Introduction
Unilateral groin pain is common, particularly in men, and it is frequently not possible to make a clear diagnosis. The most common causes are musculo-ligamentous strain, referred pain from the spine/hips/pelvis, or ‘idiopathic’. Serious intra-abdominal pathology can be ruled out if the pain is localised to below the inguinal ligament.
Hernias rarely present with pain alone: there really ought to be a lump or swelling to generate pain. Hernias also cause their discomfort when they are ‘out’, often when straining or maybe when sitting, but NOT when the patient is lying in bed at night.
Ultrasound is generally unhelpful as it can detect fat moving up and down the inguinal canal which may be labelled as a hernia but is a normal finding. Such ultrasound reports may lead to operative treatment which often fails to relieve the pain as it, frequently, was not the cause for symptoms and, subsequently, may lead to more pain from the operation itself.
History
- Unilateral pain in groin crease or region of inguinal canal without a discernible lump or swelling
- Distinct from testicular pain
- Note relation to physical activity and rest
- Note previous surgery in the area
Signs
- Reducible swelling in the groin
- Point tenderness
- Pain reproduced with leg movements against resistance
- Features of lumbar spine or hip joint arthritis
Who to refer:
To surgery only if there is a clear lump or swelling in keeping with a hernia.
Who not to refer:
Groin pain in the absence of a lump or swelling is UNLIKELY to be a hernia.
Subclinical hernias (i.e. no lump or swelling) RARELY require surgery and so imaging in the absence of a lump or swelling is usually unhelpful, even if it detects a ‘hernia’. Also see Primary Care Management
Primary Care Management
- Investigation: None. Ultrasound can be misleading and is unhelpful if it detects a subclinical hernia.
- Treatment: anti-inflammatory analgesia, reassurance; consider referral to physiotherapy: some symptoms may be sports-related.
- If a small hernia is indeed developing it will eventually become clinically apparent, at which time surgery can be offered.
