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Inguinal Hernias: Diagnosis andManagementKIM EDWARD LeBLANC, MD, PhD; LEANNE L. LeBLANC, MD; and KARL A. LeBLANC, MD, MBALouisiana State University School of Medicine, New Orleans, LouisianaInguinal hernias are one of the most common reasons a primary care patient may need referral for surgical intervention. The history and physical examination are usually sufficient to make the diagnosis. Symptomatic patients oftenhave groin pain, which can sometimes be severe. Inguinal hernias may cause a burning, gurgling, or aching sensationin the groin, and a heavy or dragging sensation may worsen toward the end of the day and after prolonged activity.An abdominal bulge may disappear when the patient is in the prone position. Examination involves feeling for a bulgeor impulse while the patient coughs or strains. Although imaging is rarely warranted, ultrasonography or magneticresonance imaging can help diagnose a hernia in an athlete without a palpable impulse or bulge on physical examination. Ultrasonography may also be indicated with a recurrent hernia or suspected hydrocele, when the diagnosisis uncertain, or if there are surgical complications. Although most hernias are repaired, surgical intervention is notalways necessary, such as with a small, minimally symptomatic hernia. If repair is necessary, the patient should becounseled about whether an open or laparoscopic technique is best. Surgical complications and hernia recurrencesare uncommon. However, a patient with a recurrent hernia should be referred to the original surgeon, if possible.(Am Fam Physician. 2013;87(12):844-848. Copyright 2013 American Academy of Family Physicians.) Patient information:A handout on this topic,written by the authorsof this article, is available at http://www.aafp.org/afp/2013/0615/p844-s1.html. Access tothe handout is free andunrestricted.CME This clinical contentconforms to AAFP criteriafor continuing medicaleducation (CME). See CMEQuiz on page 833.Author disclosure: No relevant financial affiliations.Hernia is a general term describing a bulge or protrusion ofan organ or tissue throughan abnormal opening withinthe anatomic structure. Although thereare many different types of hernias, theyare usually related to the abdomen, withapproximately 75% of all hernias occurringin the inguinal region.1 Abdominal wall hernias account for 4.7 million ambulatory carevisits annually. More than 600,000 surgicalrepairs for inguinal hernias are performednationwide each year,2 making it one of themost common general surgical proceduresperformed in the United States.Inguinal hernias have a 9:1 male predominance,3 with a higher incidence amongmen 40 to 59 years of age. It has been estimated that more than one-fourth of adultmen in the United States have a medicallyrecognizable inguinal hernia.4 Men with adiagnosed hiatal hernia have been shownto have double the risk of an inguinal hernia. Among women, taller height, chroniccough, umbilical hernia, older age, and ruralresidence have been associated with a higherincidence of inguinal hernia. Neither smoking nor alcohol use has been shown to affecthernia occurrence. Several studies havedemonstrated that men who are overweightor obese have a lower risk of inguinal herniathan men of normal weight.4,5Although this article focuses on inguinalhernias, other diagnostic possibilities shouldbe considered in a patient with groin pain(Table 1). In athletes, groin pain most commonly results from an overuse injury associated with adductor tendons and muscles,and a specific differential diagnosis shouldbe considered in these patients (Table 2).6,7Any mass palpated in the inguinal regionshould prompt a thorough clinical evaluation because there are many possible diagnoses (Table 3).Symptoms and Physical FindingsThe diagnosis of an inguinal hernia is usually made through history and physicalexamination findings. Although data arelimited, in one report, the sensitivity andspecificity of the physical examination were75% and 96%, respectively.8Symptoms of an inguinal hernia mayappear gradually over time or develop suddenly, as with incarceration (i.e., the contentsof the hernia sac cannot be returned to the June 15, 2013844 AmericanPhysicianwww.aafp.org/afp87, Number12 private,Downloadedfrom theFamilyAmericanFamily Physician website at www.aafp.org/afp.Copyright 2013 American Academy ofVolumeFamily Physicians.For thenoncommercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

Inguinal Herniasabdominal cavity). Inguinal hernias may be asymptomatic and found incidentally on routine physical examination. Symptomatic patients often present with groinpain, which can be severe. Stretching or tearing of thetissue at and around the hernia defect can lead to a burning, gurgling, or aching sensation in the groin. This usually causes localized pain directly at the site of the hernia.Pain may worsen with Valsalva maneuvers. Patients mayTable 1. Differential Diagnosisof Groin PainAdhesionsAppendicitisAthletic pubalgia (sports hernia)Diverticulosis/diverticulitisHip pathology (osteoarthritis,avascular necrosis offemoral head)Inflammatory bowel diseaseLumbar disk diseaseMeralgia parestheticaPelvic pathology (osteitispubis, adductor strain)ProstatitisTesticular disordersUrinary tract infectionTable 2. Differential Diagnosis of Groin Painin AthletesDiagnosisClinical presentationAvulsion fracturesHistory of sudden or forceful musclecontraction, tenderness over bonyprominence, ecchymosesHistory of trauma or fall, suddenonsetHistory of sudden onset duringmuscle contractionAssociated paresthesias ornumbnessTenderness over symphysis pubisAssociated findings in these areasLigamentous sprainsMuscle strainsNerve entrapmentsyndromesOsteitis pubisReferred pain fromlumbar, hip, orsacroiliac areaSports herniaStress fracturesTendinopathiesHistory of high-intensity athleticactivity, typical symptoms ofhernia with no evidence onphysical examination, painwith forced adduction againstexaminer’s resistanceHistory of repetitive motion activityor overuse, tenderness over bonePain with motion and contraction ofspecific muscleInformation from references 6 and 7.June 15, 2013 Volume 87, Number 12experience a heavy or dragging sensation in the groin,especially toward the end of the day and after prolongedactivity.1 Activities that increase intra-abdominal pressure, such as coughing, lifting, or straining, cause moreabdominal contents to be pushed through the herniadefect. As this occurs, the bulge of the hernia graduallyincreases in size. If the patient indicates that this bulgedisappears while he or she is in the supine position, clinical suspicion of a hernia should be increased.Hernias may be easily diagnosed with an adequatephysical examination. The physical examination shouldbegin by carefully inspecting the femoral and inguinalareas for bulges while the patient is standing. Then, thepatient should be asked to strain down (i.e., Valsalvamaneuver) while the physician observes for bulges. Thismay be accomplished by using the right hand to examine the patient’s right side and the left hand to examine the patient’s left side. The physician invaginates theloose skin of the scrotum with the indexChronic pain is the mostfinger on the ipsilatcommon long-termeral side of the patient,issue after hernia repair.starting at a point lowenough on the scrotum to reach as far as the internal inguinal ring. Startingon the scrotum, the examining finger follows the spermatic cord upward above the inguinal ligament to thetriangular, slit-like opening of the external inguinal ring.The external inguinal ring is medial to and just belowthe pubic tubercle. The inguinal canal is gently followedlaterally in its oblique course. While the examining finger is in the canal next to the internal inguinal ring, thepatient strains down or coughs as the physician feels forany palpable herniation.9 The diagnosis of an inguinalhernia is confirmed if an “impulse” or bulge is felt.If no bulge is detected with a Valsalva maneuver, ahernia is unlikely. However, athletic pubalgia (sportshernia) may be considered in athletes with groin painand no bulge. A sports hernia is not a true hernia, butrather a tearing of tissue fibers. This typically occurs inpatients with a history of high-intensity athletic activity.Although these patients have typical hernia symptoms,there is no evidence on physical examination. Furtherfollow-up and reexamination are needed to diagnose asports hernia. Pain along the symphysis pubis suggestsosteitis pubis, whereas pain along the adductor tendonssuggests adductor tendinopathy.It is more challenging to diagnose a hernia in femalepatients. Direct palpation with an open hand overthe groin area might detect the impulse of a herniaduring a Valsalva maneuver. However, further workupwww.aafp.org/afp American Family Physician 845