Wasteful overinvestigation — ultrasound in groin hernias and groin pain

To the Editor: Surgeons detest the waste involved in routine ultrasounds for all patients with groin hernias and those with groin pain only.

An inguinal hernia is a groin swelling with a cough impulse, clinically obvious in nearly all patients. No additional value is obtained from an ultrasound, which does not change the management.

In addition, nearly all patients with groin pain without any noticeable swelling are now unfortunately appearing with an ultrasound “diagnosing” a hernia. Pain is often exercise-induced, felt in the inner thigh, and often present at night or when rolling over in bed. The ultrasound report will invariably declare “there is an indirect inguinal hernia containing fat” (sometimes the fat is labelled omentum). Commonly this is embellished with “a neck of 4 [or 6 or 8] mm”.

Unfortunate consequences ensue from mislabelling a mobile blob of fat protruding through the deep inguinal ring as an indirect hernia. The ultrasound, the second general practitioner visit and the surgeon's visit add to delay and cost, and the true musculoskeletal, or occasionally neurogenic, cause of the groin pain is not assessed and treated.

The ultrasound report not infrequently leads to totally unnecessary surgical exploration of the groin to cure the “inguinal hernia”. The original musculoskeletal cause of groin pain persists, leading to prolonged incapacity and sometimes a chronic pain syndrome. Complications of hernia surgery or mesh are blamed for the continuing pain; this often results in a degree of permanent impairment, and litigation.

There are a few useful indications for groin ultrasounds. They can help to exclude recurrent herniation. They may also detect a narrow-necked hernia in the rare but classic patient with an intermittently presenting, reducible groin swelling. An ultrasound can help to exclude a direct hernia defect plugged with fat in a patient with groin pain on sitting, no musculoskeletal pain source and no detectable clinical hernia. Ultrasound can also be used to determine whether a fixed solid groin lump is an incarcerated hernia or a lymph node.

Otherwise, time and money should not be wasted on unnecessary groin ultrasounds.