Inguinal Hernias: Diagnosis and Management

 

Am Fam Physician. 2020 Oct 15;102(8):487-492.

  Patient information: See related handout on inguinal (groin) hernias, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Groin hernias are caused by a defect of the abdominal wall in the groin area and comprise inguinal and femoral hernias. Inguinal hernias are more common in men. Although groin hernias are easily diagnosed on physical examination in men, ultrasonography is often needed in women. Ultrasonography is also helpful when a recurrent hernia, surgical complication after repair, or other cause of groin pain (e.g., groin mass, hydrocele) is suspected. Magnetic resonance imaging has higher sensitivity and specificity than ultrasonography and is useful for diagnosing occult hernias if clinical suspicion is high despite negative ultrasound findings. Herniography, which involves injecting contrast media into the hernial sac, may be used in selected patients. Becoming familiar with the common types of surgical interventions can help family physicians facilitate postoperative care and assess for complications, including recurrence. Laparoscopic repair is associated with shorter recovery time, earlier resumption of activities of daily living, less pain, and lower recurrence rates than open repair. Watchful waiting is a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias. Watchful waiting is not recommended in patients with symptomatic hernias or in nonpregnant women.

Hernias are a common reason for primary care physicians to refer patients for surgical management. There are many different types of hernias, with most occurring in the abdomen or groin. The term groin hernia comprises three types of hernias depending on location relative to the inguinal (Hesselbach) triangle (Figure 11): direct inguinal, indirect inguinal, and femoral. A direct inguinal hernia is a protrusion of tissue through the posterior wall of the inguinal canal, medial to the inferior epigastric vessels (Figure 21), whereas an indirect inguinal hernia protrudes through the internal inguinal ring, lateral to the inferior epigastric vessels (Figure 31). A femoral hernia is the protrusion of tissue below the inguinal ligament, medial to the femoral vessels.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Ultrasonography can be used to diagnose occult groin hernias.17

B

Systematic review of lower-quality studies

Watchful waiting is reasonable and safe in men if the patient's usual activities are not limited by pain and discomfort and there is no difficulty reducing the hernia.20

A

Randomized controlled trial

Laparoscopic hernia repair is associated with shorter recovery, earlier resumption of activities of daily living, and less pain compared with open repair.29

A

Systematic review of randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Ultrasonography can be used to diagnose occult groin hernias.17

B

Systematic review of lower-quality studies

Watchful waiting is reasonable and safe in men if the patient's usual activities are not limited by pain and discomfort and there is no difficulty reducing the hernia.20

A

Randomized controlled trial

Laparoscopic hernia repair is associated with shorter recovery, earlier resumption of activities of daily living, and less pain compared with open repair.29

A

Systematic review of randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN SURGERY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Avoid the routine use of ultrasonography in evaluating a clinically apparent inguinal hernia.

Society of American Gastrointestinal and Endoscopic Surgeons


Source: For more information on the Choosing Wisely Campaign, see https://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN SURGERY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Avoid the routine use of ultrasonography in evaluating a clinically apparent inguinal hernia.

Society of American Gastrointestinal and Endoscopic Surgeons


Source: For more information on the Choosing Wisely Campaign, see https://www.choosingwisely.org. For supporting citations and to search Choosing

The Authors

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AMER SHAKIL, MD, MBA, FAAFP, is a professor in the Department of Family and Community Medicine at the University of Texas Southwestern Medical Center, Dallas....

KIMBERLY APARICIO, MD, is an assistant professor in the Department of Family and Community Medicine at the University of Texas Southwestern Medical Center.

ELIZABETH BARTA, DO, is a resident in the Department of Family and Community Medicine at the University of Texas Southwestern Medical Center.

KRISTAL MUNEZ, MD, is a resident in the Department of Family and Community Medicine at the University of Texas Southwestern Medical Center.

Address correspondence to Amer Shakil, MD, MBA, FAAFP, University of Texas Southwestern Medical Center, 5920 Forest Park Rd., Ste. 601, Dallas, TX 75235 (email: amer.shakil@utsouthwestern.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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