Nonpalpable Inguinal Hernia in Women
A nonpalpable hernia is often overlooked as a possible cause of inguinal and lower abdominal pain in women. Upon review of the literature, we find few reports on this type of hernia. We believe, however, that symptomatic, nonpalpable (incipient, occult) i
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Nonpalpable Inguinal Hernia in Women Leif Spangen and Sam G.G. Smedberg
A non palpable hernia is often overlooked as a possible cause of inguinal and lower abdominal pain in women. Upon review of the literature, we find few reports on this type of hernia. 1-7 We believe, however, that symptomatic, nonpalpable (incipient, occult) inguinal hernia is relatively common in women, although seldom diagnosed. Nevertheless, this type of hernia presents a typical clinical picture and can be accurately confirmed by simple diagnostic methods. To obtain relevant information on history, diagnosis, operative findings, and results of treatment, we carried out a follow-up study of 188 women judged preoperatively to have nonpalpable inguinal hernia. They had all consulted us about inguinal and/or lower abdominal pain, but had no history of a lump in the groin. None had undergone previous inguinal hernia repair on the involved side, and there was no palpable hernia or detectable impulse while coughing. Most of the patients were 20 to 50 years of age (Fig. 90.1), and the mean age was 32 years (range 7 to 76 years).
Symptoms and Surgical Findings In most instances, a woman with a symptomatic nonpalable indirect inguinal hernia reports dull inguinal pain aggravated by physical exertion. About three-fourths of the patients notice neuralgic-type pain that varies in intensity and occurs intermittently. In almost two-thirds there is pinprick hyperalgesia of the skin corresponding to the distribution of the ilioinguinal nerve. The patient always experiences a distinct point tenderness on palpation over the internal inguinal ring during a Valsalva maneuver, and the pressure reproduces pain or increases her current pain. The most important diagnostic and surgical findings are presented in Tables 90.1 to 90.3. The inguinal explorations were performed over an IS-year period. A total of 192 inguinal hernias in 180 women were found, 128 were on the right and 64 on the left side. The surgical findings are summarized in Table 90.3. In 192 cases we found an indirect hernia. One hundred thirty-two had a hernial sac (l.5 to 5.0 cm in length), whereas in 57 cases the hernia consisted of pre peritoneal fat only. In all the patients, the internal inguinal ring was abnormally wide (2.5 cm or more). In one patient a femoral hernia was the only surgical finding, and in eight cases the exploration provided no explanation for the patient's complaints.
During the first postoperative months, three cases of hematoma that required no treatment and two cases of superficial wound infection occurred. No other serious early complications were observed. In about 20% of the cases, mild postoperative pain of a neuralgic type continued, but this usually disappeared after 1 to 3 months. Pinprick hyperalgesia could often be demonstrated days to weeks after the patients had been pain free. In all, 186 operations for inguinal hernias were followed up (Fig. 90.2); the mean observation time was 20 months (range 1 to 60 months). At the latest examination, 108 of the 186 were
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