From the Guidelines
Diagnosing direct hernias primarily involves a thorough physical examination, potentially supplemented by imaging studies like ultrasound, to accurately assess the hernia and guide management decisions. The physical examination should be conducted while the patient is standing and lying down, asking them to cough or strain to make the hernia more visible or palpable [ 1 ]. Direct hernias are characterized by their location in the medial groin area, just above the inguinal ligament, and they typically protrude directly forward through a weakness in the transversalis fascia in Hesselbach's triangle. Unlike indirect hernias, direct hernias usually do not descend into the scrotum and may reduce spontaneously when the patient lies down.
Key points to consider during the physical examination include:
- The invagination test, where a finger is placed into the external inguinal ring and the patient is asked to cough; a direct hernia will push against the side of the finger rather than the tip.
- The presence of a bulge in the medial groin area that becomes more pronounced with coughing or straining.
- The differentiation from indirect hernias, which tend to have a more lateral location and may extend into the scrotum.
If the physical examination is inconclusive, ultrasound is recommended as the initial imaging modality due to its accessibility, lack of radiation, and dynamic assessment capabilities during Valsalva maneuvers [ 1 ]. Ultrasound can provide valuable information about the size, location, and reducibility of the hernia, which are crucial for planning surgical intervention. In complex cases or when detailed anatomical information is required, CT or MRI may be considered [ 1 ].
The accurate diagnosis of direct hernias is essential because it has implications for management, including the potential need for surgical repair, especially if the hernia is symptomatic or at risk of complications [ 1 ].
From the Research
Diagnosis of Direct Hernias
To diagnose direct hernias, the following methods can be used:
- Physical examination: easily diagnosed on physical examination in men 2
- Ultrasonography: often needed in women, helpful when a recurrent hernia, surgical complication after repair, or other cause of groin pain is suspected 2
- Magnetic resonance imaging: has higher sensitivity and specificity than ultrasonography, useful for diagnosing occult hernias if clinical suspicion is high despite negative ultrasound findings 2
- Herniography: involves injecting contrast media into the hernial sac, may be used in selected patients 2
- History and physical examination: aided by ultrasound interrogation of the groin, can establish a diagnosis of athlete's hernia, a type of direct inguinal hernia 3
Characteristics of Direct Hernias
Direct hernias have the following characteristics:
- Caused by a defect of the abdominal wall in the groin area 2
- More common in men 2
- Can be equivalent to an early direct inguinal hernia found in young athletes, such as athlete's hernia 3
- May present as chronic inguinal pain in elite athletes, such as athlete's hernia 3
Treatment Options
Treatment options for direct hernias include:
- Open repair: can be used for large direct inguinal hernia repairs, but may have higher recurrence rates and more post-operative pain compared to laparoscopic repair 4, 5
- Laparoscopic repair: associated with shorter recovery time, earlier resumption of activities of daily living, less pain, and lower recurrence rates than open repair 2, 4
- Robotic repair: may have similar outcomes to open and laparoscopic repair, but can be more expensive and have a longer operative time 4, 5
- Watchful waiting: a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias, but not recommended in patients with symptomatic hernias or in nonpregnant women 2