Local Examination of inguinal hernia

Local Examination of inguinal hernia

Overview: A systematic clinical approach utilizing Inspection, Palpation, Percussion, and Auscultation to identify the type, anatomy, and potential complications of a hernial swelling.

I. Inspection

1. Swelling Characteristics

• Indirect Hernia: Pyriform in shape, stalk at the external ring, usually extends into scrotum.
• Direct Hernia: Spherical shape, rarely enters the scrotum.
• Femoral Hernia: Spherical shape, starts below & lateral to pubic tubercle and ascends over inguinal ligament.
• Visible Peristalsis: May be seen in recurrent hernias with thin coverings. Never seen in a femoral hernia.

2. Skin Over the Swelling

• Normal: Seen in uncomplicated hernias.
• Reddened: Indicates a strangulated hernia.
• Discoloration/Pigmentation: Haemosiderin deposits from long-term truss use.
• Scarred/Puckered: Points to wound infection from previous operations (a common cause of recurrence).

3. Impulse on Coughing

• Patient turns face away and coughs. Look at superficial inguinal ring.
• Expansile Impulse: Swelling expands as abdominal tension drives contents into the sac (almost diagnostic).
• Note: Absence does not rule out hernia; neck may be blocked by adhesions.

4. Position of Penis

• A large scrotal hernia will push the penis to the opposite side.

II. Palpation

1. Position & Extent (Inguinal vs. Femoral)

2. Getting Above the Swelling

• Hold root of scrotum between thumb (front) and fingers (behind).
• Inguinal Hernia: Cannot get above the swelling.
• Pure Scrotal Swelling: Can feel structures above it within the spermatic cord.

3. Consistency

• Omentocele (Omentum): Doughy and granular.
• Enterocele (Intestine): Elastic.
• Strangulated Hernia: Tense and tender.

4. Impulse on Coughing & Zieman's Technique

• Perform in standing position. Feel for an expansile impulse separating thumb and index finger.

5. Reducibility & Taxis

• Patient lies down, flexes affected thigh, adducts, and internally rotates.
• Taxis: Gentle squeezing of contents toward the abdomen. Rough handling can be fatal.
• Enterocele: Reduces with gurgling. First part difficult, last part slips easily.
• Omentocele: First part easy, last part resents reduction.

6. Invagination Test

• Recumbent position. Invaginate skin from scrotum bottom with little finger to feel superficial ring.
• Direct Hernia: Impulse felt on the pulp of the finger (goes directly backwards).
• Indirect Hernia: Impulse felt on the tip of the finger (goes upwards, backwards, outwards).

7. Ring Occlusion Test

• Stand patient up, reduce hernia first. Press thumb on deep inguinal ring. Ask patient to cough.
• Bulge appears medial to finger: Direct Hernia.
• No bulge appears: Indirect Hernia (successfully occluded).

III. Percussion & Auscultation

• Percussion Note: Resonant note = Enterocele. Dull note = Omentocele or extraperitoneal fat. (Helps differentiate from dull notes of acute epididymitis).
• Auscultation: Peristaltic sounds may be heard over an enterocele.