Page 10 - International guidelines for groin hernia management

Hernia

KQ03.b Which diagnostic modality is the most suitable for The 1999 prospective cohort study showed that US had
diagnosing patients with obscure pain or doubtful swelling? a specificity of 0.945 and a sensitivity of 0.815 for
KQ03.c Which diagnostic modality is the most suitable for detecting groin hernias. 86 MRI demonstrated a specificity
diagnosing recurrent groin hernias? of 0.963 and a sensitivity of 0.945. 86 A 2013 meta-analysis
KQ03.d Which diagnostic modality is the most suitable for revealed that groin US had a specificity of 0.86 and a
diagnosing the course of chronic pain after groin hernia sensitivity of 0.77. 105
surgery?

Evidence in literature Two studies support the use of CE in combination with US
The gold standard for hernia diagnosis is clinical exami- to confirm the diagnosis of inguinal hernias. CE plus US was
89, 96
nation (CE) of the groin with a sensitivity of 0.745 and a found to be superior to CE alone in both studies.
specificity of 0.963 reported in a prospective cohort study Two prospective cohort studies—both of low quality—
from 1998. 86 Three consensus guidelines have been pub- showed that US performed poorly in the detection of occult
lished on groin hernia treatment. 3, 6, 87 All published groin hernias. 106, 107 Both studies did recommend the use
statements on diagnostic workup are weak, mainly focus- of US for interval assessment of patients with equivocal
ing on CE alone. Only groin pain that is obscure or groin findings since those with equivocal findings seem to have a
swelling of unclear origin (possible occult hernia) are noted high incidence of groin hernias.
to require further diagnostic investigation. 88, 89 No con- In conclusion, challenging hernia diagnoses like femoral
sensus exists presently on the best imaging modality for and clinically occult hernias can be evaluated with US
these diagnostic dilemmas. since it is: routinely available, relatively specific, cost
CE alone can miss hernias, especially those that are effective, repeatable, useful in diagnosing other conditions,
small (e.g. femoral hernias in obese women and men) and delivers no ionizing radiation and well accepted by
multiple hernias where only some of the hernias are patients. 86, 88–90, 106–114
apparent with physical examination. 90 US, MRI, CT and In pregnant women, colour-duplex US is useful for an
herniography have all been studied in various settings in an entity presenting with an inguinal lump and pain, round
88, 91–104 109, 115, 116
attempt to close this ‘‘diagnostic gap’’. ligament varicosity.
Two studies with a total of 510 patients showed that US When groin US is negative or non-diagnostic, dynamic
88, 96
is highly sensitive and a useful way to identify hernias. MRI, dynamic CT and even herniography may be consid-
Several other studies have echoed this ered in an attempt to establish a diagnosis. 117 Dynamic in
finding. 89, 100, 101, 103 this context refers to Valsalva manoeuvre during testing in
an attempt to force a possibly occult or small hernia into its

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