• The herniated contents are lined by a pouch of peritoneum and accompany the spermatic cord blood vessels and nerves in the canal.
• In girls, there may be an ovary in the hernia sac.

• Prematurity
• Ascites
• Chronic lung disease
• Congenital anomalies of the pelvis and perineum
• Ehlers-Danlos syndrome

• Intestinal obstruction
• Incarceration
• Testicular infarction
• Bowel ischemia
• Skin ulceration
• Cryptorchidism (association)

• Seminoma, teratoma, and other testicular tumors
• Scrotal trauma
• Hydrocele
• Undescended testis
• Lymphadenopathy

Question: Where is the location of the bulge?
Significance: Hernia presents as a swelling in the inguinal region. Hernia descending to the scrotum or labial area is known as complete. Hernia not entering the scrotum (labia) is known as incomplete.

Question: What makes the bulge larger?
Significance: The hernia can increase in size with maneuvers increasing intraabdominal pressure (coughing, crying, voiding, defecation).

Question: Is there any pain?
Significance: Uncomplicated hernias usually do not cause pain. Presence of inguinal pain in the absence of incarcerated hernia should raise the suspicion of hip disease.

Question: Are there signs of obstruction?
Significance: Question symptoms of obstruction (emesis, abdominal distention), bowel ischemia (pain, emesis, abdominal distention, fever, irritability, lethargy), reducibility, and traumatic attempts to reduce.

• Ensure an empty bladder.
• Older children should be in a standing position for the examination. Ensure that your hands are warm.
• If the hernia is not present at the time of examination, maneuvers increasing intraabdominal pressure can reveal suspected hernia (Valsalva maneuver, coughing, crying, voiding, defecation).
• Translumination is achieved by shining light behind the scrotum anteriorly. Hernias as opposed to hydrocele generally do not transluminate.
• Always consider testicular torsion, epididymitis, orchitis, and trauma when examinations reveal a tender mass in the scrotum.
• Try to reduce the hernia with the child in the supine or head-down position so that gravity assists the maneuver. Use a pacifier to calm the infant. Do not force a difficult incarcerated hernia.

• Herniorrhaphy is the definitive treatment. Ten percent of patients will return with contralateral hernia after a unilateral repair. Surgical exploration of the contralateral inguinal canal in patients with unilateral hernia is controversial.
• The underlying cause should be addressed when present (ascites, Ehlers-Danlos syndrome).

• Richter hernia: herniation of only part of the bowel wall, resulting in bowel ischemia without bowel obstruction; rare occurrence
• Failure to consider possibility of ovary in inguinal hernia in girls

Q: Is surgery of great urgency in childhood?
A: Irreducible incarceration is common in infants less than 1 year of age, and surgery is recommended early. Surgery for uncomplicated hernia can be postponed in the premature infant or when other medical conditions need to be treated prior to surgery. An irreducible hernia requires urgent surgery.

Q: What are concerns regarding inguinal hernias in girls?
A: Of all inguinal hernias, only 10% are present in girls. The ovary is the most common organ to herniate. Detection is more difficult than in boys and is commonly mistaken for lymphadenopathy. One percent of phenotypic females with inguinal hernia have testicular feminization syndrome with a testicle present in the inguinal canal.