Hernia, Inguinal and Femoral

© Reed Group

Risk: Any condition that increases pressure in the abdomen (such as obesity, chronic cough, straining during urination or bowel movements, heavy lifting, or pregnancy) may contribute to the development of a hernia. Premature birth and a personal or family history of hernias may be predisposing factors in some individuals (Mayo Clinic).

Incidence and Prevalence: About 750,000 inguinal and femoral hernia repairs are done annually in the US (Nicks). Of these, 80% to 90% are done in men. Inguinal hernias are the most common hernias in both men and women and account for 65% to 70% of groin hernias (Jeyarajah). About two-thirds of these are indirect and one-third are direct (Nicks). The lifetime incidence of inguinal hernia is about 25% in men and 2% in women. Femoral hernias are much less common, comprising about 3% of all hernias, and occur almost exclusively in women (Nicks).

History: A thorough medical history should be obtained, including underlying medical conditions (chronic cough, straining with urination or bowel movements, constipation, symptoms of prostate disease, liver disease, obesity), medications, occupational history (job requirements regarding lifting) and family history. Many inguinal and femoral hernias are not associated with any symptoms (asymptomatic) and are discovered only on routine medical examination. Individuals with asymptomatic hernias may notice a fullness or swelling in the groin area that enlarges when the individual stands or strains. The individual may associate onset of the swelling with an episode of heavy lifting. An incarcerated hernia may produce steady pain or discomfort that increases with straining or coughing. If nausea, vomiting, and symptoms of bowel obstruction are present, strangulation should be considered. Femoral hernias may manifest with pain in the inner thigh in addition to pain in the groin.

Physical exam: Vital signs (temperature, pulse, respiration, blood pressure) should be recorded; fever may suggest an incarcerated hernia. Physical examination is usually performed with the individual standing up and then repeated with the individual lying down on his or her back (supine). With an inguinal hernia, a bulge or swelling appears in the groin area or within the scrotal sac. This bulge can often be accentuated by asking the individual to voluntarily increase his or her intra-abdominal pressure (Valsalva maneuver). A bulge may not be apparent with a femoral hernia. During the exam, the physician attempts to find the area allowing protrusion of the hernia. For inguinal hernias in men, this is accomplished by placing a fingertip in the scrotal sac and advancing the fingertip into the inguinal canal. Reduction of the hernia is attempted and the results noted in the medical record. Sometimes, bowel sounds can be heard in a large hernia by listening with a stethoscope (auscultation). A femoral artery aneurysm masquerading as a femoral hernia may produce a sound (bruit) that can be heard with the stethoscope. An individual with a strangulated hernia may have fever, pain out of proportion to exam findings, and no decrease in pain with reduction of the hernia.

Tests: Tests are generally not needed in the diagnosis of inguinal or femoral hernias. A complete blood count may be ordered if strangulation is suspected to look for an increase in white blood cells. Electrolytes, blood urea nitrogen (BUN), and creatinine levels may be ordered if individual is nauseated and vomiting, or prior to surgery.

Ultrasound is the best noninvasive procedure to confirm the diagnosis and distinguish the hernia from abscesses or other masses. In certain rare situations in which a strangulated or incarcerated hernia is suspected, x-rays may be ordered.