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Inguinal HerniaAka: Groin Hernia, Scrotal Hernia, Indirect Inguinal Hernia, Indirect Hernia, Direct Inguinal Hernia

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  1. See Also
    1. Inguinal Hernia in Children
    2. Abdominal Hernia
    3. Femoral Hernia
    4. Sports Hernia
  2. Epidemiology
    1. Accounts for 96% groin hernias (other 4% are femoral)
    2. Bilateral in 20% of cases
    3. Gender predisposition: Male by 9 to 1 ratio
    4. Lifetime risk of inguinal herniation: 10%
  3. Types
    1. Indirect inguinal hernia (most common)
      1. Course
        1. Hernia sac passes outside Hasselbach's Triangle
        2. Herniates via Inguinal Canal
          1. Enters through Internal Inguinal Ring
          2. Lateral to inferior epigastrics
          3. See Inguinal Canal for anatomic course
        3. May result in scrotal hernia in males
      2. Pathophysiology
        1. Nonobliterated processus vaginalis (congenital)
        2. Internal abdominal ring weakened fascia
    2. Direct inguinal hernia
      1. Hernia sac passes within Hasselbach's Triangle
      2. Breaches posterior inguinal wall
      3. Passes medial to inferior epigastrics
      4. Pathophysiology
        1. Usually occurs in males
        2. Acquired deficiency in transversus abdominis muscle
  4. Symptoms
    1. Often asymptomatic (especially in direct hernias)
    2. Pain or dull sensation in groin
  5. Signs
    1. See Inguinal Canal Exam (for males)
    2. Palpable defect or swelling may be present
      1. Indirect Hernia may bulge at Internal Inguinal Ring
        1. Look for bulge site at mid-inguinal ligament
      2. Direct Hernia may bulge at External Inguinal Ring
        1. Look for bulge site at pubic tubercle
        2. Occurs just above inguinal ligament
        3. Seen medial and inferior to indirect hernia bulge
    3. Distinguishing indirect and direct hernias difficult
      1. Experienced clinicians are incorrect in 30% of cases
    4. Indirect inguinal hernia palpation difficult in women
    5. Inguinal hernias difficult to palpate in children
  6. Differential Diagnosis
    1. See Groin Pain
  7. Radiology: Inguinal Ultrasound
    1. Technique: Ultrasound in various patient positions
      1. Supine
      2. Upright
      3. Valsalva maneuver
    2. Efficacy
      1. High Test Sensitivity (>90%)
      2. High Test Specificity
        1. Distinguish Incarcerated Hernia from firm mass
  8. Management
    1. See Herniorrhaphy
  9. Complications
    1. Bowel incarceration and strangulation
    2. Small Bowel Obstruction
  10. References
    1. Goroll (2000) Primary Care Medicine, p. 431-4
    2. Degowin (1987) Diagnostic Examination, p. 489-96
    3. Bax (2001) Am Fam Physician 59(4):143

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