How do I check for an inguinal hernia?

How to Examine for an Inguinal Hernia

Examine the patient standing and ask them to cough or strain while you palpate the inguinal canal for a bulge or impulse—this physical examination alone is usually sufficient to diagnose an inguinal hernia. 1, 2

Physical Examination Technique

Patient Positioning and Initial Assessment

• Position the patient standing for optimal examination, as an abdominal bulge may disappear when the patient is prone 3
• Examine both groins bilaterally in every patient, as contralateral hernias occur in 11-50% of cases and contralateral patent processus vaginalis occurs in 64% of infants younger than 2 months 1, 2

Palpation Technique

• Feel for a bulge or impulse while the patient coughs or strains, which increases intra-abdominal pressure and makes the hernia more apparent 3
• Palpate along the inguinal canal from the internal ring to the external ring 1
• In males, palpate the testis to ensure it is present in the scrotum and not involved in the hernia, as an undescended testis may be mistaken for an inguinal hernia 1, 2

Key Clinical Signs to Identify

Look for the "silk sign" (silk glove sign) in pediatric patients—scrotal contents retract inward on coughing or straining, which is pathognomonic for an inguinal hernia with a patent processus vaginalis 1

Assess for an inguinal bulge that increases with crying or straining and may extend into the scrotum in males or labia in females 1

Critical Red Flags Requiring Urgent Assessment

Immediately assess for signs of incarceration or strangulation, which require emergency intervention 1:

• Irreducibility of the hernia
• Tenderness over the hernia
• Erythema or overlying skin changes 1
• Abdominal wall rigidity 1
• Systemic symptoms: fever, tachycardia, leukocytosis 1

Common Pitfalls to Avoid

• Do not fail to examine below the inguinal ligament—you must differentiate femoral hernias from inguinal hernias, as femoral hernias have a higher risk of strangulation and require urgent surgical intervention 2
• Do not examine only one side—always examine both groins bilaterally 1, 2
• Do not miss complications—assess for incarceration or strangulation signs that require urgent intervention 1, 2

When to Use Imaging

Clinical examination is usually sufficient for diagnosis 2, but imaging is indicated in specific situations:

Ultrasound (First-Line Imaging)

• Use ultrasound when clinical examination is uncertain, with sensitivity of 92-97% and specificity of 77-81.5% 2, 4
• Indicated for recurrent hernias, suspected hydroceles, or surgical complications 2, 3
• Particularly useful to differentiate hydroceles from inguinal hernias when diagnosis is uncertain 2
• Performance is highly dependent on operator expertise 4

MRI (Second-Line Imaging)

• Consider MRI when ultrasound results are equivocal, with 94.5% sensitivity and 96.3% specificity 2
• Indicated for occult hernias in athletes without a palpable bulge or impulse on physical examination 1, 3

CT Scanning (Emergency Settings Only)

• Use CT with contrast in emergency settings to assess for complications like bowel obstruction or strangulation 1, 2
• CT can predict bowel strangulation with 56% sensitivity and 94% specificity for reduced wall enhancement 1

Symptom Assessment

Ask about characteristic symptoms that support the diagnosis 3, 5:

• Groin pain (may be severe)
• Burning, gurgling, or aching sensation in the groin
• Heavy or dragging sensation that worsens toward end of day and after prolonged activity
• Genital pain, urinary symptoms, abdominal pain 5