GuidelinesOther guideline
An Approach to a Hernia
Doctor I have a lump in my groin! An approach to a hernia
Introduction
Differential Diagnosis
Hernias
Context: Outpatients/Sometimes in the Emergency Room
Introduction
Most of these patients will have an inguinal hernia.
Differential Diagnosis
Common | Clues |
| Inguinal hernia | Intermittent bulge, reducible, +ve cough impulse |
| Lymphadenopathy | Associated with leg or genital sepsis/ other causes of adenopathy |
Uncommon and weird | Clues |
| Femoral hernia | Typical in elderly females, just below the inguinal ligament |
| Haematoma | History of trauma |
| False aneurysm | Hx of penetrating injury in recent past/ bruit or thrill on examination |
| Cold abscess | Medial thigh/ frail TB patient/ typically painless |
| Lipoma of the cord | Can be difficult to differentiate from inguinal hernia |
| Sarcoma | Hard mass in the groin region |
| Retractile/ undescended testis | Firm mass in the inguinal canal |
Don't want to miss | Clues |
| Incarcerated hernia | Fixed mass, tender, may have associated bowel obstruction |
The common clinical question is: is this a hernia or lymphadenopathy?
| Hernia | Adenopathy | |
Duration | Often many months, or years | Recent onset |
Pain | Nil, but can be uncomfortable and have episodes of severe pain | Constant in cases caused by infective conditions |
Predisposing factors | More common in men Sudden onset after exertion Smokers, COPD | Limb trauma, sepsis Associated venereal disease Neoplasm in the limb |
Size | Range from intermittent and small to massive intra-scrotal hernias | Usually small to moderate in size |
Consistency | Soft “fatty”, +ve cough impulse, extends into the scrotum | Firm, multiple, rubbery |
Location | Usually at the external inguinal ring | Medial to femoral vessels, and below the inguinal ligament |
Hernias
The diagnosis can be made on clinical grounds in the majority of cases
- If you are not sure, before starting many expensive investigations, ask a senior colleague to examine the patient.
- A symptomatic hernia is defined as a hernia causing groin discomfort/ pain at rest or when moving, or mass interfering with normal activity.
- Asymptomatic, incidental or minimally symptomatic inguinal hernias may be safely observed, and need not be referred to SOPD.
- Femoral hernias should be repaired, as their incidence of strangulation is significantly higher.
- There is no role for routine imaging tests to confirm the diagnosis of a hernia.