The selected article for discussion during the month of December is:

“Groin Pain in Women: Use of Sonography to Detect Occult Hernias” (Grant et al)

Access the article here

Questions for discussion:

1-      The authors note that increasing the intra-abdominal pressure is crucial in the detection of occult hernias on sonography. Relative to that consideration, they cite this potential study limitation: Although most studies have used both supine and upright patient positioning for scanning to detect groin hernias, in this study all examinations were performed with the patient in the supine position, using the sometimes unpredictable Valsalva maneuver to elicit hernias. Do you think upright patient positioning would have improved the results in this study population?

2-      Based on the results of this study, will you be more likely to perform or order an ultrasound examination for women with chronic groin pain?

3-      Do you have questions or comments for these authors?

The professional gap:

A recent study from Denmark concluded that a greater proportion of women than men require emergency hernia repair with higher rates of bowel resection and death (Bay-Nielsen M, Kehlet H, Strand L, et al. Quality assessment of 26,304 herniorrhapies in Denmark: a prospective nationwide study. Lancet 2001; 358:1124-1128.).

Most symptomatic groin hernias in women and men are diagnosed on physical examination and managed without imaging. But in women, the physical examination findings are more likely to be normal because of the inherent difficulty for the clinician to examine the inguinal region. Consequently, groin hernias in women are often diagnosed only after a prolonged symptomatic period or as a surgical emergency.

The research/ study design:  

Grant et al conducted a retrospective study to test their  hypothesis that sonography could be beneficial in the diagnosis of symptomatic women with groin pain that have normal or equivocal physical examination findings. 

• Files were reviewed of 87 consecutive women referred for sonographic examination for groin or lower abdominal pain. Duration of symptoms varied from 8 days to 9 years, but most patients had difficulty identifying the precise time the symptoms began.

Sonographic examination:

• Transducer: 12 – 5-MHz multifrequency
• Spatial compound sonography, B-mode, and color Doppler imaging were used in all cases.
• Increasing the intra-abdominal pressure by using the Valsalva maneuver or increasing the tone of the abdominal muscles was the determining factor in the diagnosis for all but 1 patient.

Results:

37 groin hernias were diagnosed by ultrasound in 35 women.

• 9 indirect inguinal hernias
• 21 direct inguinal hernias
• 7 femoral hernias

Surgery was performed on 26 patients (27 groins)

• Sonography correctly depicted and classified groin hernias in 18/27 groins that had surgical confirmation.
• 1 sonographic study had false-negative findings: incarcerated right femoral hernia 4 months after sonographic findings were interpreted as normal.
• 1 indirect inguinal hernia detected on sonography was not described in the surgical report, but a lipoma of the round ligament was identified in this region.
• 1 femoral hernia was misclassified by sonography as a direct inguinal hernia.

• Sensitivity                                  95%
• Specificity                                  75%
• Positive predictive value               95%
• Negative predictive value              75%

Fourteen women with groin hernias diagnosed by sonography did not have surgery.

The groin pain in the remainder of the women was attributed to a variety of other causes.

Conclusions:

Given the confounding etiology of chronic groin pain in women, there should be a low threshold for performing sonography in symptomatic patients with normal physical examination findings. Using the proper technique can be extremely helpful in detecting occult groin hernias.