Which physical findings are characteristic of pediatric hernias?

Updated: Oct 31, 2018
  • Author: Andre Hebra, MD; Chief Editor: Carmen Cuffari, MD  more...
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Examine the patient in both supine and standing positions. Physical examination of a child with an inguinal hernia typically reveals a palpable smooth mass originating from the external ring lateral to the pubic tubercle. The mass may only be noticeable after coughing or performing a Valsalva maneuver, and it should be reduced easily. Occasionally, the examining physician may feel the loops of intestine within the hernia sac. In girls, feeling the ovary in the hernia sac is not unusual; it is not infrequently confused with a lymph node in the groin region. In boys, palpation of both testicles is important to rule out an undescended or retractile testicle.

  • Inguinal hernia incarceration: The bowel can become swollen, edematous, engorged, and trapped outside of the abdominal cavity, a process known as incarceration. Incarceration is the most common cause of bowel obstruction in infants and children and the second most common cause of intestinal obstruction in North America (second only to intra-abdominal adhesions from previous surgeries). If entrapment becomes so severe that the vascular supply is compromised, inguinal hernia strangulation results. In cases of incarceration, ischemic necrosis develops, and intestinal perforation may result, representing a true medical emergency. When an incarceration is encountered, an attempt should be made to reduce it manually if the patient has no signs of systemic toxicity (eg, leukocytosis, severe tachycardia, abdominal distention, bilious vomiting, discoloration of the entrapped viscera). If the patient appears toxic, emergent surgical exploration after appropriate resuscitation is necessary.

  • Hernia and hydrocele: In boys, differentiating between a hernia and a hydrocele is not always easy. Transillumination has been advocated as a means of distinguishing between the presence of a sac filled with fluid in the scrotum (hydrocele) and the presence of bowel in the scrotal sac. However, in cases of inguinal hernia incarceration, transillumination may not be beneficial because any viscera that is distended and fluid-filled in the scrotum of a young infant may also transilluminate. A rectal examination may be helpful if intestine can be felt descending through the internal ring.

  • Silk sign: When the hernia sac is palpated over the cord structures, the sensation may be similar to that of rubbing 2 layers of silk together. This finding is known as the silk sign and is highly suggestive of an inguinal hernia. The silk sign is particularly important in young children and infants, in whom palpation of the external inguinal ring and inguinal canal is difficult because the patients' small size.

  • Spontaneously reducing hernia: Inguinal hernias that spontaneously reduce (ie, they are only noticed by the parents or caregivers and elude the examining physician) are not unusual. In such cases, maneuvers to increase the patient's intra-abdominal pressure may be attempted. Lifting the infant's or the child's arms above the head may provoke crying or a struggle to get free and thus increased intra-abdominal pressure. Older children can be asked to cough or blow up a balloon.

  • Femoral hernia: A femoral hernia can be very difficult to differentiate from an indirect inguinal hernia. Its location is below the inguinal canal, through the femoral canal. The differentiation is often made only at the time of operative repair, once the anatomy and relationship to the inguinal ligament is clearly visualized. The signs and symptoms for femoral hernias are essentially the same as those described for indirect inguinal hernias.

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