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].

• Weight Loss

  Substantial weight loss, however, appears to make patients slightly more vulnerable to a few conditions, such as symptomatic gallstones. One wonders if patients who lose significant weight are also at increased risk of obturator hernia. [aafp.org]

  An obturator hernia is most often present in women older than 70 who have recently experienced sudden weight loss. [wisegeek.com]

  Sudden weight loss and malnutrition can have the same effect. [sharecare.com]

  CT scan in the work-up of severe gastrointestinal symptoms with weight loss may lead to a diagnosis of occult hernia, thereby allowing elective repair and, hopefully, a reduction in mortality risk. [ncbi.nlm.nih.gov]

• Swelling

  We present a 77-year-old-woman who had abdominal pain with nausea and vomiting together with swelling of the right groin for 3 days. [ncbi.nlm.nih.gov]

  There was a 2cm x 2cm irreducible tender swelling in right inguino-scrotal region, the upper limit of which was not approachable. The swelling was not trans-illuminant and the testis was not palpable separately. [docksci.com]

  The hernia may be felt as a tender swelling in the region of the obturator foramen on vaginal or rectal examination. The most specific finding is a positive Howship-Romberg sign. [gpnotebook.co.uk]

• Surgical Procedure

  There have been 16 case reports of tetanus occurring after gastrointestinal surgical procedures. [ncbi.nlm.nih.gov]

  Master Techniques in Surgery: Hernia is written by acknowledged master surgeons, emphasizes surgical procedures, and is lavishly illustrated with original full-color drawings. [books.google.it]

  However, in other cases, resection of the perforated section of the small bowel and drainage of the femoral abscess are both performed in a single surgical procedure. [bmcsurg.biomedcentral.com]

• Inflammation

  Sandhu et al, Amyand’s hernia with perforated appendix Preoperative diagnosis of hernial appendicitis/ perforated appendicitis is very difficult.[3] In case of noninflamed appendix only herniotomy is recommended while with the evidence of acute inflammation [docksci.com]

  […] cicatrization colour considerable continued convulsions cure death diarrhoea digestion dilatation discharge disease doses drachm effusion examination external extremities fact fever fluid frequently gangrenous glands goitre head heart hospital inch increased inflammation [books.google.it]

  Two-stage surgery is performed in serious cases; the femoral abscess is first drained and inflammation is reduced to minimize risk, and this is followed by intestinal resection. [bmcsurg.biomedcentral.com]

  The indices of inflammation and creatinine showed stabilization in laboratory tests. She was discharged after 5 days and remained well without any complications during subsequent outpatient follow-up. [karger.com]

• Malnutrition

  Sudden weight loss and malnutrition can have the same effect. [sharecare.com]

  Contributing factors are prior pregnancy, chronic illness, malnutrition, and any condition that produces peritoneal weakening. More than 60% of obturator hernias occur on the right side, and about 6%-15% of cases are bilateral. [ispub.com]

  The loss of protective preperitoneal fat from aging or malnutrition makes a larger space in the obturator canal and facilitates the formation of a hernia[ 8, 9 ]. Thus, it is not surprising that most of the patients are markedly underweight. [wjgnet.com]

  It is also higher in patients with ongoing increased intra-abdominal pressure, growth failure and malnutrition, prematurity, seizure disorder, or chronic respiratory problems. [emedicine.medscape.com]

• Constipation

  The vast majority of patients with obturator hernias are admitted with signs and symptoms of intestinal obstruction, namely anorexia, nausea, vomiting, constipation, and distension of 2 to 3 days' duration. [ncbi.nlm.nih.gov]

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

  An initial working diagnosis of constipation or gastroenteritis was made, and enemas and supportive treatment was initiated overnight. [edoriumjournals.com]

• Hypotension

  Case 3 was hypotensive when she presented to the emergency department with 3 days’ history of nausea and vomiting. Tumor-like bulge with tenderness in the femoral triangle was palpated in Case 1, but no groin mass was recognized in Cases 2 and 3. [criticalultrasoundjournal.springeropen.com]

• 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]

  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]

  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]

• 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]

• Hyperactivity

  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]

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].

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

Obturator Hernia: Anatomy, embryology, diagnosis, and treatment. Clin Anat 2011; 24: 562-69. 2. [degruyter.com]

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 prognosis, despite our own results, remains severe for the compromised general conditions of the great majority of the patients. [biomedsearch.com]

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]

The article presents the etiology, clinical presentation, and diagnosis of these hernias, and briefly describes the various surgical approaches, including open and laparoscopic. [scinapse.io]

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]

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]

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]

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

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]

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

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