What is the appropriate workup and management for a patient presenting with an inguinal hernia?

Inguinal Hernia Workup

For uncomplicated inguinal hernias, diagnosis is made by physical examination alone in the vast majority of cases, with imaging reserved only for uncertain diagnoses, suspected complications, or when physical examination is equivocal. 1, 2

Clinical Assessment

History

• Assess for symptoms indicating complications requiring urgent intervention: 3
  • Groin pain severity and character (burning, gurgling, aching sensation) 1
  • Heavy or dragging sensation worsening toward end of day 1
  • Red flags for strangulation: irreducibility, severe tenderness, erythema, fever, tachycardia, nausea/vomiting 3
  • Duration of symptoms (>8 hours significantly increases morbidity) 3

Physical Examination

• Examine both groins bilaterally to identify occult contralateral hernias (present in 11-50% of cases) 4, 3
• Palpate for bulge or impulse while patient coughs or strains in standing position 1
• Check if bulge disappears when patient is supine 1
• In males: palpate testis to ensure it is present in scrotum and not involved in hernia 3
• In females: examine for femoral hernias, which carry 8-fold higher risk of requiring bowel resection 4
• Signs of incarceration/strangulation requiring emergency intervention: 3
  • Abdominal wall rigidity
  • Systemic inflammatory response syndrome (SIRS) criteria
  • Inability to reduce hernia
  • Overlying skin changes

Laboratory Workup

Laboratory testing is NOT routinely indicated for uncomplicated inguinal hernias. 1

For suspected strangulation, obtain: 4

• Arterial lactate (≥2.0 mmol/L predicts non-viable bowel) 5
• Serum creatinine phosphokinase (CPK) 4
• D-dimer levels 4
• White blood cell count (elevated WBC moderately predictive of strangulation) 5
• Fibrinogen (high levels predict morbidity in incarcerated hernias) 5

Imaging

When Imaging is NOT Needed

• Physical examination alone is sufficient in the vast majority of patients with typical signs and symptoms 1, 2

When to Order Imaging

Ultrasonography is indicated for: 1, 2

• Uncertain diagnosis on physical examination
• Suspected recurrent hernia
• Suspected hydrocele or other groin mass
• Women with groin symptoms (physical examination less reliable) 2
• Athletes without palpable impulse or bulge 1
• Postoperative complications 1

CT scanning with contrast is indicated for: 5, 4

• Emergency settings with suspected bowel obstruction or strangulation (56% sensitivity, 94% specificity for reduced wall enhancement predicting strangulation) 5, 3
• Assessment of size, extent, and structures in proximity to palpable inguinal lymph nodes 5
• Evaluation when incarceration suspected but diagnosis uncertain 5

MRI is indicated for: 2

• Occult hernias when clinical suspicion is high despite negative ultrasound findings (higher sensitivity and specificity than ultrasonography) 2
• Difficult-to-assess inguinal regions (e.g., morbid obesity, previous surgery/radiation) 5

Herniography (contrast injection into hernial sac) may be used: 2

• Selected patients with persistent symptoms and negative non-invasive imaging 2

Risk Stratification

Classify hernias to guide urgency and approach: 4

Emergent (Immediate Surgery Required)

• Strangulated hernia with signs of bowel compromise 4, 3
• Systemic symptoms (fever, tachycardia, leukocytosis) 3
• Lactate ≥2.0 mmol/L 5
• CT findings of reduced bowel wall enhancement 5
• Delayed treatment >24 hours associated with significantly higher mortality 3

Urgent (Surgery Within 1-2 Weeks)

• Incarcerated but not strangulated hernia 4
• All infant inguinal hernias (to prevent bowel incarceration and gonadal infarction) 3

Elective

• Reducible, symptomatic hernias 4
• Asymptomatic or minimally symptomatic hernias in males may be managed with watchful waiting (low risk of hernia-related emergencies, though majority eventually require surgery) 6, 2
• Watchful waiting NOT recommended in women (higher risk of femoral hernias with strangulation) 6, 2

Common Pitfalls to Avoid

• Failing to examine both groins bilaterally and missing occult contralateral hernias (11-50% incidence) 4, 3
• Missing femoral hernias in women, which have higher strangulation risk 3
• Delaying evaluation when any signs of strangulation present (time from onset to surgery is most important prognostic factor) 3
• Relying on hernia size or ease of reduction to predict incarceration risk (physical features do not consistently predict risk) 3
• Ordering routine imaging for straightforward clinical diagnoses 1