Inguinal hernia examination

Introduction

• Wash hands; Introduce self; ask Patient’s name, DOB and what they like to be called; Explain examination and obtain consent
• Get a chaperone
• Expose patient from waist down and ask them to stand up
• Put on gloves

Inspection

• General
  • Patient: well/unwell, pain/discomfort (incarceration), pallor, muscle wasting/cachexia, abdominal distension (obstruction)
  • Around bed: vomit bowls
• Local
  • Lumps: size, shape, position, scrotal extension
  • Observe cough impulse

Palpation

• Scrotal contents: palpate from anteriorly. If a lump is present, determine if you can get above it.
• Lump/inguinal area (both sides): palpate from laterally, with one hand on the patient’s back, using the other to feel the lump/inguinal ligament region
• Feel cough impulse (on each side separately): compress lump/inguinal area firmly. Ask the patient to turn their head to the opposite direction and cough. If the swelling becomes tense and expands, there is a positive cough impulse.
• Check for reducibility:
  • Locate the deep inguinal ring (midway between ASIS and pubic tubercle)
  • Press firmly on the lump and, starting inferiorly, try to lift it up and compress it towards the deep inguinal ring 
  • Once it is reduced, slide your fingers up and maintain pressure over the deep inguinal ring
  • Ask patient to cough
  • If the hernia reappears, it is a direct hernia; if not, it is an indirect hernia
  • Release and watch hernia reappear if it has not already done so (indirect will slide down obliquely; direct will project forwards)

NB: If you cannot reduce the hernia, try again with patient lying supine.

Percussion and auscultation

• Percuss and auscultate lump: this may reveal if bowel is present in a hernia

To complete

• Thank patient and restore clothing
• ‘To complete my examination, I would perform a full abdominal examination.’ 
• Summarise and suggest further investigations you would consider after a full history

Do you know the types of inguinal hernia?

Direct inguinal hernia

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Indirect inguinal hernia

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Femoral hernia

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There’s other types of hernia too…