The clinical presentation of patients invariably includes some form of abdominal discomfort, which is often accompanied by pain, especially during any form of physical activity. Pain when coughing is one of the hallmarks of this condition. A sense of pressure in the groin region, as well as swelling, may be reported [13]. The majority of patients will complain about a prominent bulge in the inguinal region, most often noticed when standing for a prolonged period of time. In the case of indirect inguinal hernia, testicular enlargement is frequent. The indirect inguinal hernia usually develops unilaterally, but a bilateral presentation may occur in some individuals.

• Weakness

  These inguinal hernias are usually caused by weakness in the muscle of the abdominal wall. The weakness can be due to an acute event (heavy lifting) or slowly develop over time. Most commonly, this hernia is found in adult males. [medicinenet.com]

  Some of the potential causes for an inguinal hernia include: Pregnancy Straining during bowel movements Lifting heavy objects A weak abdominal wall Chronic coughing Increased abdominal pressure Congenital weakness What are the symptoms of an inguinal [nycherniasurgery.com]

  The term 'indirect' refers to the fact that the bowel and peritoneal protrusion don't herniate directly through a weakness in the abdominal musculature. [meddean.luc.edu]

  This is called a congenital weakness because it is usually present when you are born. [shouldice.com]

• Inguinal Pain

  A pilot study using a synthetic long-term resorbable mesh in Lichtenstein repair showed good results regarding pain and discomfort in patients with indirect inguinal hernia (IH) without recurrences, but higher recurrence rate in patients with direct inguinal [ncbi.nlm.nih.gov]

  Inguinal hernias are often asymptomatic, presenting as a painless swelling in the groin. Pain and features of intestinal obstruction are signs of a complicated inguinal hernia (obstructed/strangulated hernia). [amboss.com]

  Post herniorrhaphy pain syndrome, or inguinodynia is pain or discomfort lasting greater than 3 months after surgery of inguinal hernia. [en.wikipedia.org]

• Inguinal Mass

  The patient was initially evaluated by emergency room physicians, and an ultrasound was ordered to further determine the contents of the inguinal mass. [hindawi.com]

  mass; may be enlarging; systemic symptoms or weight loss Psoas abscess Flank or back pain, fever, inguinal mass, limp, weight loss Sebaceous cyst Soft mass, nontender, more superficial, no change with Valsalva maneuver Testicular torsion Acute onset [aafp.org]

• Constipation

  Chronic constipation. Constipation causes straining during bowel movements. Pregnancy. Being pregnant can weaken the abdominal muscles and cause increased pressure inside your abdomen. Premature birth and low birth weight. [mayoclinic.org]

  The easiest way to think about the causes of inguinal hernias is to think of: Increased intra-abdominal pressure Weakness of the abdominal muscles The causes are therefore as follows: Chronic cough Constipation Heavy lifting Advanced age Obesity How do [geekymedics.com]

  This includes eating a good diet to avoid constipation, caring for the wound, and not straining yourself too soon. [nhs.uk]

  Other risk factors include family history, premature birth, overweight or obesity, pregnancy, chronic cough and constipation. There are two types of inguinal hernia: indirect and direct. [jomi.com]

• Vomiting

  Fever, nausea, and vomiting: These are also concerning symptoms that need to be treated urgently. Indirect Hernia Causes There are two inguinal canals — one on each side of the groin. [buoyhealth.com]

  If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Strangulation. [mayoclinic.org]

  If you experience sudden pain, vomiting, or nausea, your intestine may have become trapped in a hernia and it is important to contact your doctor immediately. Inguinal hernia treatment There are different treatment methods for an inguinal hernia. [belmarrahealth.com]

  COMPLICATIONS Obstruction • Irreducible • abdominal pain, • distension and vomiting may occur • The hernia will be tense tender and irreducible Strangulation • become red and tender, • Irreducible • No impulse on cough. • If contains bowel signs of obstruction [slideshare.net]

  You have nausea, fever, or vomiting along with hernia pain. [stanfordchildrens.org]

• Nausea

  Fever, nausea, and vomiting: These are also concerning symptoms that need to be treated urgently. Indirect Hernia Causes There are two inguinal canals — one on each side of the groin. [buoyhealth.com]

  If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Strangulation. [mayoclinic.org]

  If you experience sudden pain, vomiting, or nausea, your intestine may have become trapped in a hernia and it is important to contact your doctor immediately. Inguinal hernia treatment There are different treatment methods for an inguinal hernia. [belmarrahealth.com]

  You have nausea, fever, or vomiting along with hernia pain. [stanfordchildrens.org]

  This will usually lead to severe pain, as well as nausea and vomiting. If the blood supply is cut off, the hernia is considered strangulated. A strangulated hernia is life-threatening and requires immediate surgery. [medicinenet.com]

• Abdominal Pain

  Recurrent colicky abdominal pain was the leading symptom in the others. Reoperation confirmed the diagnosis of internal hernia in all but 1 patient. [ncbi.nlm.nih.gov]

  COMPLICATIONS Obstruction • Irreducible • abdominal pain, • distension and vomiting may occur • The hernia will be tense tender and irreducible Strangulation • become red and tender, • Irreducible • No impulse on cough. • If contains bowel signs of obstruction [slideshare.net]

  In many cases, it is asymptomatic, even though postprandial abdominal pain or, during exercise, nauseas, vomiting, and weight loss could be found. [websurg.com]

  Overview Snapshot A 54-year-old male comes to the emergency room with right-sided groin pain, swelling, colicky abdominal pain and abdominal distension, nausea and 2 episodes of vomiting. [medbullets.com]

  Significant abdominal or groin pain and bloating: If this occurs, pushing on the bulge may worsen the pain. The skin overlying the hernia may appear red. [buoyhealth.com]

• Acute Abdomen

  Physical examination showed signs of an ileus in the absence of an acute abdomen. Laboratory investigations revealed no abnormalities (CRP 2.0 mg/L, white blood count 6.3 × 109/L). During admission, there was clinical deterioration on the third day. [ncbi.nlm.nih.gov]

  Computed tomography (CT) remains the best available imaging tool for evaluation of acute abdomen and abdominal hernias (6–8). [pubs.rsna.org]

• Heart Disease

  Abstract We evaluated 103 patients with indirect inguinal hernia (IIH) for the association of congenital heart disease by echocardiography. [ncbi.nlm.nih.gov]

  disease or breathing problems. [nhs.uk]

• Irritability

  Can become complicated by incarceration or strangulation. 7-30% of hernias When incarcerated the child will become uncomfortable / irritable. Strangulation of the hernia is contra-indication of manual reduction. [pedemmorsels.com]

  When a hernia becomes incarcerated, infants or children will show signs of irritability and may vomit. They may also have loss of appetite, abnormal bowel patterns, and / or tenderness of the groin area and swelling of the abdomen. [cincinnatichildrens.org]

  He or she might be irritable and have less appetite than usual. In an older child, a hernia is likely to be more apparent when the child coughs, strains during a bowel movement or stands for a long period. [mayoclinic.org]

  Using ice or a cold compress to numb any pain Avoiding putting pressure or heat on the affected area Ensuring you get enough rest Maintaining a healthy body weight Breaking unhealthy habits like drinking and smoking Wearing looser clothes to avoid irritation [belmarrahealth.com]

  Encourage the patient to bathe daily and to apply a thin film of powder or cornstarch to prevent skin irritation. Evidence-Based Practice and Health Policy Zhu, S., Zhang, H., Xie, L., Chen, J., & Niu, Y. (2013). [medical-dictionary.thefreedictionary.com]

• Confusion

  The confusion is because Kaplan only bothered mentioning breaking through the internal, but not the cremasteric, fascia. [forums.studentdoctor.net]

  Symptoms at this stage include all of those previously mentioned plus severe abdominal pain, fever, confusion, change in mental status, and shock. [canyonsurgicalutah.com]

  As the hernia enlarges, it turns upwards into the looser areolar tissue beneath the skin of the groin crease and may be confused with an inguinal hernia. Sagittal section of a femoral hernia. [surgwiki.com]

  These are not inquinal hernias, but they can sometimes confuse the diagnosis of inguinal hernias because they curve over the inguinal area. They are more often accompanied by intestinal obstruction than inguinal hernias. [surgeryencyclopedia.com]

  Spermatic cord lipomas should not be confused with fat-containing hernias or the lateral crescent sign, as lipomas are typically located lateral or inferior to the spermatic cord and cause no compression of its contents, whereas inguinal hernias protrude [pubs.rsna.org]

• Testicular Pain

  Fever, weight loss, diaphoresis, cough Recent contact with infection Femoral aneurysm Pulsing mass Epididymitis Testicular pain Discharge Painful urination Fever, chills Hydrocele Non-tender swollen testicle May be seen in addition to an inguinal hernia [physio-pedia.com]

  Visceral pain can manifest as testicular and ejaculatory pain which may be associated with mesh ingrowth into spermatic cord structures.[citation needed] Prevention[edit] Nerves management[edit] Avoiding nerve entrapment and injury is critical. [en.wikipedia.org]

  Ischaemia produces testicular pain, tenderness and swelling. Testicular atrophy is observed in 1–5% of males. [surgwiki.com]

• Swelling of the Scrotum

  Inguinal Hernia Hydroceles occur when fluid fills a sac in the scrotum of the penis (in the "inguinal canal"). About 10 in 100 male infants have a hydrocele at birth. Hydroceles can also develop with swelling or injury of the scrotum. [urologyhealth.org]

  It rarely enters the scrotum. Usually painless Reduces when person lies supine Round swelling near pubis in area of deep inguinal ring [8] Indirect Hernia [1] The contained sac protrudes through the deep inguinal ring. [physio-pedia.com]

  Changes in sensation may be experienced along the scrotum and inner thigh.[11] Urgent repair[edit] A hernia in which the small intestine has become incarcerated or strangulated constitutes a surgical emergency. [en.wikipedia.org]

• Scrotal Mass

  Communicating hydroceles frequently present with a history of a scrotal mass that changes in size; the scrotal size increases during crying, defecation and decreases after periods of inactivity, e.g. sleeping. [pedclerk.uchicago.edu]

  Differential Diagnosis of Groin and Scrotal Masses Diagnosis Clinical presentation Ectopic testis Absence of a testis in the scrotum Epididymitis Severe pain surrounding the testis, tenderness, fever, chills Femoral adenitis/adenopathy Bilateral, firm [aafp.org]

• Renal Function Impairment

  IV contrast is contraindicated in patients with renal function impairement (Cr less than 1.6). History of allergic reaction to contrast is a contraindication if there is no adequate preparation. [clinicaladvisor.com]

The diagnosis of indirect inguinal hernia is generally based on clinical grounds [9]. During a physical examination, the most important part of the diagnostic workup, a retractable bulge is observed and palpated. Palpation should be performed when the patient is both sitting and standing. To confirm the diagnosis, the patient is asked to cough, which will manifest in protrusion of the viscera that can be prevented by external mechanical pressure on the inguinal canal through the testes by the physician. Sometimes, the examination may be difficult to perform (obese patients, those unwilling to cooperate), while unskilled physicians may not differentiate the cause of swelling in the inguinal region. Imaging studies are rarely necessary to confirm the diagnosis, but they may be useful if patients complain of some other symptoms. Abdominal ultrasonography is sufficient in excluding other potential pathologies.

Surgical repair is the only method used in managing indirect inguinal hernia. Insertion of a mesh or sutured repair is the most common method used, either by laparoscopy or open surgery [5]. Studies have established much lower rates of recurrence with the use of a mesh [14] [15] and is frequently favored over suture repair. There is much debate on the choice of either laparoscopic or open surgery in managing inguinal hernias [16]. Open surgery can be performed by general surgeons, local anesthesia is used and longer recovery time is observed [17]. On the other hand, laparoscopy is shown to result in significantly less postoperative pain and less time away from normal daily activities [5], which is why both of these procedures are used in general practice.

The overall prognosis of patients with an indirect inguinal hernia is good, as the majority of patients experience mild symptoms that are effectively treated by surgery. In some patients, an inguinal hernia may recur. Indirect forms recur less frequently than direct and factors for recurrent inguinal hernia were established to be female gender and smoking in certain studies [11]. Complications are rarely encountered and are established to occur in less than 1% of patients. However, incarceration or strangulation, the most common complications reported, may have a life-threatening risk for patients, as mortality rates in acute surgery reach up to 7% [12]. Despite the fact that overall mortality rates from surgery are less than 0.5% according to various studies [5], the diagnosis of an indirect inguinal hernia should be made during the physical examination without hesitation and appropriate surgical procedures, when indicated, should be performed as soon as possible.

Although specific embryologic processes that are involved in the pathogenesis of indirect inguinal hernia have been identified, why this process persists and what are the pathophysiologic mechanisms leading to its development remain unknown. Moreover, persistent (or patent) processus vaginalis and the protrusion of the peritoneum through which indirect inguinal hernia passes was questioned as the sole factor for this abnormality. This brings into question the role of other factors in this condition [8].

Inguinal hernia repair is considered to be one of the most common surgical procedures performed in medical practice worldwide, with more than 20 million hernia repairs being done every year [1]. Somewhat recent data indicate that more than 700,000 inguinal hernia repairs are being performed in the United States on an annual basis [2]. Certain studies estimate indirect inguinal hernia being slightly more common than direct [7]. Male gender is significantly more affected by this anatomical abnormality, as its occurrence is much more common in males. Additionally, and a significantly increased lifetime risk is established for males - the estimated lifetime risk is around 26%, compared to only 7% for women [9]. Despite these findings, an indirect inguinal hernia is the most common form of a hernia in the female population. In addition to male gender, increasing age is also established in some studies to be a risk factor [4]. On the other hand, the risk of development of an inguinal hernia is reduced among African-American individuals, for unknown reasons [4].

Indirect inguinal hernias seem to occur due to the incomplete obliteration of processus vaginalis during the testicular descent into the scrotum [3]. During organogenesis, the testes originate in the retroperitoneum and migrate into the deep inguinal ring around the 6th month of pregnancy [3]. Later on, testes slowly start to descend toward the scrotal sacs via the inguinal canal enclosed by a layer of parietal peritoneum, known as processus vaginalis. This process should obliterate shortly after birth, but for some reason, it remains fully preserved, which creates favorable conditions for contents of the peritoneum to protrude through this sac [10]. As a result, the viscera, under various circumstances, mainly due to mechanical pressure, are able to descend through this process into the scrotum and give the characteristic bulging appearance on clinical examination.

Since the events that predispose patients to indirect inguinal hernia occur very early in life, prevention is not possible. Some steps in reducing the risk for complications, however, may be performed. If patients experience even mild symptoms, they should avoid activities which put pressure on the abdominal wall, such as heavy lifting and report to their physician as soon as they notice either swelling or a bulge in their groin or testes. An early diagnosis can facilitate treatment with minimal risk for complications.

An inguinal hernia is considered to be one of the most common surgically managed diseases worldwide, with estimated 20 million surgeries being performed every year [1]. It is considered to be one of the most frequent procedures in the United States, as more than 700,000 hernia repairs are being performed on an annual basis [2]. There are two main types of an inguinal hernia - direct, in which viscera protrude directly through the peritoneal wall and the posterior wall of the inguinal canal; indirect, on the other hand, is distinguished by protrusion through the deep inguinal ring and passage adjacent to the spermatic cord, eventually terminating in the testes. Additionally, the indirect inguinal hernia is recognized by its location in relation to the inferior epigastric artery, by passing laterally from this blood vessel, while a direct hernia passes medially. The pathogenesis of indirect inguinal hernia presumably includes both congenital and acquired factors. During embryonic development, the testes, once they are formed, descend into the scrotum covered by processus vaginalis, a protrusion of the parietal peritoneum created during organogenesis. As the testes descend, processus vaginalis should obliterate, but for some reason, this process does not occur in some individuals, which predisposes visceral protrusion through this processus [3]. This type of hernia is often seen in neonates at birth and infants, but adults are also commonly affected and a significant predilection toward male gender is established. In terms of epidemiology among ethnic groups, African-American individuals are shown to have a reduced risk for the development of hernias in general [4]. Clinical presentation of patients suffering from indirect inguinal hernia usually consists of abdominal pain and discomfort, but the presence of a bulge that retracts on the pressure in the inguinal region is seen in virtually all cases. In most cases, testicular involvement is prominent. In some cases, swelling and significant discomfort may be noted during the physical examination. The differentiation between the two forms of hernias is thought to be of significant importance [5], primarily because treatment principles may somewhat vary. Physical examination of the inguinal canal can provide means to a definite diagnosis and should be performed when the patient is both standing and sitting [6]. Once the diagnosis is made, surgical therapy is performed in all cases sooner or later. In the setting of acute symptoms and development of complications such as strangulation, surgery is performed immediately, while the debate regarding the timing of surgery in mild or asymptomatic patients is ongoing [7]. This condition can pose a risk for the patient, but an early diagnosis, proper therapy, and follow-up, poses little harm for individuals.

An indirect inguinal hernia is a form of a hernia occurring in the groin region which comprises a protrusion of the organs, mainly intestines, through the abdominal wall and their descent into the scrotum along with the spermatic cord. Normally, during formation of organs in the fetus, the testes slowly descend into their designated place (the scrotum) soon after birth. They descend enclosed in a pouch called processus vaginalis, a part of the sheath enclosing all abdominal organs, the peritoneum. When the testes reach the scrotum, processus vaginalis should degrade, as its function is no longer necessary, but for some reason, this structure persists and enables organs to reside in this pouch that extends to the testes. All types of inguinal hernia, including indirect, are much more common among males while increasing age is an established risk factor, but patients of any age, including neonates, can develop this type of hernia. Patients complain of abdominal discomfort and pain, especially when standing, because of mechanical pressure of abdominal organs. Usually, a bulge in the groin or enlarged testes can be observed during a physical examination. This bulge may be retracted by external pressure from the physician, which is a definite diagnostic sign of the hernia. The bulge, as well as pain, is often aggravated when coughing. This is the reason why patients will be often asked to cough during palpation of the groin and testes. The diagnosis is based on these findings and imaging studies are not necessary. For all patients, surgical repair is indicated. Surgery can be performed by laparoscopy, a procedure that necessitates general anesthesia, somewhat higher rates of recurrence, but lower postoperative pain and quicker return to normal daily activities. Open surgery, on the other hand, is performed under local anesthesia and has lower recurrence rates. Overall, the prognosis is generally good, as complications, such as incarceration (leading to bowel obstruction) and strangulation (obstruction of blood flow to the herniated tissue and is considered as a medical emergency) are very rare. However, they may pose a significant risk to the patient, which is why this condition is usually treated immediately after it is diagnosed.

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