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ORIGINAL RESEARCH

Groin Pain in Women

Use of Sonography to Detect Occult Hernias

Thomas Grant, DO, Erin Neuschler, MD, Wilson Hartz III, MD

Objectives—Symptomatic groin hernias in women may be difficult to assess clinically

Article includes CME test
and commonly mimic pathologic musculoskeletal and gynecologic conditions. The ob-
Videos online at jultrasoundmed.org
jective of our study was to investigate the accuracy of sonography in women with groin
pain and normal physical examination findings.
Methods—A consecutive group of 87 women (median age, 44.6 years; range, 19–82
years) with groin pain and normal physical examination findings were included in the
study. All patients had a standardized sonographic examination of the groin performed
by an experienced radiologist or a sonographer. If a groin hernia was identified, it was
classified as indirect, direct, or femoral. Normal examination findings and alternate
pathologic groin conditions were also recorded. The sensitivity, specificity, positive pre-
dictive value, and negative predictive value were calculated for the sonographic find-
ings and compared to the findings for patients sent for surgery.
Results—Of the 87 women with groin pain, 37 groin hernias were diagnosed in 35 pa-
tients. Surgery was performed in 26 patients (27 groins). Sonography correctly depicted
and classified groin hernias in 18 of the 21 groins that had surgical confirmation. Six
women without groin hernias also had surgical exploration of the affected side. The sen-
sitivity, specificity, positive predictive value, and negative predictive value for the pa-
tients with surgical confirmation were 95%, 75%, 95%, and 75%, respectively. Groin
pain in 26 patients was attributed to other causes. The remainder of the patients had nor-
mal examination findings or were lost to follow-up.
Conclusions—Groin hernias in women can be occult and confound the clinical diag-
nosis. In a woman with groin pain and normal or indeterminate physical examination
findings, we have found that sonography can accurately depict and classify groin hernias
and other pathologic processes.
Key Words—groin pain in women; occult hernias; sonography

Received December 17, 2010, from the Feinberg

School of Medicine, Northwestern University,
G roin pain in women is a relatively common symptom.1–3
Chicago, Illinois USA. Revision requested January
19, 2011. Revised manuscript accepted for publi-
cation August 4, 2011.
Address correspondence to Thomas Grant,
DO, Department of Radiology, Northwestern
Memorial Hospital, Feinberg School of Medicine,
Northwestern University, 676 N St Clair St,
Chicago, Il 60611 USA.
E-mail: t-grant@northwestern.edu
The causes are multifactorial and may have their origins in
the reproductive, urologic, musculoskeletal, neurologic, and
gastrointestinal systems.1,4 In women with normal physical exami-
nation findings, it is not unexpected that groin hernias often remain
occult or are diagnosed only after a prolonged symptomatic period.
Repair of groin hernias is one of the most common operations
performed in surgery, with more than 20 million operations per-
formed to date.4 Approximately 6% to 8% of groin hernia repairs
are performed in women.1,5 Surgical texts are replete with anatomic
diagrams and techniques related to the repair of hernias in men.
The literature is sparse on the subject of the groin hernias in

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Grant et al—Sonography of Occult Hernias in Women With Groin Pain
women.1,2,4 In a study by Spangen and Smedberg,6 how-
ever, it was suggested that symptomatic nonpalpable groin
hernias may be relatively common in women with dull
groin pain aggravated by physical exertion or intermittent
neurologic pain in the distribution of the ilioinguinal nerve.
An association has been established between groin
hernias in women and the entity known as a cyst of the
canal of Nuck. It is analogous to a communicating hydro-
cele in men. Approximately one-third of women with a cyst
of the canal of Nuck also have a groin hernia.7,8
Several methods have been used to diagnose occult
groin hernias. In Europe, herniography has been found to
be accurate and is one of the most commonly performed
diagnostic procedures. A study performed by Kesek and
Ekberg9 found that 24% of women younger than 40 years
had a symptomatic nonpalpable groin hernia that was de-
tected with herniography. However, in women with groin
hernias that contain only fat, herniographic findings are
often normal.4,6 Other disadvantages include its invasive-
ness, use of ionizing radiation, and its inability to depict
other pathologic conditions that may be responsible for
the patient’s symptoms. Computed tomography and mag-
netic resonance imaging successfully depict hernias when
they do not spontaneously reduce in the supine position
with quiet respiration.10,11 In some instances, diagnostic la-
paroscopy has been advocated in symptomatic women
with normal physical examination findings.
Recent studies have shown that sonography can de-
pict and differentiate hernias from other pathologic enti-
ties found in the groin.12–14 Recent studies by Robinson et
al12 and Lorenzini et al15 showed that sonography is of
value in detecting occult hernias in patients with groin pain.
However, these reports included a mixed population, with
most patients being men. Because the female inguinal canal
without a spermatic cord is a less anatomically complex re-
gion than the male equivalent, we hypothesized that sonog-
raphy could be beneficial in the diagnosis of symptomatic
women with groin pain that have normal or equivocal
physical examination findings.
Materials and Methods
The study was conducted after Institutional Review Board
approval. Given the retrospective nature of this study, no
informed consent was needed. Eighty-seven consecutive
women (median age, 44.6 years; range, 19–82 years) were
referred for a sonographic examination from September
2004 to April 2008. The referring physicians consisted of
4 general surgeons, 2 internal medicine specialists, 1 or-
thopedic surgeon, 1 gynecologist, and 1 physiatrist. Pa-
1702
tients who had a prior femoral artery or vein catheteriza-
tion, groin injury, or a previous hernia repair were excluded
from the study. All of the patients had groin or lower ab-
dominal pain. The duration of symptoms varied from 8
days to 9 years, but most patients had difficulty identifying
the precise time the symptoms began. All patients had the
sonographic examination performed within 1 week of see-
ing their clinician. Surgical repairs for patients with groin
hernias were performed using either a laparoscopic or an
open technique.
The most common symptom was unilateral deep
pelvic pain or a groin ache. Sixty-seven patients had right-
sided groin or lower abdominal pain; 16 had left-sided pain;
and 4 had bilateral pain. Seventy-six women had normal
physical examination findings. Two women had a palpable
lump in the groin on physical examination. Nine patients
had inconclusive physical examination findings. The 11 pa-
tients with a palpable lump and inconclusive physical ex-
amination findings were included in the study because the
diagnosis of a hernia was only considered by the ordering
physician in 2 of the patients, and no examination findings
were diagnostic of a hernia in any of the 11 patients.
Patients were scanned using a standardized technique
with either an HDI 5000 SonoCT or an iU22 ultrasound
machine (Phillips Healthcare, Bothell, WA), both of which
were equipped with a 12–5-MHz multifrequency trans-
ducer. Spatial compound sonography as well as B-mode
and color Doppler imaging were used in all cases. Color
Doppler imaging was integral to localize the common
femoral artery and vein as well as the origin of the inferior
epigastric artery. The inferior epigastric artery is the land-
mark for the deep inguinal ring. The inguinal ligament is
the folded-up inferior lower border of the external oblique
muscle. It is readily depicted using sonography as a fibril-
lar structure located between the pubic tubercle and the
anterior superior iliac spine.
Imaging was performed over the long axis of the
ligament, using light pressure. Because of the sound-
attenuating properties of the ligament, the transducer was
commonly placed just superior or inferior to the ligament.
Images were obtained from the superior margin of the labia
majora to just lateral to the inferior epigastric artery. The
transducer was then placed perpendicular to the ligament
and moved medially from the inferior epigastric artery over
the entire extent of the ligament. Next, the transducer was
positioned over the expected location of the femoral canal,
just medial to the common femoral vein. The femoral canal
is medial to the common femoral vein and just proximal to
the saphenofemoral junction. The contralateral groin was
also evaluated in a similar manner.
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Grant et al—Sonography of Occult Hernias in Women With Groin Pain
All examinations were performed in the supine posi-
tion during quiet breathing and with the Valsalva maneu-
ver to elicit hernias. If the patient could not perform the
Valsalva maneuver, she was asked to place both hands be-
hind the head and bend forward, which also serves to in-
crease intra-abdominal pressure. Additional images were
also obtained depending on the clinical findings in each
patient. The sonographic examinations were performed
by an experienced radiologist in 60 of the 87 patients. The
principal investigator has 25 years of experience perform-
ing musculoskeletal sonography. The remainder of the 6
radiologists had between 4 and 10 years of experience.
Experienced sonographers performed the remainder of the
examinations. The sonographers had between 5 and 10
years of experience. A radiologist was present in the room
for any examinations performed by a sonographer. The
sonograms were stored on hard copy, and video clips were
obtained.
Groin hernias include indirect, direct, and femoral
hernias (Figure 1 and Videos 1 and 2). Indirect inguinal
hernias originate at the deep inguinal ring, located lateral to
the origin of the inferior epigastric artery. Indirect hernias
extend along the long axis of the canal. Direct hernias are
located medial to the inferior epigastric artery. A femoral
hernia is not an inguinal hernia because it is located medial
Figure 1. Volume-rendered computed tomography of the lower ab-
dominal wall showing the locations of the 3 types of groin hernias and
their relationship with the vascular anatomy and the inguinal ligament: in-
direct inguinal hernia (ID), direct inguinal hernia (D), and femoral hernia
(FH). Arrowheads indicate inferior epigastric artery.
J Ultrasound Med 2011; 30:1701–1707
to the common femoral vein. The appearance of the
femoral vein was observed during the Valsalva maneuver
because the vein may decrease in caliber in the presence
of a femoral hernia. The presence of fat or bowel in one of
these locations met criteria for a hernia.
Groin hernias were also designated as having either a
narrow or wide neck. We found this distinction important.
On sonography, direct hernias present with a wide neck,
forming an obtuse angle to the abdominal wall. The Val-
salva maneuver accentuates the wide neck, which extends
into the inguinal canal. Indirect and femoral hernias usually
have a narrow neck.
The sensitivity, specificity, positive predictive value,
and negative predictive value were compared to surgical
findings for the hernia group. In the patients who had
other etiologies for their symptoms, correlation was made
with the methods of treatment and, when available, their
outcomes.
Results
Thirty-seven groin hernias were diagnosed in 35 women.
Sonography depicted 9 indirect inguinal hernias, 21 direct
inguinal hernias, and 7 femoral hernias (Table 1). Increas-
ing the intra-abdominal pressure by using the Valsalva ma-
neuver or increasing the tone of the abdominal muscles
was the determining factor in the diagnosis for all but 1 pa-
tient (Figures 2 and 3).
Surgery was performed in 26 patients (27 groins).
Unilateral hernia repair was performed in 19 patients, and
bilateral repair was performed in 2. Sonography correctly
depicted and classified groin hernias in 18 of the 21 groins
that had surgical confirmation (Table 2).
One sonographic study had false-negative findings.
A 53-year-old woman had an incarcerated right femoral
hernia 4 months after sonographic findings were inter-
preted as normal. One patient had bilateral indirect in-
guinal hernias detected on sonography. Although no
hernia was described in the surgical report on the right,
a lipoma of the round ligament was identified in this re-
gion. There was surgical confirmation of a left indirect in-
guinal hernia in this patient. One hernia was misclassified.
Table 1. Sonographic Findings in 35 Women With Groin Hernias
Type of Hernia n
Indirect 9
Direct 21
Femoral 7
Two women had bilateral hernias.
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Grant et al—Sonography of Occult Hernias in Women With Groin Pain
A 60-year-old woman with a right direct inguinal hernia di-
agnosed by sonography was found to have a femoral her-
nia at surgery. Six women without inguinal hernias on
sonography had surgical exploration of the affected groin
(Tables 3 and 4).
Fourteen women with groin hernias diagnosed by
sonography did not have surgery. Symptoms resolved in 4
of those patients. Three of the 4 women were pregnant
when sonography was performed, and their symptoms re-
solved postpartum. Another patient who was found to have
Figure 2. Longitudinal images of the right inguinal canal obtained with a
12–5-MHz linear array transducer in a 28-year-old women with groin pain
for 2 months and normal physical examination findings. The images were
obtained with and without the Valsalva maneuver. A, Direct hernia con-
taining fat (arrows) and peritoneal fluid (asterisk). B, The contents of the
hernia extended further into the inguinal canal (arrows) after the Valsalva
maneuver. The defect in the conjoint tendon is also larger (asterisk).
A
B
1704
a hernia refused surgery. Two patients had comorbid con-
ditions that prevented surgical repair. Seven patients were
lost to follow-up.
Nine women had a sonographic diagnosis of a cyst of
the canal of Nuck. Four of these women also had hernias
identified: 2 direct inguinal and 2 femoral. Three of these
patients had surgical confirmation of both the cyst and the
hernia. The final patient with a cyst and a femoral hernia
was lost to follow-up. Two patients without a hernia had
surgical confirmation of a cyst of the canal of Nuck.
The groin pain in the remainder of the 52 women was
attributed to variety of other causes, which included mus-
culoskeletal (16), gynecologic (7), vascular (1), gastroin-
testinal (1), and genitourinary (1). Confirmation was
made by sonography, other imaging modalities, clinically,
or at surgery. In 19 patients, the sonographic findings were
normal, and no cause was ever found.
Figure 3. Femoral hernia in a 55-year-old women with unexplained right
inguinal pain for 3 months. A, Transverse image obtained at rest show-
ing a femoral hernia containing fat (arrowheads) medial to the femoral
vein (FV). FA indicates femoral artery. B, During the Valsalva maneuver,
the hernia enters the femoral triangle (arrowheads), causing the femoral
vein to decrease in caliber.
A
B
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Grant et al—Sonography of Occult Hernias in Women With Groin Pain

Table 2. Sonographic and Surgical Findings in 20 Women (21
Groins) with Groin Hernias
Sonographic Surgical
Type of Hernia Findings, n Findings, n
Normal 0 1 (femoral)
Indirect 5 5
Direct 11 10
Femoral 5 6
Discussion
The diagnosis of a groin hernia in women is seldom dis-
cussed in the literature except for noting the presence of a
palpable lump and pain in the groin replicating findings in
men.2,5 Our study was able to document the presence and
location of groin hernias in a cohort of symptomatic women
with normal or near-normal physical examination findings
using sonography. We were also able to detect a variety of
other pathologic processes that cause groin pain and mimic
groin hernias.
Most symptomatic groin hernias in women and men
are diagnosed on physical examination and managed with-
out imaging. In women, the physical examination findings
are more likely to be normal because of the inherent diffi-
culty for the clinician to examine the inguinal region. The
inguinal region in men is easily explored, making even
minor hernias palpable. In contrast, the skin of the labium
majus is not redundant enough to allow the examining fin-
ger to palpate the inguinal floor directly. A cough impulse
through the skin and the firm external oblique aponeuro-
sis are often difficult or impossible to detect.6 It is not un-
expected that groin hernias in women are often diagnosed
only after a prolonged symptomatic period or as a surgical
emergency.5,16 When the physical examination findings are
normal, the diagnosis of a groin hernia is often disregarded
or attributed to genitourinary or musculoskeletal disorders.
A recent study from Denmark concluded that a greater
proportion of women than men require emergency hernia
repair with higher rates of bowel resection and death.17
Table 3. Surgical Findings in 6 Patients Without Groin Hernias on
Sonography
Surgical Findings Patients, n
Cyst of the canal of Nuck 2
Lipoma of the round ligament 1 Sensitivity, %
Hemangioma of the round ligament 1 Specificity, %
Endometriosis of the round ligament 1 Positive predictive value, %
Labral tear 1 Negative predictive value, %
In 1975, Herrington16 was the first to describe a small
group of symptomatic women with nonpalpable or occult
hernias that caused groin or lower abdominal pain. Thir-
teen years later, Spangen et al4 identified a similar group of
women who had no palpable swelling but had persistent
groin pain often exacerbated by physical activity and ten-
derness over the inguinal ring. Our study addressed a simi-
lar patient population. Sonography allowed us to document
the presence and location of groin hernias in women with
normal physical examination findings. Twenty-one of the
37 occult groin hernias diagnosed by sonography were re-
paired at our institution. This number represented almost
9% of the 204 groin hernia repairs in women performed at
our institution during the same period as our study.
With a few exceptions, the sonographic technique
used in our study was similar to that used by others. After
locating the inguinal ligament adjacent to the pubic tuber-
cle, the entire length of the canal was scanned. Light trans-
ducer pressure was used to avoid obscuring a hernia or
reducing it. Only the supine position was used to image the
groin.
Increasing the intra-abdominal pressure is crucial in
the detection of occult hernias on sonography. With only
1 exception, the Valsalva maneuver was needed to detect a
groin hernia in our patient population. According to Span-
gen and Smedberg,6 during the Valsalva maneuver, the
posterior wall of the inguinal canal is partly protected by a
shutter mechanism, and the deep inguinal ring is normally
closed. Therefore, it is often only after this maneuver that
a hernia can be elicited. In a more recent study by Span-
gen et al,6 in women that were found to have inguinal her-
nias at exploration, the deep inguinal ring was wider than
normal and could admit 1 or more fingertips. The normal
inner shutterlike closing mechanism is incompetent in this
situation, making the Valsalva maneuver highly effective.
Identifying the vascular anatomy of the groin is an-
other important parameter in detecting and classifying
groin hernias on sonography. The inferior epigastric artery
arises from the external iliac artery and defines the medial
border of the internal ring. The neck of an indirect hernia
enters the internal ring just lateral to the inferior epigastric
artery. Direct inguinal hernias are located medial to the
Table 4. Analysis of the 26 Patients (27 Groins) Who Had Surgery
Parameter Value
95
75
95
75

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Grant et al—Sonography of Occult Hernias in Women With Groin Pain
inferior epigastric artery and enter the canal through a wide
fascial defect or a markedly stretched posterior wall at the
conjoint tendon. The conjoint tendon is formed medially
from the internal oblique and the transverses abdominis
muscles and constitutes the posterior wall and roof of the
inguinal canal.
Femoral hernias occupy the femoral triangle, which is
located inferior to the inguinal ligament adjacent to the
femoral vein. Identifying the femoral vessels is therefore in-
tegral to diagnosing femoral hernias. Normally, the Valsalva
maneuver will cause the femoral vein to increase in size.
A femoral hernia will paradoxically decrease the caliber of
the femoral vein secondary to the contents of the hernia
entering the femoral triangle. This finding corresponds to a
clinical observation by Williams18 of a femoral venous thrill
due to temporary femoral vein stenosis (Figure 4).
We also documented whether the hernia had a nar-
row or wide neck. Direct hernias form an obtuse angle
with the abdominal wall. The wide neck is accentuated
by increasing the intra-abdominal pressure. Indirect and
femoral hernias usually have narrow necks and are more
likely to incarcerate.16
According to the surgical literature, indirect hernias in
women are the most common, accounting for approxi-
mately 70% of all groin hernias. Femoral and direct hernias
account for the remainder. Direct inguinal hernias are con-
sidered rare in women because the conjoint tendon is bet-
ter developed.1 Our patient population differed markedly.
Direct hernias are uncommon in clinical practice but rep-
resented 48% (10 of 21) of the hernias confirmed at sur-
gery in our study. We postulate that direct inguinal hernias
are more difficult to detect on the physical examination
and therefore not repaired. Instead, the patients often live
with idiopathic pelvic or groin pain.
Figure 4. Transverse color Doppler image during the Valsalva maneu-
ver showing the contents of a femoral hernia (FH) compressing the
femoral vein (arrowhead). FA indicates femoral artery.
1706
Approximately one-third of patients with a cyst of the
hydrocele of Nuck also have a groin hernia.8 Nine patients
in our study were found to have a hydrocele of the canal of
Nuck (Figure 5). In women, the round ligament is at-
tached to the uterus near the origin of the fallopian tube,
and a small extension of the parietal peritoneum accom-
panies the round ligament through the deep inguinal ring
into the inguinal canal. This extension normally undergoes
obliteration during the first year of life. In rare occasions, if
the peritoneal extension does not obliterate, a cyst forms.8
These cysts vary in size and may present clinically as fluc-
tuating nonreducible masses or cause mild groin pain.7
In our study, 4 patients with a cyst of the canal of Nuck had
a hernia. Two patients had a direct inguinal hernia, and 2
had a femoral hernia confirmed at surgery.
Limitations of this study included the patients who had
groin hernias detected on sonography but did not have sur-
gery. Although some of these patients were lost to follow-
up, 3 patients with groin hernias were pregnant at the time
of diagnosis. It has been well established that in pregnancy
the abdominal pressure rises, and groin hernias may appear
for the first time and disappear after birth.19 Other patients
with groin pain had normal sonography findings. Although
the symptoms resolved in some of these women, no etiol-
ogy was found in the remainder. Another limitation was that
most of the patients in this study were evaluated by a single
radiologist. Further studies at our institution are currently
being performed to determine interobserver variability.
Last, most studies have used both supine and upright
scanning to detect groin hernias. We only used the supine
position, which could be seen as a potential limitation. The
Valsalva maneuver can be unpredictable because some pa-
tients may have difficulty understanding or performing the
maneuver. In the upright position, the Valsalva maneuver
may not be necessary.
Figure 5. Image from a 59-year-old women with mild groin pain and
swelling for 6 months. A cyst of the canal of Nuck (C) is shown adjacent
to the inguinal ligament (arrowheads). FA and FV indicate common
femoral artery and vein, respectively.
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Grant et al—Sonography of Occult Hernias in Women With Groin Pain

The etiology of chronic groin pain in women can be
confounding. There should be a low threshold for per-
forming sonography in symptomatic patients with normal
physical examination findings. We think that sonography
performed using the proper technique can be extremely
helpful in detecting occult groin hernias.
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