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'''Original Editors '''- Lindsey Roederer and Stephanie McCauley [[Pathophysiology of Complex Patient Problems|from Bellarmine University's Pathophysiology of Complex Patient Problems project.]]  
'''Original Editors '''- Lindsey Roederer and Stephanie McCauley [[Pathophysiology of Complex Patient Problems|from Bellarmine University's Pathophysiology of Complex Patient Problems project.]]  


'''Lead Editors''' - Your name will be added here if you are a lead editor on this page.  [[Physiopedia:Editors|Read more.]]
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== Definition/Description<br> ==
== Introduction ==
[[File:InguinalHernia.png|thumb|Inguinal Hernia, direct.]]
Inguinal [[Hernia|hernias]] (IH) are groin herniation that occurs above the inguinal ligament and through the inguinal canal. They are a subset of abdominal wall hernias.<ref name=":0">Radiopedia Inguinal Hernia Available: https://radiopaedia.org/articles/inguinal-hernia<nowiki/>(accessed 20.12.2022)</ref>


Inguinal hernias occur when soft tissue, usually intestines, protrudes from the abdominal cavity. &nbsp;There are two types of inguinal hernias that occur in the groin region - direct and indirect.<ref name="Pathology Book" /> &nbsp;
Classification: broadly divided into two types:


A '''direct hernia''' occurs when a portion of the intestine protrudes directly outward through a weak point in the abdominal wall. &nbsp;This weak point could be caused by a deficiency in the number of transversus abdominus aponeurotic fibers. &nbsp;The inguinal triangle (Hesselbach's triangle) is a common location for direct hernias to occur.<ref name="Pathology Book" /> &nbsp;A direct inguinal hernia leaves the abdominal cavity medial to the inferior epigastric vessels.<ref name="Grant">Tank, PW, Grant's Dissector. The Abdomen. Lippincott, Williams, and Wilkins, 2013. p95-6.</ref> &nbsp;
# Direct hernia: occurs when a portion of the intestine protrudes directly outward through a weak point in the abdominal wall eg may be caused by a deficiency in the number of [[Transversus Abdominis|transversus abdominus]] [[Aponeurosis|aponeurotic]] fibers. &nbsp;
# Indirect hernia: occurs when a portion of the intestine pushes downward through the deep inguinal ring into the inguinal canal where the testes descend into the scrotum before birth (males) or to the labia (females)&nbsp;<ref name="Pathology Book">Goodman CC, Fuller KS, Pathology: Implications for the Physical Therapist. The Gastrointestinal System. Saunders, Elsevier Inc., 2009. p870-74.</ref>


An '''indirect hernia''' occurs when a portion of the intestine pushes downward through the deep inguinal ring into the inguinal canal where the testes descend into the scrotum before birth (males) or to the labia (females)&nbsp;<ref name="Pathology Book" />&nbsp;An indirect inguinal hernia leaves the abdominal cavity lateral to the inferior epigastric vessels.<ref name="Grant" />&nbsp;
== Epidemiolgy ==
[[Abdominal Muscles|Abdominal wall]] hernias are common, with a prevalence of 1.7% for all ages and 4% for those aged over 45 years. Inguinal hernias account for 75% of abdominal wall hernias, lifetime risk of 27% in men and 3% in women.<ref>Jenkins JT, O’dwyer PJ. Inguinal hernias. Bmj. 2008 Jan 31;336(7638):269-72.Available;https://www.bmj.com/content/336/7638/269 (accessed 20.12 2022)</ref> They are most often acquired.<ref name=":0" />  


<br>  
Little is known about the epidemiology of inguinal hernia, a common easily treatable surgical condition, in resource-poor settings.<ref>Beard JH, Oresanya LB, Ohene-Yeboah M, Dicker RA, Harris HW. Characterizing the global burden of surgical disease: a method to estimate inguinal hernia epidemiology in Ghana. World journal of surgery. 2013 Mar;37(3):498-503. Available:https://pubmed.ncbi.nlm.nih.gov/23224074/ (accessed 20.12.2022)</ref>


[[Image:17075.jpg|left]]  
== Etiology ==
[[File:Common Sites of Lower Abdominal Hernias.jpg|thumb|Depicts direct and indirect IH]]
Increased risk for


[[Image:Inguinal triangle.png|right|350x350px]]<br>
# Indirect inguinal hernia include: Prematurity and low birth weight; urologic conditions; abdominal wall defects; family history
# Direct inguinal hernia, is a consequence of weakened abdominal musculature, often brought on by: Advanced age; strain; previous abdominal surgery


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<br>  
Direct hernias, in particular, are rare in women since the broad ligament (uterine ligament) acts as an additional barrier.<ref name=":0" />


&nbsp; &nbsp;&nbsp;<ref>Inguinal Hernia. PubMed Health. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001956/</ref>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<ref>Inguinal Hernia. http://commons.wikimedia.org/wiki/File:Inguinal_triangle.png (accessed 5 March 2013)</ref>
== Characteristics/Clinical Presentation ==


== Prevalence  ==
An inguinal hernia can present with the following signs and symptoms:  
 
Rougly 5 million Americans of all ages have some type of abdominal hernia. &nbsp;Inguinal hernias account for 75% of all hernias. &nbsp;They affect 2% of men in the United States. &nbsp;<ref name="Pathology Book">Goodman CC, Fuller KS, Pathology: Implications for the Physical Therapist. The Gastrointestinal System. Saunders, Elsevier Inc., 2009. p870-74.</ref>&nbsp; &nbsp;It is estimated that approximately 25% of males and 2% of females will have an inguinal hernia during their lifetime. Children can also have inguinal hernias. &nbsp;The incident rate for children ranges up to 4.5%.<ref name="Medscape" />&nbsp; Direct inguinal hernias are more common in older adults, whereas indirect inguinal hernias occur more often in infants, males, and young people.&nbsp;<ref name="Pathology Book" />&nbsp; In general, indirect inguinal hernias are more common than direct inguinal hernias having a frequency that ranges from two-thirds to three-fourths of inguial hernias. &nbsp;<ref name="Clinical">Moore KL, et al, Essential Clinical Anatomy. Abdomen. Lippincott, Williams, and Wilkins, 2011. p134-5.</ref><br>
 
In the United States, over 1 million abdominal hernia repairs are performed each year. &nbsp;Of those 1 million repairs, it is estimated that 770,000 of them are inguinal hernia repairs. &nbsp;Males receive 90% of all inguinal hernia repairs.<ref name="Medscape">Medscape Reference. Hernias. http://emedicine.medscape.com/article/775630-overview#a0199 (accessed 8 February 2013)</ref>
 
== Characteristics/Clinical Presentation<br>  ==
 
'''An inguinal hernia can present with the following signs and symptoms:'''


*Intermittent or persistent bulge in the groin&nbsp;<ref name="Pathology Book" />  
*Intermittent or persistent bulge in the groin&nbsp;<ref name="Pathology Book" />  
*Pain or discomfort in the groin, especially when lifting, coughing, or bending<ref name="Mayo" />  
*Pain or discomfort in the groin, especially when lifting, coughing, or bending<ref name="Mayo">Mayo Clinic. Inguinal Hernia. http://www.mayoclinic.com/health/inguinal-hernia/DS00364/DSECTION=symptoms (accessed 10 February 2013)</ref>
*Weakness or pressure in the groin<ref name="Mayo" />  
*Weakness or pressure in the groin<ref name="Mayo" />  
*Men can experience pain and swelling in the scrotum<ref name="Mayo" />
*Men can experience pain and swelling in the scrotum<ref name="Mayo" />


Inguinal hernias tend to be more noticeable following a heavy meal or after standing for a prolonged period of time. The pain associated with an inguinal hernia is usually sharp and localized. It can be heightened by changes in position, physical exertion, and with any activity causing the Valsalva maneuver.<ref name="Pathology Book" /><br>
Inguinal hernias tend to be more noticeable following a heavy meal or after standing for a prolonged period of time. The pain associated with an inguinal hernia is usually sharp and localized. It can be heightened by changes in position, physical exertion, and with any activity causing the [[Valsalva Test|Valsalva]] maneuver.<ref name="Pathology Book" />
 
<br>
 
{| width="800" border="1" align="center" cellpadding="1" cellspacing="1"
|-
! scope="col" width="100" bgcolor="#ffff66" | Type
! scope="col" width="200" bgcolor="#ffff66" | Location
! scope="col" width="225" bgcolor="#ffff66" | Signs/Symptoms
! scope="col" bgcolor="#ffff66" width="200" | Picture
|-
! scope="row" |
Direct
 
Hernia
 
<ref name="Pathology Book" />
 
| width="175" align="left" valign="middle" | It is typically located superior to the inguinal ligament, but behind and through the inguinal ring. It rarely enters the scrotum.
| width="200" |
*Usually painless
*Reduces when person lies supine
*Round swelling near pubis in area of deep inguinal ring
 
| width="250" | [[Image:DIRECTH.jpg|thumb|center]]<ref name="AMC">Albany Medical Center. Inguinal Hernia. http://academic.amc.edu/martino/grossanatomy/site/Medical/CASES/GI/pop%20ups/hernia%20anspop_up2.htm (accessed 5 March 2013)</ref><br>
|-
! scope="row" |
<br> Indirect
 
Hernia
 
<ref name="Pathology Book" />  
 
| width="175" valign="middle" | The contained sac protrudes through the deep inguinal ring. The tissue can remain in the canal or pass into the scrotum (men) or labia (women).
| width="200" |
*Pain with straining
*May decrease when person lies supine
*Swelling that increases as intraabdominal pressure rises
 
|
[[Image:INDIRHER.jpg|thumb|center]]<ref name="AMC" />
 
|}
 
<br>
 
== Associated Co-morbidities  ==
 
Inguinal hernia may be associated with the following co-morbidities<ref name="comorbid">U.S.  National Library of Medicine. Hernia. http://www.nlm.nih.gov/medlineplus/ency/article/000960.htm (accessed 2 Feb 2013)</ref>:


*Congenital abdominal weakness
== Differential Diagnosis&nbsp; ==
*Chronic constipation
Possible imaging differential considerations include
*Chronic cough
*Enlarged prostate
*Cystic fibrosis
*Overweight, obesity, or pregnancy
*Ascites
*Smoking
*Overexertion
*Undescended testicles
*Any condition that increases pressure on the abdominal wall<br>


# femoral hernia: often remain lateral to the pubic tubercle and compress the femoral vein
# hydrocele (may coexist)
# varicocele<ref name=":0" />
== Medications  ==
== Medications  ==
[[Antibiotics]] are prescribed for strangulated hernias if ischemic bowel or infection&nbsp;is suspected. Over-the counter or prescribed [[Pain Medications|medication for pain relief]]&nbsp;is utilized following surgical procedures<ref name="discharge">U.S. National Library of Medicine. Inguinal Hernia- discharge. http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000274.htm (accessed 2 Feb 2013)</ref>.


Antibiotics are prescribed for strangulated hernias if ischemic bowel or infection&nbsp;is suspected. Over-the counter or prescribed medication for pain relief&nbsp;is utilized following surgical procedures<ref name="discharge">U.S. National Library of Medicine. Inguinal Hernia- discharge. http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000274.htm (accessed 2 Feb 2013)</ref>.<br><br>
== Surgery ==
 
[[File:Inguinal Hernia Repair.png|right|frameless|333x333px]]
== Diagnostic Tests/Lab Tests/Lab Values  ==
[[Surgery and General Anaesthetic|Surgical]] treatment options include  
 
To diagnose an inguinal hernia, the doctor obtains a thorough medical history and conducts a physical examination. The patient will be asked to stand and/or cough as the doctor palpates the suspected hernia for movement. Typically, no diagnostic tests are necessary, but an ultrasound or CT scan may be utilized in some cases.<br>
 
== Etiology/Causes<br>  ==
 
{| width="225" border="1" align="right" cellpadding="1" cellspacing="1"
|-
| align="center" valign="middle" bgcolor="#00ccff" | '''Risk Factors'''
|-
| 1. Abdominal wall defects<br>2. Advanced age<br>3. Ascites<br>4. Connective tissue disorders<br>5. Cystic fibrosis<br>6. Prematurity<br>7. Positive family history<br>8. Shunt for hydrocephalus<br>9. Undescended testis<ref name="Pathology Book" />
|}
 
Herniations can be caused by a multitude of factors. &nbsp;A&nbsp;'''direct inguinal hernia''' is caused &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; by an acquired weakness such as obesity, pregnancy, muscle atrophy, chronic cough, &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; ascites, heavy lifting, straining during bowel movements or urination, surgical incision, or &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; blunt pressure from a trauma. &nbsp;An&nbsp;'''indirect inguinal hernia''' can be congenital or acquired.<ref name="Pathology Book" /> &nbsp;
 
<br>
 
There are several factors that can predispose a person to a hernia such as situational stress, degenerative changes associated with an increase in abdominal pressure, producing several &nbsp; &nbsp; &nbsp; offspring during one gestation, altered collagen synthesis in middle age, and simply the wear and &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; tear of the body over time.&nbsp;<ref name="Pathology Book" />
 
<br>
 
<br>
 
== Systemic Involvement  ==
 
'''''Gastrointestinal&nbsp;'''''<i>-</i> In the case of an inguinal hernia, abdominal&nbsp;contents protrude through a defect in the fascia. An inguinal hernia can become incarcerated,&nbsp;in which&nbsp;a piece of intestine or fat becomes trapped in the hernia opening and an obstruction occurs. In a strangulated hernia, the blood supply gets cut off and a portion of the intestine may die. Symptoms of a strangulated hernia or intestinal obstruction include pain, nausea, vomiting, inability to flatulate or have a bowel movement, fever, chills, and/or abdominal swelling. This is a medical emergency and requires immediate surgical treatment<ref name="inguinal" />.
 
<br>
 
'''''Cardiovasular&nbsp;'''''<i>-</i> In the case of surgical hernia repair, complications from surgical intervention may include cardiac arrest, cardiac arrythmias, damage to blood vessels, excessive bleeding, and formation of blood clots<ref name="inguinal" />.
 
<br>
 
'''''Integumentary&nbsp;'''''<i>-</i> Depending on the severity of protrusion, the various layers of the integumentary system may be affected. In this situation, typical presentation is redness and inflammation of the skin covering the hernia. Following inguinal hernia repair, wound management of the surgical incision is necessary to prevent infection&nbsp;and excessive scar tissue formation. Signs of infection include redness, swelling, pain, and discharge<ref name="discharge" />.
 
<br>
 
'''''Reproductive&nbsp;'''''<i>-</i>&nbsp;A long-standing inguinal hernia may negatively affect the microstructure of the testis and spermatic tract. Pressure or protrusion into the scrotum interrupts the thermoregulatory process of the testis&nbsp;and&nbsp;disrupts the production of sperm<ref name="reproductive">MT Zaidi, Khan AA. Effects of longstanding inguinal hernia on the microstructure of testis and spermatic tract system.  Biomedical Research 2011; 22(2):183-186. Available from: http://www.biomedres.org/journal/pdf/463.pdf (accessed 12 Feb 2013)</ref>.
 
== Medical Management (current best evidence)  ==
 
If the hernia is small, it may be managed conservatively with activity modification and observation by the physician. However, if the intestines become trapped inside the hernia, it can be life threatening situation. Immediate surgery will be necessary in this case. Additionally, inguinal hernias that continue to enlarge or cause symptoms are treated surgically. In children, inguinal hernias are surgically repaired to prevent entrapment of abdominal contents from occurring. Inguinal hernia repairs are typically treated on an outpatient basis and will be surgically managed by one of the following methods<ref name="inguinal">U.S. Department of Health and Human Services. Inguinal Hernia. http://digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/index.aspx (accessed 2 Feb 2013)</ref>:
 
<br>
 
*'''''Herniorrhaphy''' (Open hernia repair)&nbsp;''- Local or general anesthesia is administered. The surgeon makes an incision in the groin, moves the hernia back into the abdomen, and reinforces the muscle wall with stitches.
 
<br>
 
*'''''Laparoscopy'''&nbsp;''- General anesthesia is administered. The surgeon inserts a laparoscope in the lower abdomen and repairs the hernia using synthetic mesh. Typically, patients experience a shorter recovery time and fewer complications.
 
<br>
 
*'''''Hernioplasty'''&nbsp;''- The area of muscle weakness is reinforced with a synthetic mesh or screen to provide additional support. This method may be utilized in open or laparoscopic repairs.
 
<br>Medication is prescribed for pain management following surgery. Vigorous activity and heavy lifting are restricted for several weeks<ref name="discharge" />.<br><br>
 
== Physical Therapy Management (current best evidence)  ==
 
'''''Education'''''<i>&nbsp;</i>- Physical therapists educate clients on work strategies, including body mechanics, proper breathing, and lifting techniques. By reducing strain and increased intraabdominal pressure, one may decrease the risk of developing a hernia or worsening an already existing hernia<ref name="Pathology Book" />.<br>
 
'''''Screening&nbsp;'''''<i>-</i> Obtaining a thorough medical history and conducting a physical examination is critical in determining the need for potential referral to a physician for diagnosis of an inguinal hernia. To palpate for an inguinal hernia, place hand at the location of the inguinal canal, superior to inguinal ligament and just lateral to the scrotum. Have the patient strain down or cough in standing to feel for a palpable mass&nbsp;<ref name="Clinical" />.<br>
 
'''''Postoperative Rehabilitation&nbsp;'''''<i>-</i> Often, patients are not seen for post-operative rehabilitation of an inguinal hernia repair. However, patients may require physical therapy services in order to return to prior level of function. A rehabilitation program will include posture exercises, education of proper body mechanics, and core strengthening. The program will be progressed as appropriate to include sport or work-specific functional activities<ref name="Pathology Book" />. <br>
 
== Alternative/Holistic Management (current best evidence)  ==
 
With inguinal hernias that present with minimal symptoms, it is acceptible to watch and wait instead of opting for surgical repair. Supports and trusses can be used as a short term option to contain the hernia and prevent it from increasing in size. Also, there are strapping techniques available to contain the hernia; however, they are not recommended for use because the tape could cause an ulceration of the skin covering the hernia.<ref name="Pathology Book" />
 
During the acute phase when the hernia is small in size, it can be reduced by pushing it back in place. &nbsp;A person could manually push it back into place using their hands. &nbsp;If swelling is an issue, one could place ice over the affected area prior to pushing the contents back into the abdominal cavity. &nbsp;Additionally, one could lie with their pelvis higher than their head to assist them in pushing it back in place.<ref name="Mayo">Mayo Clinic. Inguinal Hernia. http://www.mayoclinic.com/health/inguinal-hernia/DS00364/DSECTION=symptoms (accessed 10 February 2013)</ref>
 
== Differential Diagnosis&nbsp;  ==


<br>It is critical to differentiate between an inguinal hernia and other conditions that may present with similar signs and symptoms<ref name="BMJ">British Medical Journal. Inguinal Hernia Differential Diagnosis.  http://bestpractice.bmj.com/best-practice/monograph/723/diagnosis/differential.html (accessed 2 Feb 2013)</ref><ref name="medscape">Medscape. Hernias Differential Diagnoses. http://emedicine.medscape.com/article/775630-differential (accessed 2 Feb 2013)</ref> .  
*Herniorrhaphy (Open hernia repair)&nbsp;- Local or general anesthesia is administered. The surgeon makes an incision in the groin, moves the hernia back into the abdomen, and reinforces the muscle wall with stitches.


<br>
*Hernioplasty&nbsp;- The area of muscle weakness is reinforced with a synthetic mesh or screen to provide additional support. This method may be utilized in open or laparoscopic repairs.


{| width="744" align="center" border="1" cellspacing="1" cellpadding="1"
Medication is prescribed for pain management following surgery. Vigorous activity and heavy lifting are restricted for several weeks<ref name="discharge" />.
|-
| align="center" valign="middle" bgcolor="#99ff00" |
'''Condition'''


| align="center" valign="middle" bgcolor="#99ff00" |
== Conservative Management ==
'''Differentiating Signs and Symptoms'''
Generally inguinal hernias should be repaired. M Hammoud and J Gerken (2018)<ref name=":1" /> state this has been brought into question in recent reports. Possibly watchful waiting is a safe and acceptable option for those with who are asymptomatic or minimally symptomatic. The as the risk of incarceration and strangulation recent studies was minimal.<ref name=":1">Hammoud M, Gerken J. Inguinal hernia.Available:https://www.ncbi.nlm.nih.gov/books/NBK513332/ (accessed 20.12.2022)</ref>


|-
== Physical Therapy Management ==
| align="center" valign="middle" | '''Undescended testis'''
|
*Groin mass
*Underdeveloped scrotum with absent testis on affected side
*Not associated with cough impulse


|-
'''''Education'''''<i>&nbsp;</i>- Physical therapists educate clients on work strategies, including body mechanics, proper breathing, and [[Lifting|lifting techniques]]. By reducing strain and increased intraabdominal pressure, one may decrease the risk of developing a hernia or worsening an already existing hernia<ref name="Pathology Book" />.
| align="center" valign="middle" | '''Enlarged lymph nodes'''  
|
*May be associated with infection, trauma, or malignancy
*Able to palpate above mass and may be moveable
*Not associated with cough impulse


|-
'''''Screening&nbsp;'''''<i>-</i> Obtaining a thorough medical history and conducting a physical examination is critical in determining the need for potential referral to a physician for diagnosis of an inguinal hernia. To palpate for an inguinal hernia, place hand at the location of the inguinal canal, superior to inguinal ligament and just lateral to the scrotum. Have the patient strain down or cough in standing to feel for a palpable mass&nbsp;<ref name="Clinical">Moore KL, et al, Essential Clinical Anatomy. Abdomen. Lippincott, Williams, and Wilkins, 2011. p134-5.</ref>.<br>'''''Postoperative Rehabilitation&nbsp;'''''<i>-</i> Often, patients are not seen for post-operative rehabilitation of an inguinal hernia repair. However, patients may require physical therapy services in order to return to prior level of function. A rehabilitation program will include posture exercises, education of proper body mechanics, and core strengthening. The program will be progressed as appropriate to include sport or work-specific functional activities<ref name="Pathology Book" />.
| align="center" valign="middle" | '''Psoas abscess'''  
|
*Softer bulge, ill-defined borders
*Often accompanied with low back and buttock pain
*Fever, weight loss, diaphoresis, cough
*Recent contact with infection


|-
See also [[Assessment of Fitness for Return to Work]]
| align="center" valign="middle" | '''Femoral aneurysm'''
|
*Pulsing mass
 
|-
| align="center" valign="middle" | '''Epididymitis'''
|
*Testicular pain
*Discharge
*Painful urination
*Fever, chills
 
|-
| align="center" valign="middle" | '''Hydrocele'''
|
*Non-tender swollen testicle
*May be seen in addition to an inguinal hernia
 
|-
| align="center" valign="middle" | '''Femoral hernia'''
|
*Contents through femoral canal; difficult to differentiate from inguinal hernia
 
|-
| align="center" valign="middle" | '''Athletic pubalgia'''
|
*Often no palpable mass
*Testicular pain
 
|}
 
== &nbsp;Case Reports/ Case Studies  ==
 
DeSantana JM, et al.&nbsp;Hypoalgesic Effect of the Transcutaneous Electrical Nerve Stimulation Following Inguinal Herniorrhaphy: A Randomized, Controlled Trial. The Journal of Pain [Internet]. 2008 [cited 2013 Feb 9]; 9(7): 623-629. Available from: http://www.sciencedirect.com.echo.louisville.edu/science/article/pii/S1526590008003878#<br>
 
Pesanelli KE, Cigna JA, Basu SG, Morin AR. Occupational rehabilitation following open mesh surgical repair of an inguinal hernia. Phys Ther [Internet]. 2003 Jan [cited 2013 Feb 2]; 83(1): 58-66. Available from: [http://ptjournal.apta.org/content/83/1/58.full ptjournal.apta.org/content/83/1/58.full]
 
Unverzagt CA, Schuemann T, Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete. J of Orthop Sports Phys Ther [Internet]. 2008 [cited 2013 Feb 2]; 38(2): 63-70. Available from:&nbsp;[http://ejournals.ebsco.com.libproxy.bellarmine.edu/Direct.asp?AccessToken=5WJ4W49TRWSVPUZPR4PZQUPSWPY6TJW9UW&Show=Object ejournals.ebsco.com.libproxy.bellarmine.edu/Direct.asp]&nbsp;<br><br>
 
== Resources <br>  ==
 
[http://www.facs.org/public_info/operation/brochures/hernrep.pdf Brochure on Hernia Repairs]  
 
[http://www.herniainfo.com/ Hernia Resource Center]
 
[http://www.nlm.nih.gov/medlineplus/hernia.html#cat64 Medline Plus: Videos, Interactive Tutorials, and Patient Handouts]
 
[http://digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/index.aspx U.S. Department of Health and Human Services: Digestive Diseases]<br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox"></div><div class="researchbox"><rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1VE-4vX3y68YgZGqIvHvzqC-v_P9VF90LTBhtLxyNuhTv1FMLD|charset=UTF-8|short|max=10</rss></div>
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />  
<references />  


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Latest revision as of 02:53, 23 December 2022

 

Original Editors - Lindsey Roederer and Stephanie McCauley from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Admin, Lindsey Roederer, Stephanie McCauley, Lucinda hampton, Elaine Lonnemann, WikiSysop, Kim Jackson and Wendy Walker  

Introduction[edit | edit source]

Inguinal Hernia, direct.

Inguinal hernias (IH) are groin herniation that occurs above the inguinal ligament and through the inguinal canal. They are a subset of abdominal wall hernias.[1]

Classification: broadly divided into two types:

  1. Direct hernia: occurs when a portion of the intestine protrudes directly outward through a weak point in the abdominal wall eg may be caused by a deficiency in the number of transversus abdominus aponeurotic fibers.  
  2. Indirect hernia: occurs when a portion of the intestine pushes downward through the deep inguinal ring into the inguinal canal where the testes descend into the scrotum before birth (males) or to the labia (females) [2]

Epidemiolgy[edit | edit source]

Abdominal wall hernias are common, with a prevalence of 1.7% for all ages and 4% for those aged over 45 years. Inguinal hernias account for 75% of abdominal wall hernias, lifetime risk of 27% in men and 3% in women.[3] They are most often acquired.[1]

Little is known about the epidemiology of inguinal hernia, a common easily treatable surgical condition, in resource-poor settings.[4]

Etiology[edit | edit source]

Depicts direct and indirect IH

Increased risk for

  1. Indirect inguinal hernia include: Prematurity and low birth weight; urologic conditions; abdominal wall defects; family history
  2. Direct inguinal hernia, is a consequence of weakened abdominal musculature, often brought on by: Advanced age; strain; previous abdominal surgery

Direct hernias, in particular, are rare in women since the broad ligament (uterine ligament) acts as an additional barrier.[1]

Characteristics/Clinical Presentation[edit | edit source]

An inguinal hernia can present with the following signs and symptoms:

  • Intermittent or persistent bulge in the groin [2]
  • Pain or discomfort in the groin, especially when lifting, coughing, or bending[5]
  • Weakness or pressure in the groin[5]
  • Men can experience pain and swelling in the scrotum[5]

Inguinal hernias tend to be more noticeable following a heavy meal or after standing for a prolonged period of time. The pain associated with an inguinal hernia is usually sharp and localized. It can be heightened by changes in position, physical exertion, and with any activity causing the Valsalva maneuver.[2]

Differential Diagnosis [edit | edit source]

Possible imaging differential considerations include

  1. femoral hernia: often remain lateral to the pubic tubercle and compress the femoral vein
  2. hydrocele (may coexist)
  3. varicocele[1]

Medications[edit | edit source]

Antibiotics are prescribed for strangulated hernias if ischemic bowel or infection is suspected. Over-the counter or prescribed medication for pain relief is utilized following surgical procedures[6].

Surgery[edit | edit source]

Inguinal Hernia Repair.png

Surgical treatment options include

  • Herniorrhaphy (Open hernia repair) - Local or general anesthesia is administered. The surgeon makes an incision in the groin, moves the hernia back into the abdomen, and reinforces the muscle wall with stitches.
  • Hernioplasty - The area of muscle weakness is reinforced with a synthetic mesh or screen to provide additional support. This method may be utilized in open or laparoscopic repairs.

Medication is prescribed for pain management following surgery. Vigorous activity and heavy lifting are restricted for several weeks[6].

Conservative Management[edit | edit source]

Generally inguinal hernias should be repaired. M Hammoud and J Gerken (2018)[7] state this has been brought into question in recent reports. Possibly watchful waiting is a safe and acceptable option for those with who are asymptomatic or minimally symptomatic. The as the risk of incarceration and strangulation recent studies was minimal.[7]

Physical Therapy Management[edit | edit source]

Education - Physical therapists educate clients on work strategies, including body mechanics, proper breathing, and lifting techniques. By reducing strain and increased intraabdominal pressure, one may decrease the risk of developing a hernia or worsening an already existing hernia[2].

Screening - Obtaining a thorough medical history and conducting a physical examination is critical in determining the need for potential referral to a physician for diagnosis of an inguinal hernia. To palpate for an inguinal hernia, place hand at the location of the inguinal canal, superior to inguinal ligament and just lateral to the scrotum. Have the patient strain down or cough in standing to feel for a palpable mass [8].
Postoperative Rehabilitation - Often, patients are not seen for post-operative rehabilitation of an inguinal hernia repair. However, patients may require physical therapy services in order to return to prior level of function. A rehabilitation program will include posture exercises, education of proper body mechanics, and core strengthening. The program will be progressed as appropriate to include sport or work-specific functional activities[2].

See also Assessment of Fitness for Return to Work

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Radiopedia Inguinal Hernia Available: https://radiopaedia.org/articles/inguinal-hernia(accessed 20.12.2022)
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Goodman CC, Fuller KS, Pathology: Implications for the Physical Therapist. The Gastrointestinal System. Saunders, Elsevier Inc., 2009. p870-74.
  3. ↑ Jenkins JT, O’dwyer PJ. Inguinal hernias. Bmj. 2008 Jan 31;336(7638):269-72.Available;https://www.bmj.com/content/336/7638/269 (accessed 20.12 2022)
  4. ↑ Beard JH, Oresanya LB, Ohene-Yeboah M, Dicker RA, Harris HW. Characterizing the global burden of surgical disease: a method to estimate inguinal hernia epidemiology in Ghana. World journal of surgery. 2013 Mar;37(3):498-503. Available:https://pubmed.ncbi.nlm.nih.gov/23224074/ (accessed 20.12.2022)
  5. ↑ 5.0 5.1 5.2 Mayo Clinic. Inguinal Hernia. http://www.mayoclinic.com/health/inguinal-hernia/DS00364/DSECTION=symptoms (accessed 10 February 2013)
  6. ↑ 6.0 6.1 U.S. National Library of Medicine. Inguinal Hernia- discharge. http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000274.htm (accessed 2 Feb 2013)
  7. ↑ 7.0 7.1 Hammoud M, Gerken J. Inguinal hernia.Available:https://www.ncbi.nlm.nih.gov/books/NBK513332/ (accessed 20.12.2022)
  8. ↑ Moore KL, et al, Essential Clinical Anatomy. Abdomen. Lippincott, Williams, and Wilkins, 2011. p134-5.
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