SIGNS AND SYMPTOMS 
History
- Pain and swelling:
- Localized to region of hernia
- Persistent pain, vomiting, fever may indicate:
- Incarceration
- Strangulation
- Bowel obstruction
Physical Exam
- Vital signs:
- Frequently normal
- Tachycardia with pain, dehydration, infection
- Hypotension with dehydration, strangulation, infection/sepsis
- Fever with infection/sepsis
- Skin color changes with strangulation
- Inguinal hernia:
- Pain:
- Localized to inguinal region
- Exacerbated by straining/positional changes
- Relieved by rest
- Swelling:
- Males: Bulge in scrotum
- Females: Bulge immediately inferior to inguinal ligament or in labia
- Swelling of spermatic cord, scrotum, or testes
- Valsalva maneuver performed with finger directed toward internal ring—may allow hernia sac to descend against finger
- Femoral hernia:
- Pain/swelling:
- Localized to femoral orifice inferior to inguinal ligament
- Incisional hernia:
- Pain/swelling:
- Localized to previous incision/scar
- Obturator hernia:
- Nonspecific abdominal pain
- Intermittent intestinal obstruction
- Weight loss
- Pain:
- Owing to pressure on obturator nerve from hernia (Howship–Romberg sign)
- Along medial thigh
- Radiating to hip
- Relieved with thigh flexion
- Exacerbated by hip extension, adduction, or external rotation
- Spigelian hernia:
- Abdominal pain/mass along anterior abdominal wall
- Increased pain with maneuvers increasing intra-abdominal pressure
- Intermittent bowel obstruction
- Palpable mass along spigelian line:
- Convex line extending from costal arch to pubic tubercle along lateral edge of rectus muscle
Pediatric Considerations
- Diagnosis often difficult:
- Parents describe bulge in inguinal area often no longer present at time of exam.
- Incarcerated hernias may present with irritability, abdominal pain, or intermittent vomiting.
- Incidence of incarceration/strangulation is 10–20%:
- > 50% in patients younger than 6 mo of age
- Incidence of incarceration higher in girls than boys
- Umbilical hernias:
- Strangulation and incarceration rare
- Most close spontaneously
- Most surgeons will delay closure until 4 yr of age, although timing is controversial
- Inguinal hernias (consider hydrocele):
- If hydrocele, neck narrows at external inguinal canal without extension into inguinal canal
Pregnancy Considerations
- Hernias uncommon during pregnancy, manifesting before or during
- Inguinal hernia: 1:1,000–3,000 incidence, 75% occurring in multiparas
- Recognition of emergent situations (incarceration, strangulation) may be a diagnostic and management challenge
- No consensus exists regarding treatment of unreducible hernia during pregnancy; complications during pregnancy may outweigh elective hernioplasty and emergent surgical consultation recommended
Geriatric Considerations
- Higher risk of bowel resection if older than 65 years of age with incarcerated hernias
- Higher postoperative pulmonary and cardiovascular complications
ESSENTIAL WORKUP
Careful history and physical exam:
- Palpate inguinal/femoral area for tenderness/masses.
- Attempt exam with the patient standing or straining (Valsalva maneuver) if hernia not obvious.
- Pelvic exam in women to evaluate gynecologic etiologies of groin pain
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC:
- Leukocytosis with strangulation
- Electrolytes, BUN/creatinine, glucose:
- Urinalysis:
- Genitourinary causes of groin pain
Imaging
- Plain abdominal radiographs:
- Obstructive bowel pattern with incarceration or strangulation
- US:
- For identifying masses in groin or abdominal wall
- May be difficult in obese patients
- CT:
- To diagnose obturator or spigelian hernia
- Consider in symptomatic patients in whom body habitus precludes adequate physical exam or US study
DIFFERENTIAL DIAGNOSIS
[Outline]
INITIAL STABILIZATION/THERAPY
- 0.9% NS IV fluid resuscitation for dehydration, bowel strangulation, obstruction, or sepsis:
- Adults: 1 L bolus
- Peds: 20 mL/kg bolus
ED TREATMENT/PROCEDURES
- Incarcerated or strangulated hernias:
- IVFs
- Nasogastric tube (NGT)
- Surgical consultation
- Preoperative broad-spectrum antibiotics for strangulated hernia (controversial)
- Hernia reduction procedure:
- IV sedation (benzodiazepines) and analgesia (opiates) if necessary
- Place patient in Trendelenburg position.
- For spontaneous reduction, allow 20–30 min
- For manual reduction:
- Place constant, gentle pressure on hernia.
- For inguinal hernias, achieve reduction by putting fingers of 1 hand on internal ring while gently pulling then pressing on hernia distal to external ring.
- Obtain surgical consultation if reduction is unsuccessful after 1 or 2 attempts.
- Contraindications to reduction include:
- Fever
- Leukocytosis
- Signs of strangulation
- Complications:
- Introduction of strangulated bowel into abdomen
- Further ischemia/necrosis occurs with no clinical improvement.
- Reduction in girls may be more difficult if ovary encased within hernia.
MEDICATION
- Analgesics:
- Morphine sulfate: 2–10 mg per dose (peds: 0.1–0.2 mg/kg IV/IM/SC q2–4h) IV/IM/SC
- Fentanyl: 1–4 µg/kg (peds: 1–4 µg/kg IV) IV
- Sedatives:
[Outline]
DISPOSITION
Admission Criteria
- Strangulated hernias require immediate surgical intervention.
- Incarcerated hernias require admission for urgent surgical intervention.
- Intestinal obstruction
- Peritonitis
- Vomiting/dehydration
- Severe pain
Discharge Criteria
After successful reduction has been achieved and patient asymptomatic
Issues for Referral
Referral to surgery with instructions to return if recurrent persistent pain, fever, vomiting
FOLLOW-UP RECOMMENDATIONS
General surgery referral
[Outline]
- Derici H, Unalp HR, Bozdag AD, et al. Factors affecting morbidity and mortality in incarcerated abdominal wall hernias. Hernia. 2007;11(4):341–346.
- Nicks BA. Hernias: Treatment & medication. Available at http://emedicine.medscape.com/article/775630-treatment. Updated on June 6, 2012. Accessed on February 2013.
- Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2007;18(3):CD003769.
- Strange CD, Birkemeier KL, Sinclair ST, et al. Atypical abdominal hernias in the emergency department: Acute and non-acute. Emerg Radiol. 2009;16(2):121–128.
- Wang KS, Committee on Fetus and Newborn, American Academy of Pediatrics, et al. Assessment and management of Inguinal Hernia in Infants. Pediatrics. 2012;130(4):768–773.
See Also (Topic, Algorithm, Electronic Media Element)
Abdominal Pain