Groin Pain Etiology: The Inguinal Hernia, the Occult Inguinal Hernia, and the Lipoma

Abstract

The differential diagnosis for groin pain is quite long, and among the many etiologies can include such diagnoses as chronic appendicitis, diverticulitis, urologic diseases, and gynecological processes. One must not forget, however, the importance of the inguinal hernia in the workup for groin pain, as it is the cause of 4.7 million visits each year. Many of these hernias are evident on clinical exam, though an occult hernia may be suspected in absence of a palpable bulge.

If groin pain is present in the absence of clinical exam findings, one could consider the presence of an occult groin hernia, whether it is indirect, direct in nature, or an obturator or Spigelian hernia. Lipomas of the spermatic cord and round ligament can also cause pain and symptoms similar to that of a hernia as well. Several imaging modalities such as CT, ultrasound, or MRI may be used to diagnose an occult hernia, and the decision of which to use depends on the surgeon preference, level of suspicion that a hernia is present, the patient’s body habitus, and gender. Women are an important population to consider. Though inguinal hernias present with a 9:1 male predominance, women with hernias are often underdiagnosed. Women with chronic pelvic pain can go up to 20 years without a diagnosis, and it seems that diagnostic laparoscopy can often be the most effective tool in diagnosing an occult hernia in females, which is especially the case when the history is suggestive of a hernia.