HOW TO DISTINGUISH BETWEEN A DIRECT AND AN INDIRECT INGUINAL HERNIA ON PHYSICAL EXAMINATION

 





To distinguish between a direct and an indirect inguinal hernia on physical examination, connecting  the ANTERIOR SUPERIOR ILIAC SPINE and the PUBIC TUBERCLE is the INGUINAL LIGAMENT,not inguinal canal.You can palpate the ANTERIOR SUPERIOR ILIAC SPINE(ASIS) and the PUBIC TUBERCLE.In thin and muscular people, you may be able to palpate the inguinal ligament, but in most people you cannot palpate that ligament.So as long as you can palpate the two bony attachment (ANTERIOR SUPERIOR ILIAC SPINE and the PUBIC TUBERCLE), you just draw an imaginary  line to connect them and that tells you that is where the inguinal ligament is. Once you know where the inguinal ligament is,then know that the INGUINAL CANAL is about an half an inch above the medial half of the inguinal ligament,with the superficial inguinal ring just above the pubic tubercle and the deep inguinal ring just above the midpoint of the inguinal ligament. You can place your examining finger on the superficial inguinal ring and then ask the patient to cough as the cough will increase intra-abdominal pressure and the increase in the intra-abdominal pressure will force the hernia sac out if there’s a hernia and with your finger on the superficial ring, the hernia sac will push out against your finger and you will feel it with your finger.Remember all inguinal hernias come out through the superficial inguinal ring whether direct or indirect.So when a hernia pushes out against your finger at the superficial inguinal ring, it tells you there’s an inguinal hernia but it does not tell whether it is direct or indirect.So with your examining finger still at the superficial inguinal ring, take another finger and place it over the deep ring and press the deep ring and ask the patient to cough a second time. If you do not feel the hernia sac hit against your finger at the superficial inguinal ring, it means your compression of the deep inguinal ring is what has stopped the hernia from coming out and this means that hernia goes through the deep ring  and this means it is an INDIRECT INGUINAL HERNIA. On the other hand when you place the second finger  over the deep ring and press the deep ring with the first finger at the superficial inguinal ring ,and ask the patient to cough a second time and the hernia bulges out through the first finger at the superficial inguinal ring, it means your compression of the deep ring has no effect on the hernia because the hernia does not go through the deep ring and if the hernia isn’t going though the deep ring, then it is a DIRECT INGUINAL HERNIA.

 

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