Hernias: Examination

Inguinal hernia

  1. Inspect
  2. Palpate, cough impulse
  3. Direct vs. indirect summary
Femoral hernia

  1. Inspect
  2. Palpate

Inguinal hernia

Inspect
  • Is pt. male (predisposing factor).
  • Pt's lifting muscles, ascities (predisposing factors).
  • Pt. stands, exposed area visible.
  • Swellings.
  • Swellings: bilateral (direct) or unilateral (indirect).
  • Swellings: only appear on standing?
  • Swelling location: above or below inguinal ligament. See Inguinal Canal Reference.
  • Hernia surgical scars.
  • External genitalia, including undescended testicle (DDx).
  • Ask pt. to reduce hernia themselves.
  • Pt. coughs to highlight hernia.
Palpate
  • Ask pt. about tenderness first.
  • See Inguinal Canal Reference for landmarks.
  • Inguinal hernia goes in inguinal canal.
  • Palpate mass, scrotal ones can be done up scrotum with little finger.
  • Optionally can cough here while little finger up scrotum to feel an impulse on end of finger (indirect) vs. superior part of finger.
  • See whether can reduce it back up through the inguinal ring to reduce it.
Palpate: cough impulse
  • Reduce.
  • Hold two fingers on internal ring.
  • Pt. coughs while holding fingers on ring.
  • See if hernia  can extrude around elsewhere (direct) or stays reduced (indirect).
Direct vs. indirect summary
  • Bilateral (direct) vs. unilateral (indirect).
  • Strangulation concern (indirect) vs. rarely strangulate (direct). Usually obstruction precedes strangulation (except Richter's).
  • Through inguinal ring (indirect) vs. around inguinal ring (direct).

Femoral hernia

Inspect
  • Is pt female? (predisposing factor).
  • Pt. stands, exposed area visible.
  • Swellings.
  • Swellings: only appear on standing?
  • Reddening.
  • Hernia surgical scars.
  • External genitalia.
  • Ask pt. to reduce hernia themselves.
  • Pt. coughs to highlight hernia, though may not appear in femorals.
  • Whether hernia goes through Hasselbach's triangle. See Inguinal Canal Reference.
Palpate
  • Ask pt. about tenderness first.
  • Femoral 'neck' is usually palpated inferior and lateral to pubic tubercle.
  • Femorals more likely to be irreducible than inguinals.
  • Can have pt. cough while palpating, reducing.
  • Don't confuse with firm lymph node, femoral vein.