Eur Radiol (2005) 15: 2457–2461

DOI 10.1007/s00330-005-2825-7 GASTRO INTESTINAL

Adeeb Alam
Colin Nice
The accuracy of ultrasound in the diagnosis
Raman Uberoi of clinically occult groin hernias in adults

Received: 21 January 2005

Revised: 9 May 2005
Accepted: 12 May 2005
Published online: 29 June 2005
# Springer-Verlag 2005
A. Alam (*) . R. Uberoi
Department of Radiology,
John Radcliffe Hospital,
Headley Way,
Oxford, OX3 9DZ, UK
e-mail: pnumbers@yahoo.com
C. Nice
Department of Radiology,
Queen Elizabeth Hospital,
Sheriff Hill,
Gateshead, NE9 6SX, UK
Abstract This prospective study ex-
amined the accuracy of ultrasound in
diagnosing occult groin hernias in
adults. The study included 52 con-
secutive patients reviewed in the sur-
gical out-patient clinic with a history
suggestive of groin hernia but with a
normal or inconclusive clinical exam-
ination. Each patient underwent a
preliminary ultrasound examination
by an experienced consultant radiolo-
gist who was aware that the patient
had a history suggestive of a hernia
but was blinded to the side of the
symptoms. The patient then proceeded
to herniography, and some patients
also had surgical exploration. The
results of the ultrasound were assessed
in relation to the herniography, and the
patients who proceeded to surgical
exploration had further correlation
with surgery. Ultrasound had a sensi-
tivity of 29% and specificity of 90%
compared with the herniography.
Correlation with surgical findings
showed ultrasound to have a sensitiv-
ity of 33% and a specificity of 100%.
The sensitivity of ultrasound in de-
tecting clinically occult hernias in a
non-acute presentation is poor, and
patients with normal ultrasound
should be considered for further
investigation.
Keywords Ultrasound . Hernia .
Herniography . Surgery

Introduction accurate modality in diagnosing a groin hernia in patients

Some hernias are clinically occult and are a source of
persistent groin pain. Herniography (Fig. 1a) has been
accepted as a reliable means of diagnosing both clinically
apparent and occult groin hernias [1–3], with sensitivity
up to 97% and specificity up to 98%. However, this pro-
cedure is invasive and is associated with potential com-
plications, including visceral puncture, haematoma at the
injection site and allergic reaction to iodinated contrast
agent [4]. Variable complication rates from 0% to 5.8%
have been reported [1, 5]. Herniography also involves ion.
izing radiation. Ultrasound (Fig. 1b) offers the benefit of
being non-invasive whilst also allowing dynamic exami-
nation of the groin. However, it is an operator-dependent
technique and may be difficult to perform in obese patients.
Also, patients with reducible hernias may not have pro-
trusion at the time of the examination. The aim of this
prospective study was to establish whether ultrasound is an
with clinically occult features.
Materials and method
The study included 52 consecutive adult patients referred
from a surgical clinic for assessment of groin pain believed
to be originating from a groin hernia (35 men, 45.2±13
years; 17 women, 42.4±16 years). A total of 104 groins
were examined by ultrasound and herniography, and the
presence or absence of a hernia was recorded. Informed
written consent for the procedures were obtained, and eth-
ics committee approval was obtained for the study. All the
patients either had a normal examination or the clinician
was uncertain whether a cough impulse was present in the
absence of a palpable lump. However, all the patients had a
history suggestive of hernia, complaining of either groin
pain or sensation of a lump or both, and therefore war-
2458
Fig. 1 a Herniography demonstrates the presence of an indirect
inguinal hernia (black arrow) in a 56-year-old man. b Longitudinal
ultrasound image (8- to 10-MHz linear probe, Acuson Sequoia 512)
in the same patient showing an indirect inguinal hernia (white
arrow) taken in the resting position. Short white arrow femoral head
ranting further investigation. This included two patients
suspected of having recurrent hernias following previous
repair. Patients with clinically obvious hernias, or acute
presentations such as incarceration or strangulation, were
excluded from the study. Also, patients with groin lumps
that were clinically not hernias, such as enlarged lymph
nodes, were excluded from the study if the patient’s symp-
toms were attributed to the clinical findings. An experi-
enced consultant radiologist performed ultrasound scans in
all the patients using a linear 8- to 10-MHz probe (Acuson
Sequoia 512, Acuson, Mountain View, Calif., USA). Pa-
tients were scanned in the lying and standing positions, and
the assessment included well-recognized techniques such
as cough impulse evaluation, straight-leg raising and the
Valsalva manoeuvre [6]. A hernia was diagnosed when a
hernial sac containing omentum or bowel, or abnormal
ballooning of the inguinal canal was seen on straining. We
are unaware of any reliable data looking at the dimensions
of the inguinal canal and ring to accurately diagnose a her-
nia and we therefore did not use size criteria to make a
diagnosis. The patients immediately proceeded to hernio-
graphy which was performed using a standard technique by
the same radiologist, as has been previously described [7].
In brief, the patients were asked to empty their bladder
and lie supine on a tilting table. The skin 2 cm below the
umbilicus was sterilized and 3–5 ml 1% lidocaine instilled.
A 20-gauge spinal needle (Beckton Dinkinson, S Augustin
del Guadalux Madrid, Spain) was passed vertically down
until the tip was felt to ‘pop’ into the peritoneal cavity. We
then instilled 70–10 ml iopamidol 300 (Braco, Bucking-
hamshire, UK), and the patient asked to strain, Valsalva and
cough in a semi-erect, then in erect positions. The results of
the two procedures were compared. No attempt was made
to grade the size of the hernia as there is no reliable stan-
dardized data for measurements. Surgical evaluation in-
volved an open procedure to directly inspect the presence
or absence of a hernia, and, if present, a mesh repair was
undertaken. Clinical follow-up after herniography was pos-
sible for 49 out of 52 patients with a follow-up period
ranging from 12 to 73 months (mean 38). Three patients, all
with negative herniograms, were lost to clinical follow-up.
Results
A total of 104 groins were examined by ultrasound and
herniography, and the presence or absence of a hernia was
recorded. One patient experienced a vaso-vagal reaction
following herniography, which was treated by intravenous
fluid and atropine but this was the only known complica-
tion. Herniography demonstrated hernias in 32 groins in 24
patients (30.8% of the total; 8 bilateral, 16 unilateral). Ul-
trasound correctly showed the presence of a hernia in 10 of
these groins, giving a sensitivity of 29% (Table 1). How-
ever, over two-thirds (24 hernias) were not demonstrable
by ultrasound. In the 72 groins that had negative hernio-
grams and negative clinical follow-up, ultrasound correctly
confirmed the absence of a hernia in 63, giving a specificity
of 90%.
A total of 13 patients underwent surgical exploration
(Table 2). One patient (no. 4) had a negative ultrasound,
and herniography confirmed this on exploration. Therefore
Table 1 Accuracy of ultrasound in relation to herniographyic result
and surgery: percentages (n number of groins for each correlation,
PV predictive value)
Herniography (n=104) Surgery (n=13)
Sensitivity 29 33
Specificity 90 100
Positive PV 59 100
Negative PV 72 11
 2459

Table 2 Operative findings in
relation to pre-operative imag-
ing for the symptomatic
(operated) groin
Patient no. Ultrasound result
1 No hernia
2 No hernia
3 No hernia
4 No hernia
5 No hernia
6 Right inguinal hernia
7 Bilateral hernias
8 No hernia
9 No hernia
10 No hernia
11 Right inguinal hernia
12 No hernia
13 Right inguinal hernia
Herniographic result Operative findings
Left inguinal hernia Left inguinal hernia repair
Right inguinal hernia Right inguinal hernia repair
Bilateral hernias Only left side repaired
No hernia No hernia found
No hernia Right inguinal hernia repair
Right inguinal hernia Right inguinal hernia repair
Bilateral hernias Only left side repaired
Right inguinal hernia Right inguinal hernia repair
Left inguinal hernia Left inguinal hernia repair
Left inguinal hernia Left inguinal hernia repair
Right inguinal hernia Right inguinal hernia repair
Bilateral hernias Only left side repaired
Right inguinal hernia Right inguinal hernia repair

a total of 12 patients had surgically confirmed hernias, and
three of these patients had bilateral hernias on herniography
but underwent unilateral repair of the symptomatic side.
Table 2 shows that ultrasound failed to pick up a hernia in
9 of 12 patients who were found to have a hernia following
a groin exploration (sensitivity 25%). In contrast, hernio-
graphy failed to detect only one of 12 patients who were
subsequently shown to have a hernia giving a sensitivity
of 92%. We found no other causes of mechanical groin
pain, such as lipoma of the spermatic cord or enlarged
nodes, in any of our patients. There were 13 patients who
had a definite hernia on herniography, but in whom no
surgical repair was performed. In three the symptoms had
resolved, and in five the symptoms were on the contra-
lateral side. In a further three patients the surgical team felt
that the hernia was unlikely to be the cause of the symp-
toms, and two patients declined surgery.
Discussion
Groin hernias are diagnosed clinically by the presence of a
lump which is reducible and which demonstrates an ex-
pansile cough impulse [8]. When signs are absent, the di-
agnosis is often suspected by the exclusion of other causes
of a lump [9]. Ultrasound is a low-cost, high-resolution
investigation which can allow direct scanning and dynamic
evaluation of the site of the patient’s pain (Figs. 1, 2, 3).
However, the views may be sub-optimal in obese patients,
and the procedure is very operator dependent. Our study
shows that whilst ultrasound can reliably exclude a groin
hernia (63 of the 72 groins without hernias were correctly
predicted), the detection rate for picking up hernias that
were present was poor (Fig. 4). Indeed, ultrasound failed to
pick up over two-thirds of hernias that were subsequently
found to be present on herniography and over 75% of the
hernias in the group of patients who underwent surgery. In
contrast, other studies have shown ultrasound to be highly
accurate in diagnosing groin hernias [10–12]. The dif-
ference can be explained by patient selection. Our study
included only those patients who had groin pain but nor-
mal or inconclusive clinical examination. Since hernias
have characteristic clinical features, there is no need to do
any form of investigation in patients with a reducible groin
mass that demonstrates an expansile cough impulse. Stud-
ies which state a high accuracy rate in diagnosing hernias

Fig. 2 a An ultrasound image

in a 65-year-old man (8- to 10-MHz
linear probe, Acuson Sequoia
512) taken in the longitudinal
section of the groin showing a
hernia (asterisks) with hyper-
echoic bowel gas shadows. The
hernia was demonstrated during
Valsalva straining. b Corre-
sponding herniogram showing a
right indirect inguinal hernia
2460
Fig. 3 a A direct hernia (H)
containing peritoneum in a
43-year-old woman taken in the
transverse plane with the patient
straining (8- to 10-MHz linear
probe, Acuson Sequoia 512).
b The corresponding hernio-
gram demonstrating a direct
inguinal hernia (black arrow)
Fig. 4 Herniogram demonstrating a small right indirect hernia
(black arrow) in a 38-year-old man taken during Valsalva. The
preceding ultrasound study did not demonstrate a hernia. The hernia
was confirmed at surgery, and an open repair was undertaken
on sonography, have included those patients who would
not normally have been referred for further imaging, such
as those with clinically obvious hernias demonstrating char-
acteristic features. This introduces a statistical error in fa-
vour of a higher detection rate. Lilly et al. [11] report an
accuracy rate of 75% for ultrasound in 20 of their patients
who did not have a palpable bulge. However, they did not
differentiate a hernia from lipoma of the cord, and it is
unclear what proportion of these patients had a true hernia.
In addition, those who had a negative ultrasound did not
have a further procedure to confirm or deny the absence
of a hernia. Similarly, Bradley et al. [12] reported 100%
specificity and sensitivity for ultrasound, but all the pa-
tients had a clinical diagnosis of a hernia, and therefore
imaging these selected patients would normally be un-
necessary and also introduces a bias to their results.
Whilst it may be possible to distinguish different types of
groin hernias on ultrasound using well described anatom-
ical landmarks [6], we believe that this is time consuming
and unnecessary as most patients with a symptomatic groin
hernia, irrespective of type, will proceed to surgical explo-
ration and repair using standard approaches and techniques.
One weakness of our study was that relatively few pa-
tients subsequently had surgery, which can be regarded as
the absolute gold standard. We observed a correlation with
surgical findings in 13 patients, and the low sensitivity of
ultrasound is demonstrated whether correlation is with sur-
gical exploration (33%) or herniography (29%). However,
we believe that herniography performed by an experienced
operator is sufficiently sensitive and specific to act as a
reliable gold standard, and when this procedure is com-
pared with surgical outcome, our results are comparable to
published data [1, 2]. There were seven false-positive re-
sults with ultrasound when compared with the hernio-
graphic result (n=104). None of these patients proceeded to
surgical exploration. The most likely explanation is that that
these patients had small pre-peritoneal or cord lipomas
giving the impression of a hernia, but without surgical cor-
relation it is impossible to confirm this.
Although ideally we would have liked to have identified
a cause of symptoms in all patients, this was not always
possible, and few patients underwent any further imaging
to look for other possible causes of groin pain, as clinicians
and patients were often reassured by a negative hernio-
gram. However, the aim of this project was not to dem-
onstrate the whole range of pathology causing groin pain
but to look specifically at the accuracy of ultrasound in
diagnosing or excluding a hernia in patients with normal or
inconclusive clinical examination but a history suspicious
of the condition. Also, the same radiologist who performed
the ultrasound also performed the herniography. This may
introduce some interpretation bias with the herniographic
result. The usefulness of ultrasound in looking for other
causes of groin pain such as lipoma of the spermatic cord,
enlarged lymph nodes, ectopic testis and neoplasms [6]
should not be understated and Larmark et al. [13] have
shown a beneficial role of ultrasound in assessing com-
plications following hernia repair.
 2461

Conclusion clusive clinical examination. The sensitivity of ultrasound

in detecting clinically occult hernias in a non-acute pre-
To our knowledge, this is the first prospective study to look sentation is poor, and patients with normal ultrasound
specifically at the detection rate for hernias using ultra- should be considered for further investigation.
sound in patients with groin pain but normal or incon-

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