What is the appropriate evaluation and management for a patient presenting with painful inguinal hernia?

Evaluation and Management of Painful Inguinal Hernia

All symptomatic inguinal hernias causing pain should undergo urgent surgical referral for repair within 1-2 weeks, with immediate assessment for signs of incarceration or strangulation that would require emergency intervention. 1

Immediate Assessment for Complications

Your first priority is determining whether this is a surgical emergency requiring same-day intervention:

Red flags requiring emergency surgery include: 1, 2

• Constant pain (versus intermittent reducible pain) indicating progression from simple hernia to incarceration/strangulation 2
• Irreducibility of the hernia bulge 1
• Overlying skin changes: erythema, warmth, or swelling 1
• Abdominal wall rigidity - a critical red flag 1
• Systemic symptoms: fever, tachycardia, leukocytosis (signs of SIRS) 1, 2
• Abdominal tenderness - especially concerning if the hernia spontaneously reduced, as ischemic bowel may now be in the abdomen 2

Critical pitfall: If a previously palpable hernia is no longer present but the patient has new constant pain and abdominal tenderness, this suggests spontaneous reduction of strangulated bowel - the hernia may have auto-reduced with compromised bowel still in the abdomen requiring emergency diagnostic laparoscopy. 2

Laboratory Evaluation for Suspected Strangulation

When clinical concern exists for strangulation, obtain: 1

• Arterial lactate (≥2.0 mmol/L predicts non-viable bowel) 1
• Serum creatinine phosphokinase (CPK) 1
• D-dimer levels 1
• White blood cell count (elevated WBC moderately predictive of strangulation) 1
• Fibrinogen levels (can predict morbidity in incarcerated hernias) 1

Important caveat: Do not delay surgical exploration for laboratory results if clinical suspicion is high - time from symptom onset to surgery is the most important prognostic factor, with symptomatic periods >8 hours significantly affecting morbidity and delayed treatment >24 hours associated with higher mortality. 1, 2, 3

Physical Examination Specifics

Examine both groins bilaterally - contralateral hernias occur in 11-50% of cases and femoral hernias (which have higher strangulation risk) can be missed. 1

Key examination findings: 4

• Palpate for bulge or impulse while patient coughs or strains 4
• Assess reducibility - have patient lie supine to see if bulge disappears 4
• In males, palpate the testis to ensure it's in the scrotum and not involved in the hernia 1
• Check for tenderness over the inguinal canal 1

Characteristic pain patterns include: 4

• Burning, gurgling, or aching sensation in the groin 4
• Heavy or dragging sensation worsening toward end of day and after prolonged activity 4

Imaging Decisions

Physical examination alone is sufficient for diagnosis in the vast majority of patients. 4

Imaging is indicated when: 1, 4

• Emergency setting with suspected bowel obstruction or strangulation: CT with contrast (56% sensitivity, 94% specificity for reduced wall enhancement predicting strangulation) 1
• High body mass index or prior groin surgery where physical exam is unreliable: CT is preferred 1
• Occult hernia with high clinical suspicion despite negative exam: MRI for difficult-to-assess inguinal regions 1
• Recurrent hernia or suspected hydrocele when diagnosis is uncertain 4

Critical warning: Imaging should never delay surgical exploration when strangulation is suspected clinically - the clinical picture warrants urgent surgery and CT would only delay definitive management. 2

Surgical Referral Timing

For uncomplicated symptomatic hernias: Urgent surgical referral for repair within 1-2 weeks 1

For complicated hernias requiring emergency intervention: 2

• Unsuccessful manual reduction - immediate surgery 2
• Suspected strangulation - immediate surgery 2
• Successful manual reduction of incarcerated hernia - same-admission surgery 2

Pre-operative Counseling

Discuss surgical approach options: 1, 5

• Mesh repair is recommended as first choice (either open or laparoscopic) 5
• Laparoscopic approaches (TEP or TAPP) offer faster recovery, lower chronic pain risk, and are cost-effective when expertise is available 1, 5
• Open Lichtenstein repair remains an excellent option 5
• Choice depends on patient factors (age, comorbidities), hernia characteristics, and surgeon expertise 1

Activity Restrictions Pending Surgery

Patients should avoid activities that increase intra-abdominal pressure to prevent incarceration and strangulation while awaiting repair. 2 The goal is preventing complications that would necessitate emergency surgery with higher complication rates. 2

Special Consideration for Bilateral Examination

During laparoscopic TAPP repair, the contralateral side should be inspected after patient consent, as contralateral patent processus vaginalis occurs frequently. 1 This is particularly relevant given the 11-50% rate of occult contralateral hernias. 1