Inguinal hernias: Clinical sciences

An inguinal hernia is a defect or weakness in the abdominal wall that allows the passage of abdominal contents through the lower abdominal wall into the inguinal region, or groin. Some common risk factors for the development of an inguinal hernia include male sex, age younger than 5 years or older than 75 years, family history of inguinal hernia in first-degree relatives, impaired collagen metabolism, and previous history of benign prostatic hyperplasia or prostatectomy.

Inguinal hernias can be classified by etiology, meaning they can be either congenital or acquired. Congenital inguinal hernias occur when the processus vaginalis fails to close during gestation. On the other hand, acquired hernias can be due to patent processus vaginalis or a weakness in the abdominal wall, allowing intra-abdominal contents to protrude through the defect. Common causes of tissue weakness include abdominal wall injury or connective tissue abnormalities. 

Inguinal hernias can also be classified anatomically as either direct or indirect. A direct inguinal hernia protrudes medially to the inferior epigastric vessels within Hesselbach’s triangle, which is formed inferiorly by the inguinal ligament, laterally by the inferior epigastric vessels, and medially by the rectus abdominis muscle. Direct hernias are usually a result of a weakened inguinal canal floor.

On the other hand, indirect inguinal hernias occur in the internal inguinal ring, lateral to the inferior epigastric vessels. In males, this is the site where the spermatic cord exits, while in females it’s the site where the round ligament exits the abdomen. Indirect inguinal hernias are the most common type of hernia, and they occur more frequently on the right side. Both direct and indirect hernias can present as either asymptomatic, symptomatic, incarcerated, or strangulated.

When you encounter a patient with signs and symptoms suggestive of an inguinal hernia, you should first perform an ABCDE assessment to determine whether the patient is stable or unstable. If the patient is unstable, stabilize their airway, breathing, and circulation. This means that you may need to intubate the patient, obtain IV access, and administer fluids before continuing with your assessment.

Alright, now that unstable patients are taken care of, let’s talk about stable patients. If the patient is stable, your first step is to obtain a focused history and physical examination. There are a few findings you might see here. First, you might identify a patient with an asymptomatic inguinal hernia. In this case, your patient does not currently have symptoms. However, on physical examination, you’ll notice a small, easily reducible bulge in the groin area, superior to the inguinal ligament. The bulge may also protrude when you ask your patient to perform a Valsalva maneuver. If you see this, you can diagnose an asymptomatic inguinal hernia.

When it comes to treatment, asymptomatic inguinal hernias can often be managed with watchful waiting, and might not need surgical intervention. However, you should advise your patient to seek medical attention if they have new-onset or worsening groin pain, or if they are suddenly unable to reduce the hernia.