Palpate for an inguinal hernia. Using in turn your right hand for the patient's right side and your left hand for the patient's left side, invaginate loose scrotal skin with your index finger. Start at a point low enough to be sure that your finger will have enough mobility to reach as far as the internal inguinal ring if this proves possible. Follow the spermatic cord upward to above the inguinal ligament and find the triangular slitlike opening of the external inguinal ring. This is just above and lateral to the pubic tubercle. If the ring is somewhat enlarged, it may admit your index finger. If possible, gently follow the inguinal canal laterally in its oblique course. With your finger located either at the external ring or within the canal, ask the patient to strain down or cough. Note any palpable herniating mass as it touches your finger.

See Table 10-3, Course and Presentation of Hernias in the Groin (p. 381).

See Table 10-4, Differentiation of Hernias in the Groin (p. 382).

Palpate for a femoral hernia by placing your fingers on the anterior thigh in the region of the femoral canal. Ask the patient to strain down again or cough. Note any swelling or tenderness.

Evaluating a Possible Scrotal Hernia. If you find a large scrotal mass and suspect that it may be a hernia, ask the patient to lie down. The mass may return to the abdomen by itself. If so, it is a hernia. If not:

■ Can you get your fingers above the mass in the scrotum?

If you can, suspect a hydrocele.

■ Listen to the mass with a stethoscope for bowel sounds.

Bowel sounds may be heard over a hernia, but not over a hydrocele.

If the findings suggest a hernia, gently try to reduce it (return it to the abdominal cavity) by sustained pressure with your fingers. Do not attempt this maneuver if the mass is tender or the patient reports nausea and vomiting.

History may be helpful here. The patient can usually tell you what happens to his swelling on lying down and may be able to demonstrate how he reduces it himself. Remember to ask him.

A hernia is incarcerated when its contents cannot be returned to the abdominal cavity. A hernia is strangulated when the blood supply to the entrapped contents is compromised. Suspect strangulation in the presence of tenderness, nausea, and vomiting, and consider surgical intervention.

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