Hernias Clinical Presentation

Patients with hernias present to the emergency department (ED) secondary to a complication associated with the hernia. Hernias also may be detected in the ED on routine physical examination. However, in relation to the chief complaint, the following clinical issues must be considered:

• Asymptomatic hernia

  • Presents as a swelling or fullness at the hernia site
  • Aching sensation (radiates into the area of the hernia)
  • No true pain or tenderness upon examination
  • Enlarges with increasing intra-abdominal pressure and/or standing
• Incarcerated hernia

  • Painful enlargement of a previous hernia or defect
  • Cannot be manipulated (either spontaneously or manually) through the fascial defect
  • Nausea, vomiting, and symptoms of bowel obstruction (possible)
• Strangulated hernia

  • Symptoms of an incarcerated hernia present combined with a toxic appearance
  • Systemic toxicity secondary to ischemic bowel is possible
  • Strangulation is probable if pain and tenderness of an incarcerated hernia persist after reduction
  • Suspect an alternative diagnosis in patients who have a substantial amount of pain without evidence of incarceration or strangulation

Further anatomic considerations must be assessed in relation to the above clinical findings. The location of the underlying hernia may provide a unique constellation of symptoms with or without specific anatomic findings.

• Femoral hernia

  • Medial thigh pain as well as groin pain are possible because of the position of this hernia
• Obturator hernia

  • Because this hernia is hidden within deeper structures, it may not present as a swelling
  • The patient may complain of abdominal pain or medial thigh pain, weight loss, or recurrent episodes of bowel or partial bowel obstruction
  • Pressure on the obturator nerve causes pain in the medial thigh that is relieved by thigh flexion. This same pain may be exacerbated by extension or external rotation of the hip (Howship-Romberg sign)
• Incisional hernia

  • As these are usually asymptomatic, patients present with a bulge at the site of a previous incision
  • Lesion may become larger upon standing or with increasing intra-abdominal pressure

In general, the physical examination should be performed with the patient in both the supine and standing positions, with and without the Valsalva maneuver. The examiner should attempt to identify the hernia sac as well as the fascial defect through which it is protruding. This allows proper direction of pressure for reduction of hernia contents. The examiner should also identify evidence of obstruction and strangulation.

• When attempting to identify a hernia, look for a swelling or mass in the area of the fascial defect.

  • Place a fingertip into the scrotal sac and advance up into the inguinal canal. If the hernia is elsewhere on the abdomen, attempt to define the borders of the fascial defect.
  • If the hernia comes from superolateral to inferomedial and strikes the distal tip of the finger, it most likely is an indirect hernia.
  • If the hernia strikes the pad of the finger from deep to superficial, it is more consistent with a direct hernia.
• A bulge felt below the inguinal ligament is consistent with a femoral hernia.
• Strangulated hernias are differentiated from incarcerated hernias by the following:

  • Pain out of proportion to examination findings
  • Fever or toxic appearance
  • Pain that persists after reduction of hernia

Any condition that increases the pressure in the intra-abdominal cavity may contribute to the formation of a hernia, including the following:

• Marked obesity
• Heavy lifting
• Coughing
• Straining with defecation or urination
• Ascites
• Peritoneal dialysis
• Ventriculoperitoneal shunt
• Chronic obstructive pulmonary disease (COPD)
• Family history of hernias^[14]