Examination of the Groin for Hernias

Question 1

What is involved in the inspection stage of the examination of the groin for hernias?

Answer 1

• With the patient standing, inspect for a swelling in the groin. Ask the patient to cough (this may make an occult hernia visible)

Question 2

What is involved in the palpation stage of the examination of the groin for hernias?

Answer 2

If you see a swelling, ask the patient to repeat the cough whilst palpating the swelling. Feel for a cough impulse. Always examine the hernia standing on the same side of the patient as the swelling and using your left hand for left-sided hernias and your right hand for right-sided hernias.
• Examine the scrotum (See scrotal swellings below). You cannot ‘get above’ an inguinal hernia, whereas you can palpate the upper extent of lumps originating in the scrotum.
• Ask the patient to lie flat.
• Identify the pubic tubercle. Identify its relationship to the neck of the hernial sac. Inguinal hernias enter the scrotum via the superficial inguinal ring, above and medial to the pubic tubercle. Femoral hernias pass under the inguinal ligament to enter the thigh, below and lateral to the pubic tubercle.
• Attempt to reduce the hernia by gentle sustained pressure (or ask the patient to do this – many patients can reduce their own hernia). Once reduced, an indirect inguinal hernia can be controlled by finger-pressure over the deep inguinal ring at the mid-point of the inguinal ligament, midway between the pubic tubercle and the anterior superior iliac spine (ASIS). A direct hernia will bulge through the abdominal wall medial to this and cannot be controlled by pressure on the deep ring. (You should be aware that distinguishing clinically between direct and indirect inguinal hernias by this technique is notoriously unreliable and often the correct diagnosis is only established during surgery.) (N.B. the inferior epigastric artery passes medial to an indirect inguinal hernia and lateral to a direct inguinal hernia and forms an important anatomical landmark. It leaves the external iliac artery at the midinguinal point, halfway between the pubic symphysis and the ASIS).