Obturator hernia has an incidence of 0.07–1% of all forms of hernias and accounts for 0.2–1.6% of all cases with mechanical obstruction of the small bowel. With the highest rate of mortality among hernias of the abdominal wall (13-40%), it also has a predilection for female patients and a female-to-male ratio of 6:1. Obturator hernia is sometimes referred to as "little old lady’s hernia" because it mostly affects elderly females due to atrophy of preperitoneal fat surrounding obturator vessels in the obturator canal. In 6% of cases, bilateral hernias can be detected. Obturator hernia generally presents as acute intestinal obstruction. In the majority of cases, the contents are small bowel. However, it may also contain omentum, appendix, or Meckel's diverticulum. The hernia sac follows the path of obturator nerves and muscles by passing through the foramen obturatum [1] [2].

Conditions causing a raised intra-abdominal pressure such as multiparity, ascites, chronic obstructive pulmonary disease (COPD) and constipation are other risk factors [3].

The clinical diagnosis is challenging because of rarity, deep location, and infrequent signs and symptoms. The physical examination is usually not contributory resulting in diagnostic delay. The hernial sac compresses and irritates the obturator nerve in the canal leading to medial thigh pain radiating down to the medial aspect of the knee and less frequently to the hip due to compression of the anterior division, a sign known as the Howship-Romberg sign. It is pathognomic of obturator hernia and is observed in 15–50% of cases. A palpable mass is identified in 20% of the patients in the medial proximal aspect of the thigh at the origin of the adductor muscles [2] [4]. When a patient presents with obstruction of the small bowel and intermittent symptoms with medial thigh pain, obturator hernia must be suspected.

The further symptoms are that of bowel obstruction, dull and crampy abdominal pain, nausea, and emesis. These symptoms are present in more than 80% of patients. Obstruction may be acute or intermittent [5].

• Inguinal Mass

  No palpable inguinal mass or hernia was found. A radiograph of the abdomen showed dilated loops of small bowel and multiple air–fluid levels suggestive of small-bowel obstruction ( Figure 1A ). [cmaj.ca]

• Inguinal Pain

  Contrary to what one might believe, and unlike usual inguinal hernia, the pubic inguinal pain syndrome does not show any visible swelling in the inguinal canal. [youcoach.it]

• Multiple Organ Dysfunction Syndrome

  She recovered well despite of the complication of multiple organ dysfunction syndrome. Literature is reviewed, and the pathogenesis, clinical manifestation, imaging features and treatment are discussed. [ncbi.nlm.nih.gov]

• Pallor

  Physical examination revealed mild abdominal distension with pallor in a thin, lean patient. Routine investigations were unremarkable. Ultrasonography abdomen showed distension of small gut loops. [saudisurgj.org]

• Hyperactive Bowel Sounds

  There were hyperactive bowel sounds. No abnormal signs were found on rectal and vaginal examinations. Biochemical parameters were within normal limits. Plain abdominal radiography revealed multiple distended bowel loops. [oapublishinglondon.com]

  There was diffuse abdominal distension and tenderness on palpation with hyperactive bowel sounds on auscultation. Initial abdominal radiographs dem?on?strated dilated loops of small bowel, consistent with obstruction. [hcplive.com]

  Physical examination revealed an emaciated lady with a soft but distended abdomen, visible bowel coils, mild tenderness over the lower abdomen, and hyperactive bowel sounds. No mass or rebound pain of the abdomen was noted. [wjgnet.com]

• Projectile Vomiting

  An 81-year-old Caucasian emaciated female presented with 3 days history of colicky abdominal pain nausea, projectile vomiting and abdominal distension. A pre-operative diagnosis of mechanical bowel obstruction was made. [ncbi.nlm.nih.gov]

  Physicians had ignored mild pain, projectile vomiting and failed to take surgical opinion in time. Upper gastrointestinal endoscopy showed some degree of reflux in lower end of oesophagus and antral gastritis. [casereports.in]

  Because the hernial opening measured 5mm in diameter, it could be closed with four pieces of End-Univ... more An 81-year-old Caucasian emaciated female presented with 3 days history of colicky abdominal pain nausea, projectile vomiting and abdominal distension [scinapse.io]

• Lower Abdominal Pain

  An elderly emaciated female patient presented with recurrent lower abdominal pain associated with nausea and vomiting due to obstruction of the small bowel. [ncbi.nlm.nih.gov]

• Decreased Bowel Sounds

  On physical examination, she had a distended abdomen with decreased bowel sounds. No palpable inguinal mass or hernia was found. [cmaj.ca]

• Hip Pain

  Physicians should consider obturator hernia in the differential diagnosis of knee and hip pain, and investigate for Howship-Romberg sign. [ncbi.nlm.nih.gov]

  Case Report An 86-year-old Caucasian female presented to hospital with a five-day history of vomiting, generalized colicky abdominal pain and constipation as well as right hip pain. [edoriumjournals.com]

  She also complained of intermittent right hip pain with radiation to the medial aspect of the thigh for several months, which worsened with extension, abduction, or internal rotation of right leg. [medsci.org]

• Thigh Pain

  When a patient presents with obstruction of the small bowel and intermittent symptoms with medial thigh pain, obturator hernia must be suspected. The further symptoms are that of bowel obstruction, dull and crampy abdominal pain, nausea, and emesis. [symptoma.com]

  Obturator hernia presents subtly with medial thigh pain and no lump. They are notorious for difficulty to diagnosis. [ncbi.nlm.nih.gov]

  After two months, she was admitted with left thigh pain. With these findings computed tomography scans confirmed left obturator hernia. [mona.uwi.edu]

• Opisthotonus

  The diagnosis of tetanus was clinically made after the appearance of generalized spastic contractions with opisthotonus. [ncbi.nlm.nih.gov]

Several imaging methods have been used to diagnose the disorder including ultrasonography, plain radiography of the abdomen, and barium enema. Computed tomography (CT) of the abdomen and pelvis is the most relevant diagnostic tool. Recent reports have shown that a definite and early diagnosis of obturator hernia s possible by CT of the abdomen and pelvis [6] [7]. It is readily available, requires a short time, and is minimally invasive. CT scan can be especially helpful in the initial presentation when nonspecific signs and symptoms are identified [5].

The abdominal radiography often shows a nonspecific pattern of small bowel obstruction. Occasionally, gas shadows in the foramen obturatum or intraluminal air bubbles proximal to the superior ramus of the pubic bone will be diagnostic [8] [9]. On upper gastrointestinal tract series and barium enema, a loop of small bowel may be seen in the obturator canal [10].

• Staphylococcus Aureus

  In spite of this drainage, disseminated intravascular coagulation (DIC), necrotizing fasciitis, and methicillin-resistant Staphylococcus aureus (MRSA) infection were detected after surgery in four cases in which the thigh wound was closed, and two of [bmcsurg.biomedcentral.com]

1. Lo CY, Lorentz TG, Lau PW. Obturator hernia presenting as small bowel obstruction. Am J Surg. 1994;167:396–398.
2. Hodgins N, Cieplucha K, Conneally P, Ghareeb E. Obturator hernia: a case report and review of the literature. Int J Surg Case Rep. 2013;4(10):889–892.
3. De Clercq L, Coenegrachts K, Feryn T, et al. An elderly woman with obstructed obturator hernia: a less common variety of external abdominal hernia. JBR-BTR. 2010;93(6):302-4.
4. Antoniou Z, Volakaki E, Giannakos E, Kostopoulos DC, Chalazonitis A. Intestinal obstruction due to an obturator hernia: a case report with a review of the literature. OA Case Reports. 2013;2(1):5.
5. Mantoo SK, Mak K, Tan TJ. Obturator hernia: diagnosis and treatment in the modern era. Singapore Med J. 2009;50(9):866.
6. Yokoyama Y, Yamaguchi A, Isogai M, et al. Thirty-six cases of obturator hernia: does computed tomography contribute to postoperative outcome? World J Surg. 1999;23:214-217.
7. Dundamadappa SK, Tsou IY, Goh JS. Clinics in diagnostic imaging (107). Singapore Med J. 2006;47:88-94.
8. Hsu CH, Wang CC, Jeng LB, et al. Obturator hernia: a report of eight cases. Am Surg. 1993;59:709-711
9. Young A, Hudson DA, Krige JEJ. Strangulated obturator hernia: can mortality be reduced? South Med J. 1988;81:1117-1120.
10. Carriquiry LA, Pineyro A. Pre-operative diagnosis of non-strangulated obturator hernia: the contribution of herniography. Br J Surg. 1988;75:785.