Iguinal Hernia Examination-1

Inguinal Hernia & inguinoscrotal region Examination
“A hernia is defined as protrusion of whole or part of a viscus through the wall that
contains it”.
History:
1. Age: Indirect inguinal hernias are usually met in younger age and direct
inguinal hernias mostly in older age.
2. Occupation: Strenuous work is responsible for development of hernias if
there is underlying weakness of abdominal muscles or patent processus
vaginalis.
3. Lump: How did it start? (Whether on straining like coughing or lifting
heavy weight), Where did it first appear? (Appeared in groin & gradually
extended into the scrotum – like an inguinal hernia, or appeared below the
groin and gradually ascends above – like femoral hernia), what was the size
and extent when it was first appeared? Does it disappear automatically on
lying down? Any severe sharp pain with irreducibility? (Strangulated
hernia), sharp pain in swelling with irreducibility and signs & symptoms
intestinal obstruction? (Obstructed hernia).
4. History relevant to precipitating factors: Chronic cough, tuberculosis,
bronchial asthma or other respiratory diseases; constipation, altered bowel
habits, tenesmus, bloody stool—in relation to anorectal
stricture/carcinoma; ascites or DCLD; dysuria/urgency/hesitancy/altered
stream/night frequency/retention of urine/burning urine/haematuria—in
relation to benign prostatic hyperplasia/urethral stricture .
5. Past history of hernia surgery—same side/opposite side. Type of
surgery whether mesh used or repair done. History appendicectomy done
earlier (ilioinguinal nerve may be injured causing direct hernia) and if so
details about the surgery (can cause right sided direct hernia). Past history
Dr Imran Latif
suggestive of irreducibility/obstruction and treatment received for that
whether conservative/surgical should be asked.
Examination: Patient is first examined in the standing position and
then in the lying position. Both inguinal regions must be exposed from the
level of umbilicus to mid-thigh. He must not bend forward while being
examined. Inspection:
1. Site: Inguinal hernia extends from above the inner part of the inguinal
ligament down to the scrotum. Note if the swelling goes right down to the
bottom of the scrotum (complete) or stops just above the testis
(incomplete). Femoral hernia extends from below the inguinal ligament and
ascends over it.
2. Size:
3. Shape: An indirect hernia is pyriform in shape, with a stalk at the external
inguinal ring. It usually extends down into the scrotum. A direct hernia is
spherical in shape and shows little tendency to enter into the scrotum.
Femoral hernia takes up a spherical shape starting from below and lateral
to the pubic tubercle.
Dr Imran Latif
4. Skin overlying the swelling: In uncomplicated hernia the overlying skin

should be normal. If the hernia is strangulated the skin may be reddened. If
the patient is using truss for a long time, discoloration and streaks of brown
pigmentation due to deposition of haemosiderin may be seen. The
subcutaneous tissue may be atrophied, so the skin may be wrinkled. In case
of recurrent hernia scar of previous operation will be evident. A wide,
irregular and puckered scar indicates wound infection following previous
operation. This is one of the common causes of recurrence.
5. Impulse on Coughing: The patient is asked to turn his face away from the
clinician and to cough. This is done to avoid the salivary shower from the
patient. Look carefully at the superficial inguinal ring. Presence of expansile
cough impulse is almost diagnostic of a hernia, but absence of this sign does
not exclude a diagnosis of hernia. If the neck of the sac is blocked by
adhesions additional viscera will not get access into the sac during
coughing.
Dr Imran Latif
6. Position of penis: This is only important in case of inguinal hernia. A large

hernia in the scrotum will push the penis to the other side.
Palpation: It is palpated systematically from in front, from the side

and from behind.
1. Temperature: Compare to normal abdominal skin.

2. Tenderness:
3. Size: use measuring tape. Size in vertical and transverse
directions.
4. Skin overlying the swelling: pinchable and mobile.
5. Surface: smooth/irregular.
6. Margins: well defined/ill-defined.
7. Consistency: The swelling feels doughy and granular if the hernia
contains omentum (omentocele). It is elastic if it contains intestine
(enterocele). A strangulated hernia feels tense and tender. This is of
great importance in diagnosing this condition.
Dr Imran Latif
8. Position & Extent: If the swelling descends into the scrotum or

labia majora, it is obviously an inguinal hernia. When it remains
confined to the groin, it should be differentiated from a femoral
hernia. Two anatomical structures are considered in this respect —
(a) the pubic tubercle and (b) the inguinal ligament. An inguinal
hernia is positioned above the inguinal ligament and medial to the
pubic tubercle, whereas a femoral hernia lies below the inguinal
ligament and lateral to the pubic tubercle. But it must be
remembered that a large femoral hernia ascends superficial to the
inguinal ligament though its base will still be below the inguinal
ligament. In obese patients it is very difficult to feel the pubic
tubercle. One may follow the tendon of adductor longus upwards to
reach the pubic tubercle.
Dr Imran Latif
9. To get above the swelling: This examination differentiates a
scrotal swelling from an Inguino-scrotal swelling. The root of the
scrotum is held between the thumb in front and other fingers behind
in an attempt to reach above the swelling. In case of inguinal hernia
one cannot get above the swelling, whereas in case of the pure
scrotal swelling one can feel nothing between the fingers except the
structures within the spermatic cord.
10. Impulse on coughing: This examination should always be
performed in standing position of the patient. When there is no
swelling a finger is placed on the superficial inguinal ring and the
patient is asked to cough. A distinguished method to find out
whether the case is one of direct, indirect (oblique) or femoral hernia
is to place the index finger over the deep inguinal ring (1/2 inch
above the mid-inguinal point, which is the midpoint between
anterior superior iliac spine and symphysis pubis), the middle finger
over the superficial inguinal ring and the ring finger over the
saphenous opening (4 cm below and lateral to the pubic tubercle).
Remember this technique (Zieman's technique) can only be applied
when there is no obvious swelling or after the hernia has been
completely reduced. The patient is asked to hold the nose and blow
(this is better according to Zieman) or to cough. When impulse is felt
on the index finger the case is one of indirect hernia, when impulse is
felt on the middle finger the case is one of direct hernia and when it
is felt on the ring finger the case is one of femoral hernia.
Dr Imran Latif
11. Transillumination: it will be absent in case of hernia.

12. Reducibility: The patient is first instructed to lie down on the bed.
In many instances the hernia reduces itself when the patient lies
down (direct hernia). You may ask the patient to reduce the hernia
and in majority of cases the patients can reduce it aptly. In the
remaining cases the patient is asked to flex the thigh of the affected
side and to adduct and rotate it internally. This will not only relax the
pillars of the superficial ring but also will relax the oblique muscles of
the abdomen. The fundus of the sac is gently held with one hand and
even pressure is applied to it to squeeze the contents towards and
abdomen while the other hand will guide the contents through the
superficial inguinal ring. This is known as 'Taxis'. Taxis must be carried
out very gently. Rough handling will bring forth fatal complications.
Note whether the contents reduce with gurgling. This occurs in an
enterocele. In enterocele the first part is often difficult to reduce but
the last part slips in easily. In an omentocele the first part goes in
easily while the last part resents to be reduced.
Dr Imran Latif
13. Deep ring (1/2 inch above the mid-inguinal point, which is
the midpoint between anterior superior iliac spine and
symphysis pubis) occlusion test: When deep ring is occluded
after reducing the contents, if impulse on coughing is absent in
standing position then it is indirect inguinal hernia; if impulse on
coughing is still present then it is direct inguinal hernia.
Dr Imran Latif
14. Finger invagination test: Size of the superficial ring is noted and
site of the impulse felt is observed whether it is in the tip of the
finger or on the pulp.
15. Palpation of testis, epididymis and spermatic cord should be done

without fail. Relation of swelling to testis also should be noted. Testes
are separately palpable in case of hernia.
16. Opposite inguinal region, opposite testis, epididymis and spermatic

cord should be examined. Presence or absence of impulse on
coughing on opposite side should be mentioned.
Dr Imran Latif
17. Bulbar urethra is palpated by lifting the scrotum and feeling in the
midline (To look for thickening and button-like depression—a feature
of stricture urethra).
18. Percussion: Without reducing contents of the swelling, percussion

is done over the surface. If it is resonant, it is enterocele. If it is dull
on percussion then it is omentocele.
19. Auscultation: Bowel sounds may be heard over the swelling if it is
enterocele.
20. Abdominal Examination & DRE: it is mandatory to perform.
Malgaigne’s bulgings —minor bulging of both inguinal

canal region in head -raising test. T his is normal and
seen when the muscles are weak .
Dr Imran Latif
When the hernial sac contains a portion of the

circumference of the bowel then it is called
Richter’s hernia.
When the wall of the hernial sac (usually the posterior wall) is formed by a
viscus then it is called a sliding hernia. On the right cecum or urinary
bladder may form the posterior wall of the sac and on the left side sigmoid
or urinary bladder may form the posterior wall of the hernial sac.
Dr Imran Latif
3 Types of inguinal hernias depending upon distal extent:

• Bubonocele: is an incomplete inguinal hernia where the hernial sac is
confined to the inguinal canal.
• Funicular type: in this type the hernial sac goes beyond the superficial
inguinal ring and reaches upper pole of testis. The testis and epididymis
can be felt separately from the hernial contents.
• Complete hernia: the hernial contents reaches up to the bottom of
scrotum. Testis and epididymis could not be felt separately from the
hernial swelling.
Maydl’s Hernia?
This is the so-called W loop hernia where the small

intestine forms a W loop within the hernial sac. The
importance of this type of hernia is in case of
Obstruction, even if the visible intestine inside the
sac is viable, if one is not pulling out the rest of the
intestine, you are likely to miss gangrene for the
rest of the bowel.
Dr Imran Latif
Hernial sac containing Meckel’s diverticulum as the content is called

Littre’s hernia.
A pantaloon (saddle bag) hernia is described as having both a direct and

indirect inguinal hernial sac lying on either side of inferior epigastric
vessels. It is also known as dual hernia.
Untreated the hernias may lead to a number of complications. These

includes: Irreducible hernia, Obstructed hernia, Incarcerated hernia,
Strangulated hernia, Inflamed hernia due to inflammation of the
contents of hernia, Hydrocoele of the hernial sac.
Dr Imran Latif
Strangulated hernia: Due to impairment of blood supply there is

ischaemic necrosis of the hernial contents. The hernial swelling
becomes irreducible, no cough impulse, tense, tender and there may
be rebound tenderness.
Incarcerated hernia: This is a type of obstructed hernia where the lumen of the colon is blocked with faecal
matter. The hernial contents may be indented with the finger. The term incarcerated hernia is often used as
an alternative to obstructed or strangulated hernia. Contents are fixed in the sac because of their size &
adhesions.
Obstructed hernia: Hernia containing intestine may lead to acute

intestinal obstruction due to obstruction of the lumen of the gut
inside the hernia.
Inflamed hernia: When the contents of the hernial sac get inflamed, this is known as
inflamed hernia. Patient complains of pain over the swelling and may be febrile. The
hernia may become irreducible, there may be localized tenderness over the hernia.
Dr Imran Latif
Triangle of pain is formed by gonadal vessels medially, iliopubic tract laterally and
peritoneal reflection below. Genitofemoral nerve and lateral cutaneous nerve of
thigh traverse this triangle. Injury to these nerves either by dissection or by tack
(during laparoscopic hernia repair) cause postoperative pain. Tacks/staplers should
not be placed in this triangle.
External iliac vessels lie in a triangle formed by gonadal vessels laterally, vas deferens
medially and peritoneal reflection inferiorly (triangle of doom).
Dr Imran Latif
Dr Imran Latif

Iguinal Hernia Examination-1

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Inguinal Hernia & inguinoscrotal region Examination

4. Skin overlying the swelling: In uncomplicated hernia the overlying skin

6. Position of penis: This is only important in case of inguinal hernia. A large

Palpation: It is palpated systematically from in front, from the side

1. Temperature: Compare to normal abdominal skin.

8. Position & Extent: If the swelling descends into the scrotum or

11. Transillumination: it will be absent in case of hernia.

15. Palpation of testis, epididymis and spermatic cord should be done

16. Opposite inguinal region, opposite testis, epididymis and spermatic

18. Percussion: Without reducing contents of the swelling, percussion

Malgaigne’s bulgings —minor bulging of both inguinal

When the hernial sac contains a portion of the

3 Types of inguinal hernias depending upon distal extent:

This is the so-called W loop hernia where the small

Hernial sac containing Meckel’s diverticulum as the content is called

A pantaloon (saddle bag) hernia is described as having both a direct and

Untreated the hernias may lead to a number of complications. These

Strangulated hernia: Due to impairment of blood supply there is

Obstructed hernia: Hernia containing intestine may lead to acute

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