Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Abdominal Hernia |
Umbilical hernia |
Common at extremes of age, e.g., neonates and elderly.
Periumbilical defect in abdominal muscle wall. |
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Epigastric hernia |
Congenital or acquired, acquired ↑common age 30-50 years.
Defect in linea alba, obesity, chronic cough, constipation ↑risk. |
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Spigelian hernia |
Spigelian fascia defect (separates rectus abdominis and transverse oblique).
Usual presentation is lower abdominal wall pain +/-palpable lump. High risk of complications e.g., strangulation due to narrow base. |
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Diastasis recti |
Congenital or acquired, acquired ↑common in pregnancy or obesity.
Weakening and widening of linea alba, not strictly a hernia. Midline abdominal bulge ↑visible with patient supine, neck forward flexed. |
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Hiatus hernia |
RF: older age, obesity, pregnancy. Present with dyspesia symptoms.
Herniation of stomach through defect in diaphragm. Sliding or rolling types. Sliding: whole stomach slides up, gastro-oesophageal junction in thorax. Rolling: portion of stomach (e.g., fundus) folds around and up into thorax. |
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| Groin Hernia |
Direct inguinal hernia |
Herniation through posterior inguinal canal wall defect at Hesselbach’s triangle (borders: rectus abdominis, inferior epigastric vein, inguinal ligament.
Pressure over the deep inguinal ring will not stop the herniation. Superior to pubic tubercle. Unlikely to extend into scrotum. |
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Indirect inguinal hernia |
Herniation of viscera through inguinal canal (deep→superficial inguinal ring).
Failure of deep inguinal ring closure and processus vaginalis obliteration. Hernia will remain reduced with pressure over deep inguinal ring. Superior to public tubercle. Commonly extend into scrotum. |
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Femoral hernia |
Herniation of abdominal contents through femoral canal.
Below inguinal ligament. High risk of complications (e.g., strangulation). |
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Obturator hernia |
↑risk: women, older age, multiple previous pregnancies, vaginal deliveries.
Herniation of viscera through obturator foramen due to pelvic floor defect. May be asymptomatic, may cause obturator nerve irritation (e.g., groin pain). |
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| Miscellaneous |
Incisional hernia |
Defect in muscle after surgical incision and closure. Often recur.
↑risk if large incision or multiple medical co-morbidities at time of surgery. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Chaperone | ||
| Position patient lying supine on couch | ||
| Ask patient to cover with sheet | ||
| Inspection | Put on gloves | |
| Expose patient | ||
| Abdomen | ||
| Bilateral groins | ||
| Swelling | ||
| Scars | ||
| Cough impulse | ||
| Examine standing if unable to locate hernia supine. | ||
| Palpation | Brief palpation of unaffected areas | |
| Palpate affected area | ||
| Size | ||
| Location and borders (including scrotum) | ||
| Cough impulse | ||
| Tenderness | ||
| Reducibility | ||
| Deep inguinal ring | ||
| Auscultation | Bowel sounds | |
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
“I have been asked to carry out a hernia examination. This involves looking at and then feeling the lump you have found. There will be a chaperone present whilst I carry out this examination. Are you happy for me to do that?”
Ask the patient to undress from the waist down and position them lying on the examination couch. Cover the patient with a sheet until you are ready to start the examination.
Inspection
Put on gloves for the examination. Expose the patient and check they are comfortable.
Inspect the abdomen and bilateral groins for:
- Swelling
- Scars (e.g., from previous hernia repair)
- Cough impulse
Ask the patient to cough. A positive cough impulse (visible enlargement of swelling with a cough) indicates a hernia as raised intra-abdominal pressure pushes abdominal contents through the defect in the abdominal wall.
Ask the patient to stand if you are unable to appreciate a swelling that the patient has noted, as standing increases intra–abdominal pressure and may make a hernia more evident.
Palpation
Examination should be focused on the affected area, with a brief initial examination of the unaffected area(s).
For example, if the patient has noticed a swelling in the left groin, briefly palpate the abdomen and the right groin before examining the left groin in more detail.
Palpate the swelling and consider the following:
- Size
- Location and borders – palpate the full extent of swelling including the scrotum if appropriate.
- Cough impulse
- Tenderness – a tender hernia raises concern for complications (e.g., strangulation) and may require urgent referral.
- Reducibility – first ask the patient to reduce the hernia themselves, then reduce yourself if the patient is unable.
- Pubic tubercle – inguinal hernias are superior to the pubic tubercle, femoral hernias are inferior.
- Deep inguinal ring
If a hernia is non–reducible with the patient supine, ask the patient to stand and try to reduce the swelling in this position.
A non–reducible hernia should raise concern for complications (e.g., strangulation) and may require urgent referral for review.
Palpation over the deep inguinal ring can help to determine whether an inguinal hernia is direct or indirect.
Reduce the hernia and locate the deep inguinal ring (halfway between the anterior superior iliac spine (ASIS) and the pubic tubercle). Maintain pressure over the deep ring and ask the patient to cough. An indirect inguinal hernia will remain reduced, whereas a direct inguinal hernia will reappear.
Auscultation
Auscultate over the swelling with your stethoscope for the presence of bowel sounds, indicating herniation of bowel through the defect.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings you may wish to carry out further investigations, including an ultrasound scan to further evaluate the swelling.
Last updated Aug 2025
Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.
