page_title: Inguinal hernia
section_title: Indirect inguinal hernia
hierarchical_section_title: Inguinal hernia / Diagnosis / Indirect inguinal hernia
caption_attribution_description: English: T2 weighted MRI of a 67 year old man who had pain in his left groin. It shows a left-sided indirect inguinal hernia (right side in image) containing fat.
context_page_description: An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. Symptoms are present in about 66% of affected people. This may include pain or discomfort especially with coughing, exercise, or bowel movements. Often it gets worse throughout the day and improves when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.
  Risk factors for the development of a hernia include: smoking, chronic obstructive pulmonary disease, obesity, pregnancy, peritoneal dialysis, collagen vascular disease, and previous open appendectomy, among others. Predisposition to hernias is genetic and occur more often in certain families. Deleterious mutations causing predisposition to hernias seem to have dominant inheritance. It is unclear if inguinal hernias are associated with heavy lifting. Hernias can often be diagnosed based on signs and symptoms.
context_section_description: An indirect inguinal hernia results from the failure of embryonic closure of the deep inguinal ring after the testicle has passed through it. It is the most common cause of groin hernia.
  In the male fetus, the peritoneum gives a coat to the testicle as it passes through this ring, forming a temporary connection called the processus vaginalis. In normal development, the processus is obliterated once the testicle is completely descended.  The permanent coat of peritoneum that remains around the testicle is called the tunica vaginalis.  The testicle remains connected to its blood vessels and the vas deferens, which make up the spermatic cord and descend through the inguinal canal to the scrotum.
  The deep inguinal ring, which is the beginning of the inguinal canal, remains as an opening in the fascia transversalis, which forms the fascial inner wall of the spermatic cord.  When the opening is larger than necessary for passage of the spermatic cord, the stage is set for an indirect inguinal hernia.  The protrusion of peritoneum through the internal inguinal ring can be considered an incomplete obliteration of the processus.
  In an indirect inguinal hernia, the protrusion passes through the deep inguinal ring and is located lateral to the inferior epigastric artery. Hence, the conjoint tendon is not weakened.
  There are three main types
  Bubonocele: in this case the hernia is limited in inguinal canal.
  Funicular: here the processus vaginalis is closed at its lower end just above the epididymis. The content of the hernial sac can be felt separately from the testis which lies below the hernia.
  Complete (or scrotal): here the processus vaginalis is patent throughout. The hernial sac is continuous with the tunica vaginalis of the testis. The hernia descends down to the bottom of the scrotum and it is difficult to differentiate the testis from hernia.
  In the female, groin hernias are only 4% as common as in males.  Indirect inguinal hernia is still the most common groin hernia for females.  If a woman has an indirect inguinal hernia, her internal inguinal ring is patent, which is abnormal for females.  The protrusion of peritoneum is not called "processus vaginalis" in women, as this structure is related to the migration of the testicle to the scrotum.  It is simply a hernia sac.  The eventual destination of the hernia contents for a woman is the labium majus on the same side, and hernias can enlarge one labium dramatically if they are allowed to progress.
caption: T2 weighted MRI of the same case (done for another purpose), also demonstrating fat content.
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