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

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

This clinical content conforms to AAFP criteria for CME.

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.

RecommendationSponsoring organization
Avoid the routine use of ultrasonography in evaluating a clinically apparent inguinal hernia.Society of American Gastrointestinal and Endoscopic Surgeons

In the United States, 1.6 million groin hernias are diagnosed annually, and 700,000 are repaired surgically.2 The lifetime prevalence of groin hernias is 27% in men and 3% in women.3 The frequency of groin hernia repair rises from 0.25% in patients 18 years of age to 4.2% in patients 75 to 80 years of age.3

In the United States, approximately 96% of groin hernias are inguinal hernias, about 20% of which are bilateral.1 Femoral hernias comprise the remaining 4% of groin hernias and are more common in women (16% to 37% of women).4 Risk factors for inguinal hernias include a family history of the condition, male sex, older age, low body mass index, systemic connective tissue disease, and history of radical prostatectomy or radiation therapy.58 In women, inguinal hernias have also been associated with taller height, chronic cough, umbilical hernia, and rural residence.6 No association has been found between smoking or alcohol use and hernias.4

Presentation

Patients with a groin hernia may report a bulge in the groin that becomes progressively larger over time. Most patients with groin hernias report pain or vague discomfort, but up to one-third of patients have no symptoms.9 Symptoms may worsen with standing, straining, lifting, or coughing. These movements increase intra-abdominal pressure, causing intra-abdominal contents to be pushed through a hernial defect.10 Patients may report having symptoms only at the end of the day or after prolonged activity and that the bulge disappears when they are lying flat. However, the absence of a reducible mass or palpable defect does not rule out a hernia. In a subset of patients, groin or pelvic pain is caused by an occult, or hidden, hernia.

Groin pain, if present, is described as a dull aching, pulling, or burning sensation. Localized discomfort may develop from stretching or tearing of the tissue at or around the site of the hernial defect. As this occurs, the hernia usually increases in size. Severe pain could suggest that the hernia has become incarcerated and may require emergent surgical intervention. Table 110,11 and Table 210 list other diagnoses to consider in patients presenting with groin pain with or without a scrotal mass. However, asymptomatic hernias may be found incidentally on physical examination.

Visceral
Abdominal hernia
Adhesion
Appendicitis
Diverticulosis
Inguinal or femoral hernia
Testicular torsion
Varicocele
Associated with the hip
Acetabular labral tear and femoroacetabular impingement
Avascular necrosis
Iliotibial band syndrome
Osteoarthritis
Snapping hip syndrome and iliopsoas tendinitis
Infectious
Abscess
Diverticulitis
Herpes infection
Osteomyelitis
Septic arthritis
Urinary tract infection
Inflammatory
Endometriosis
Epididymitis and orchitis
Inflammatory bowel disease
Pelvic inflammatory disease
Prostatitis
Synovitis
Traumatic
Muscle contusion
Stress fracture
Tendon avulsion
Neurologic
Nerve compression syndrome
Referred pain (sacroiliitis, hamstring pain, knee pain)
DiagnosisClinical presentation
Ectopic testisAbsence of a testis in the scrotum
EpididymitisSevere pain surrounding the testis, tenderness, fever, chills
Femoral adenitis/adenopathyBilateral, firm, tender nodes; fever
Femoral arterial aneurysmOlder patient, pulsatile mass, no systemic symptoms
HematomaAssociated trauma, ecchymoses, tenderness, no change with Valsalva maneuver
HidradenitisDraining abscesses in intertriginous skin of the groin
HydroceleMass in the scrotum or inguinal canal that transilluminates
Inguinal adenitis/adenopathyTenderness and redness possible, often bilateral, systemic symptoms
Inguinal or femoral herniaBulge or impulse detected in inguinal canal with Valsalva maneuver or coughing
LipomaSoft, asymptomatic mass; does not change in size
LymphomaFirm, tender mass; may increase in size; organomegaly; systemic symptoms
Metastatic neoplasiaFirm, tender mass; may be enlarging; systemic symptoms or weight loss
Psoas abscessFlank or back pain, fever, inguinal mass, limp, weight loss
Sebaceous cystSoft, nontender mass; more superficial; no change with Valsalva maneuver
Testicular torsionAcute onset of pain with a high-riding testis, swelling, very tender
VaricoceleUsually asymptomatic or dull ache, unilateral “bag of worms” in the scrotum

Physical Examination

In men, the examination should begin with the patient standing and the physician seated in front of the patient. The groin should be inspected for an obvious bulge. The physician should observe for any expansile bulge while the patient “bears down” (Valsalva maneuver). An indirect hernia is often piriform in shape—broad in the scrotum and narrow over the medial half of the inguinal ligament. A direct hernia is globular in shape over the medial half of the inguinal ligament and usually does not enter the scrotum.12

If a hernia is not visualized, additional maneuvers should be performed. Using an index finger, the physician should palpate the base of the scrotum and gently invaginate the redundant skin of the scrotum into the inguinal canal toward the pubic tubercle. The finger follows adjacent to the spermatic cord, and the fingertip will be just within the external ring. The patient should then be asked to strain or cough as the physician palpates for a soft impulse, which is suggestive of herniation.13

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