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 Pain

  Pain may be so severe as to seriously affect or even stop sporting activities. 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]

• 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]

• Intravenous Administration

  Intravenous administration of contrast medium helps check the vascular supply of the bowel wall to detect complications such as ischemia. Dilation of small bowel proximal to the hernia is a sign of obstructed hernia. [oapublishinglondon.com]

• 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]

• Persistent Vomiting

  A 91-year-old woman had a 6-day history of nausea and vomiting. She was referred to surgery because of persisting vomiting, but without any abdominal pain. A CT scan showed a hernia in the right groin area but the diagnosis was delayed. [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]

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

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

Knowledge of the anatomy and pathogenesis of obturator herniation is essential in diagnosis and treatment. [ncbi.nlm.nih.gov]

Signs of complication, including: bowel obstruction strangulation resulting in perforation Treatment and prognosis Treatment involves surgery and repair of the hernial orifice. [radiopaedia.org]

Preoperative diagnosis is still uncommon and influences treatment and prognosis. Clinical suspicion and tomography are fundamental for establishing a preoperative diagnosis. [ncbi.nlm.nih.gov]

Signs of complication, including: bowel obstruction strangulation resulting in perforation Treatment and prognosis Treatment involves surgery and repair of the hernial orifice. [radiopaedia.org]

Early diagnosis, appropriate imaging and prompt surgical intervention can reduce morbidity and mortality and improve prognosis. 3, 4 Footnotes Previously published at www.cmaj.ca This article has been peer reviewed. [cmaj.ca]

The poor prognosis is attributed to a delay in diagnosis and complications of surgery in patients of advanced age and debilitated condition. Two recent articles emphasize the importance of early diagnosis of obturator hernia. [aafp.org]

Pelvic CT is almost 100% accurate in the diagnosis of obturator hernia and should be the modality of choice in older patients presenting with intestinal obstruction of unknown etiology. [ncbi.nlm.nih.gov]

Contrast-enhanced computed tomography abdomen of the patient revealed evidence of small bowel obstruction, but no obvious etiology. Thus, the patient was taken for emergency laparotomy via midline vertical incision. [jpgmonline.com]

Access Authors: 1, &, Benhammane Hossam 1, Yazough Issam 1, Toughrai Imane 1, Ait Laalim Said 1, Ibn Majdoub Karim 1, Mazaz Khalid 1 Publication date (Electronic): 24 February 2015 Journal: The Pan African Medical Journal Publisher: The African Field Epidemiology [scienceopen.com]

Export Citation: APA/MLA Format Download EndNote Download BibTex MeSH Terms Descriptor/Qualifier: Female Hernia, Obturator / diagnosis*, epidemiology, physiopathology, surgery Humans Male From MEDLINE®/PubMed®, a database of the U.S. [biomedsearch.com]

Obturator hernia Microchapters Home Patient Information Overview Historical Perspective Pathophysiology Causes Differentiating Obturator hernia from other Diseases Epidemiology and Demographics Risk Factors Natural History, Complications and Prognosis [wikidoc.org]

Current epidemiologic assessments suggest that gender distribution and anatomic distribution are similar to those in more developed countries. Age-related demographics The prevalence of all varieties of hernias increases with age. [emedicine.medscape.com]

Obturator hernia Microchapters Home Patient Information Overview Historical Perspective Pathophysiology Causes Differentiating Obturator hernia from other Diseases Epidemiology and Demographics Risk Factors Natural History, Complications and Prognosis [wikidoc.org]

PATOPHYSIOLOGY Many attempts have been made to explain the pathophysiological mechanisms that cause the pubic inguinal pain syndrome, like a weakness of the lower abdominal wall, an imbalance between the (strong) adductor muscles of the hip and the (weak [youcoach.it]

Pathophysiology Inguinal hernia The pinchcock action of the internal ring musculature during abdominal muscular straining prohibits protrusion of the intestine into a patent processus. Muscle paralysis or injury can disable the shutter effect. [emedicine.medscape.com]

Hernia Pathophysiology Hernia Treatment Hernia Complications Last Updated: Feb 26, 2019 Written by Dr. Ananya Mandal Dr. Ananya Mandal is a doctor by profession, lecturer by vocation and a medical writer by passion. [news-medical.net]

Early intervention can prevent the morbidity and mortality associated with complicated obturator hernia. [ncbi.nlm.nih.gov]

Recurrence is prevented by stitching the broad ligament over the opening. Links: Howship-Romberg sign [gpnotebook.co.uk]

Secondary Prevention Cost-Effectiveness of Therapy Future or Investigational Therapies Case Studies Case #1 Obturator hernia CT On the Web Most recent articles Most cited articles Review articles CME Programs Powerpoint slides Images American Roentgen [wikidoc.org]

López-Cano M; Pereira JA; Lozoya R; Feliu X; Villalobos R; Navarro S; Arbós MA; Armengol-Carrasco M PREBIOUS trial: A multicenter randomized controlled trial of PREventive midline laparotomy closure with a BIOabsorbable mesh for the prevention of incisional [irblleida.org]

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.