected—reduced bowel wall enhancement has 56% sensitivity and 94% specificity for strangulation 1
• MRI is reserved for occult hernias when clinical suspicion remains high despite negative ultrasound, with 94.5% sensitivity and 96.3% specificity 5, 7

Common pitfall: Do not order imaging routinely for straightforward cases, as this delays treatment and increases costs without improving outcomes 2, 3

Management Algorithm

For Asymptomatic or Minimally Symptomatic Hernias:

Watchful waiting is a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias, as the risk of hernia-related emergencies is low. 2, 3, 8

• Counsel patients that the majority will eventually require surgery 3
• Advise avoiding activities that increase intra-abdominal pressure 1
• Watchful waiting is NOT recommended for women due to higher femoral hernia risk 2, 3

For Symptomatic Hernias:

All symptomatic inguinal hernias should undergo surgical mesh repair. 1, 3

Surgical approach selection:

• Laparoscopic repair (TEP or TAPP) is preferred when expertise is available, offering shorter recovery time, less chronic pain (10-12% vs higher with open), earlier return to activities, and lower recurrence rates 1, 2, 3
• Open Lichtenstein mesh repair is acceptable for primary unilateral hernias in men, particularly when laparoscopic expertise is unavailable 7, 3
• Bilateral hernias should preferentially undergo laparoscopic repair 7, 3
• Tissue repair (Shouldice technique) may be offered only after extensive patient counseling about higher recurrence rates compared to mesh 3

Timing of surgery:

• Elective repair within 1-2 weeks for uncomplicated symptomatic hernias 1
• Emergency repair immediately for any signs of incarceration or strangulation 1, 6
• Day surgery is recommended for the majority of cases provided aftercare is organized 3

Anesthesia Considerations

• Local anesthesia is recommended for open repair when surgeon expertise exists, offering many advantages 3
• General anesthesia is preferred over regional in patients ≥65 years, as it is associated with fewer complications including myocardial infarction, pneumonia, and thromboembolism 3
• Perioperative field blocks should be used in all open repairs to reduce postoperative pain 3

Common Pitfalls to Avoid

• Missing femoral hernias by failing to examine below the inguinal ligament—these have higher strangulation risk 1, 5
• Delaying evaluation when any signs of strangulation are present—symptomatic periods >8 hours significantly worsen outcomes 1, 6
• Not examining the contralateral side—bilateral disease is common and changes surgical planning 1, 3
• Assuming physical features predict incarceration risk—hernia size and ease of reduction do not consistently predict complications 1, 6

Postoperative Management

• Patients should resume normal activities without restrictions as soon as comfortable 3
• Monitor for chronic postoperative inguinal pain (CPIP), defined as bothersome moderate pain lasting ≥3 months—overall incidence is 10-12%, with debilitating pain affecting daily activities in 0.5-6% 3
• Recurrence after anterior repair should be managed with posterior approach, and vice versa 3