Indirect Inguinal Hernia
The most likely diagnosis is an indirect inguinal hernia (Option C). This patient's presentation of inguinoscrotal swelling that worsens with increased intra-abdominal pressure (coughing, prolonged standing) and is manually reducible is classic for an indirect inguinal hernia that extends through the inguinal canal into the scrotum 1, 2.
Clinical Reasoning
Why Indirect Inguinal Hernia is Most Likely
Inguinoscrotal extension is the defining feature that distinguishes this from other hernia types—indirect inguinal hernias follow the path of the spermatic cord through the internal inguinal ring and can descend into the scrotum, while direct inguinal hernias typically do not extend beyond the superficial inguinal ring 1, 3.
Provocation with coughing and standing indicates the hernia responds to increased intra-abdominal pressure, which forces abdominal contents through a patent processus vaginalis in indirect hernias 1, 4.
Manual reducibility confirms the hernia is not incarcerated or strangulated, which is consistent with an uncomplicated indirect inguinal hernia 2, 3.
Why Other Options Are Less Likely
Direct inguinal hernias (Option D) protrude through a weakness in the posterior inguinal wall (Hesselbach's triangle) and rarely extend into the scrotum—they typically present as a bulge in the groin that does not descend into the scrotal sac 4.
Femoral hernias (Option B) occur below the inguinal ligament through the femoral canal and present as a bulge in the upper medial thigh, not as inguinoscrotal swelling 2, 4.
Lacunar hernias (Option A) are a specific subtype of femoral hernia that protrudes through the lacunar ligament and would not present with scrotal extension 4.
Key Diagnostic Features to Confirm
Bilateral examination should be performed, as contralateral patent processus vaginalis occurs in up to 64% of cases, particularly in younger patients 1.
Palpation of the external inguinal ring while the patient coughs or performs a Valsalva maneuver will reveal an impulse that originates lateral to the inferior epigastric vessels (characteristic of indirect hernias) 3, 4.
Assessment for complications including irreducibility, tenderness, erythema, or systemic symptoms (fever, tachycardia) is crucial to rule out incarceration or strangulation 1, 2.
Management Implications
Surgical referral is indicated for all symptomatic inguinal hernias to prevent complications such as incarceration and strangulation 1, 2, 4.
Mesh repair is the standard of care with significantly lower recurrence rates compared to tissue repair, and can be performed via open (Lichtenstein) or laparoscopic (TEP/TAPP) approaches 2, 4.
Urgent repair within 1-2 weeks is recommended once diagnosed, as the risk of incarceration exists even in reducible hernias 1.
Common Pitfalls to Avoid
Do not assume all groin swelling is benign—always assess for signs of incarceration (firm, tender, irreducible mass with skin changes) or strangulation (systemic symptoms, peritoneal signs) that require emergency intervention 2.
In women with groin hernias, carefully distinguish inguinal from femoral hernias, as femoral hernias carry an 8-fold higher risk of requiring bowel resection and should be repaired promptly 2.
Imaging is rarely needed for diagnosis when physical examination findings are classic, but ultrasound or MRI may be helpful in uncertain cases or when evaluating for complications 3, 4.