What is the appropriate evaluation and management protocol for a male patient presenting with an abdominal hernia?

Evaluation and Management Protocol for Abdominal Hernia in Males

For a male patient presenting with an abdominal hernia, perform a focused physical examination targeting a palpable bulge that enlarges with coughing or Valsalva, examine both groins bilaterally to avoid missing contralateral or femoral hernias, and obtain contrast-enhanced CT abdomen/pelvis with IV contrast if complications are suspected or the diagnosis is uncertain. 1

Initial Clinical Assessment

History and Physical Examination

• Target specific findings during examination: 1

  • Palpable bulge that enlarges with coughing or Valsalva maneuver
  • Assess reducibility of the hernia by attempting gentle manual reduction
  • Examine for the "silk sign" (scrotal contents retracting inward on coughing), which is pathognomonic for inguinal hernia with patent processus vaginalis 1

• Always examine both groins bilaterally to avoid missing contralateral hernias (occur in 11-50% of cases) or femoral hernias, which carry higher strangulation risk 1

• Assess for complications requiring urgent intervention: 1

  • Irreducibility (inability to reduce the hernia manually)
  • Tenderness over the hernia
  • Erythema or overlying skin changes (redness, warmth, swelling)
  • Abdominal wall rigidity (critical red flag)
  • Systemic symptoms: fever, tachycardia, or signs of sepsis

• Quantify symptom duration: Symptoms persisting >8 hours significantly increase morbidity and mandate urgent evaluation 1

Laboratory Testing

Routine laboratory tests are unnecessary for uncomplicated hernias. 1 However, if strangulation is suspected, obtain:

• Complete blood count: Elevated white blood cell count offers moderate predictive value for strangulation 1
• Arterial lactate level: ≥2.0 mmol/L predicts non-viable bowel (this is the only laboratory parameter strongly associated with non-viable bowel) 1
• Serum fibrinogen: Can help predict morbidity in incarcerated hernias 1

Critical caveat: A normal lactate does not exclude ischemia 1

Imaging Protocol

When Imaging is Indicated

• Imaging is NOT required for uncomplicated, reducible hernias that can be diagnosed clinically 2

• Obtain imaging when: 1, 2

  • Complications suspected (incarceration, strangulation, bowel obstruction)
  • Diagnosis uncertain on physical examination
  • Patient is obese or has history of prior groin surgery (physical exam unreliable)
  • Internal hernia suspected (cannot be diagnosed clinically)

Preferred Imaging Modality

Contrast-enhanced CT abdomen and pelvis with IV contrast is the imaging modality of choice 1, 2

• Sensitivity: 14-82% for diaphragmatic hernias; higher for other abdominal wall hernias 2
• Specificity: 87% 2

CT provides critical information: 2

• Hernia location and size of defect
• Hernial contents
• Complications: obstruction, ischemia, perforation
• Discontinuity of abdominal wall
• "Collar sign" (constriction at hernia defect)
• Signs of bowel ischemia: wall thickening, pneumatosis, lack of contrast enhancement

Key CT finding for strangulation: Reduced bowel wall enhancement has 56% sensitivity and 94% specificity for predicting strangulation 1

Alternative Imaging Considerations

• Ultrasound: May be useful for initial evaluation in some cases, but CT is superior for detecting complications 3
• MRI: Reserved for occult hernias when clinical suspicion is high despite negative ultrasound, or in pregnant patients to avoid radiation 1, 3

Management Algorithm

Uncomplicated Hernias (No Red Flags)

Refer for elective surgical repair within 1-2 weeks 1

• Prosthetic (mesh) repair is the preferred treatment for most uncomplicated inguinal hernias in adult males 1
• Choice between open and laparoscopic approach depends on patient factors, hernia characteristics, and surgeon expertise 1
• Laparoscopic approaches (TEP or TAPP) are viable options 1

Complicated Hernias (Red Flags Present)

Immediate (same-day) surgical referral is required for: 1

• Any signs of strangulation or incarceration:

  • Irreducible hernia with tenderness or erythema
  • Systemic symptoms (fever, tachycardia, leukocytosis)
  • Elevated lactate ≥2.0 mmol/L

• Peritonitis or abdominal wall rigidity

• Hemodynamic instability

• Symptoms persisting >8 hours with concerning features

Emergency hernia repair should be performed immediately when intestinal strangulation is suspected, as delayed treatment beyond 24 hours is associated with significantly higher mortality 1

Special Considerations

Internal Hernias

• Cannot be diagnosed clinically and require CT for diagnosis 2
• CT is the only reliable method to identify internal hernias before progression to strangulation 2
• Maintain low threshold for diagnostic laparoscopy if symptoms persist despite negative CT 2

Post-Bariatric Surgery Patients

• CT with both oral and IV contrast is mandatory due to altered anatomy 2
• Negative CT does not rule out internal hernia in this population 2
• Maintain low threshold for diagnostic laparoscopy if clinical suspicion persists 2

Rare Variants

• Amyand's hernia (appendix within inguinal hernia sac) carries 14-30% mortality if complicated by appendicitis and peritoneal sepsis 4
• Consider this diagnosis in males with right inguinal hernia and abdominal pain 4

Common Pitfalls to Avoid

• Failing to examine both groins bilaterally and missing contralateral or femoral hernias 1
• Delaying evaluation when any signs of strangulation are present 1
• Relying on normal lactate alone to exclude ischemia 1
• Not assessing for complications that require urgent intervention 1
• Ordering imaging for straightforward, reducible hernias that can be diagnosed clinically 2