What is the initial management of an adult presenting with right‑sided inguinal pain?

Initial Management of Right Inguinal Pain in Adults

Begin with CT abdomen and pelvis with IV contrast as the definitive first-line imaging study, as this achieves 95% sensitivity and 94% specificity for appendicitis and identifies alternative diagnoses in 23-45% of cases, which is critical since right inguinal pain has a broad differential diagnosis beyond appendiceal pathology. 1, 2

Immediate Pre-Imaging Steps

Before ordering imaging, complete these essential actions:

• Obtain beta-hCG in all women of reproductive age to exclude ectopic pregnancy and guide contrast decisions 1, 2
• Establish NPO status and initiate IV fluid resuscitation to prepare for potential surgical intervention 2
• Document pain onset, migration pattern (periumbilical to right lower quadrant suggests appendicitis), fever, and presence of peritoneal signs 1
• Obtain surgical consultation immediately if clinical suspicion for appendicitis is high, without waiting for imaging 2

Why CT Over Ultrasound

CT abdomen and pelvis with IV contrast is superior to ultrasound for initial evaluation because:

• Ultrasound has highly variable sensitivity (21-95.7%) depending on operator experience and patient body habitus, with the appendix not visualized in 20-81% of cases 3
• Equivocal ultrasound results require CT anyway, resulting in diagnostic delay without avoiding radiation 3
• CT identifies the full spectrum of pathology including diverticulitis, bowel obstruction, malignancy, and vascular emergencies in a single study 3, 2

Reserve ultrasound only for pregnant patients or when gynecologic pathology is the primary concern in women of reproductive age, using combined transabdominal and transvaginal approach 3

Critical Differential Diagnoses Beyond Appendicitis

Right inguinal pain has multiple etiologies that CT can differentiate:

Gastrointestinal Causes

• Right-sided colonic diverticulitis (increasingly common with age, mimics appendicitis precisely) 3
• Bowel obstruction (85% sensitivity for adhesions if prior abdominal surgery) 3
• Colorectal malignancy (accounts for 60% of large bowel obstructions in elderly) 3, 2
• Crohn disease, cecal diverticulitis 2

Gynecologic Causes (Women)

• Ectopic pregnancy (hence mandatory beta-hCG) 2
• Ovarian torsion, tubo-ovarian abscess, ruptured ovarian cyst, pelvic inflammatory disease 2

Urologic Causes

• Ureteral stones, urinary tract infection 1

Hernia-Related Pain

• Chronic postoperative inguinal pain (if prior hernia repair history) 4, 5
• Incarcerated inguinal hernia 6

Post-CT Management Algorithm

If CT Confirms Appendicitis:

• Initiate broad-spectrum IV antibiotics immediately covering anaerobic bacteria 2
• Obtain immediate surgical consultation for appendectomy 2
• Do not delay surgery for oral contrast or additional imaging 1

If CT Shows Right-Sided Diverticulitis:

• IV antibiotics, bowel rest, surgical consultation if complicated (perforation, abscess) 2

If CT Shows Bowel Obstruction:

• Nasogastric decompression, IV fluids, surgical consultation 3
• Consider malignancy if elderly with no prior surgery history 3

If CT Shows Gynecologic Pathology:

• Obtain gynecology consultation for ovarian torsion (surgical emergency), tubo-ovarian abscess, or ectopic pregnancy 2

If CT Shows Chronic Postoperative Inguinal Pain (Prior Hernia Repair):

• Initiate multimodal pain management with NSAIDs (ibuprofen 400mg every 4-6 hours) 7
• Refer to pain management team for nerve blocks if conservative measures fail after several months 5
• Consider referral to dedicated hernia surgeon for triple neurectomy if refractory to conservative treatment (98.5% report pain improvement, 70.2% report >50% reduction) 4, 5, 8

Common Pitfalls to Avoid

• Never assume normal laboratory values exclude serious pathology in elderly patients, who frequently have normal white blood cell counts despite perforation or serious infection 3, 2
• Do not delay CT for oral contrast administration in suspected appendicitis, as IV contrast alone provides equivalent diagnostic accuracy 1, 2
• Do not limit CT to pelvis only, as this misses 7% of surgical pathology located in the abdomen 1
• Recognize atypical presentations in elderly patients, who lack classic symptoms, have blunted inflammatory responses, and present later with higher complication rates 3, 2
• In young women, distinguish between appendicitis and pelvic visceral disease by eliciting precise pain location—right-sided low inguinal pain may be referred from pelvic organs (T10-L2 innervation) rather than appendiceal origin 6