A 62-year-old man comes to the physician due to intermittent groin pain. The pain is most severe when the patient lifts heavy loads and after a long day at his job as a construction worker. Physical examination shows a right-sided groin bulge directly above the inguinal ligament. The bulge increases in size when he bears down. An ultrasound reveals that the mass originates medial to the inferior epigastric vessels. This patient's condition is most likely caused by which of the following?

Question

A 62-year-old man comes to the physician due to intermittent groin pain.  The pain is most severe when the patient lifts heavy loads and after a long day at his job as a construction worker.  Physical examination shows a right-sided groin bulge directly above the inguinal ligament.  The bulge increases in size when he bears down.  An ultrasound reveals that the mass originates medial to the inferior epigastric vessels.  This patient's condition is most likely caused by which of the following?

Quizplus · Accepted Answer

11ec160b_3582_5cf0_9249_79acb9f22390_MD0001_00 Direct and indirect inguinal hernias are both located above the inguinal ligament. They can be differentiated by their side of origination in relation to the inferior epigastric vessels. Direct inguinal hernias originate medial to the inferior epigastric vessels, while indirect inguinal hernias originate lateral to the inferior epigastric vessels. This patient's groin mass originating medial to the inferior epigastric vessels is characteristic of a direct inguinal hernia in the Hesselbach triangle. The transversalis fascia makes up the floor of the triangle, and defects or weakness involving the transversalis fascia can lead to protrusion of abdominal contents. Failure of this fascial layer is most often due to acquired connective tissue abnormalities or chronic abdominal wall injury (most commonly in older men). Unlike indirect inguinal hernias, direct inguinal hernias do not pass through the internal (deep) inguinal ring but only through the external (superficial) inguinal ring. As a result, they do not have a direct route to the scrotum. (Choices A and B) Indirect inguinal hernias are the most common type of groin hernia in both sexes. The underlying etiology is usually congenital; due to failure of the processus vaginalis to obliterate (in males) or of the deep inguinal ring to close (in females). Indirect inguinal hernias protrude through the internal inguinal ring, lateral to the inferior epigastric vessels, allowing them to follow the same path as the spermatic cord though the inguinal canal and into the scrotum. (Choice C) Diastasis rectus abdominus is characterized by an abnormally large separation between the rectus abdominus muscles due to stretching and laxity of the linea alba. This usually occurs in states with increased intraabdominal pressure (eg, pregnancy, obesity) and characteristically presents with a bulge in the midline around the umbilicus (rather than in the groin directly above the inguinal ligament). (Choice E) Femoral hernias occur mainly in older women due to laxity and widening of the femoral ring, which allows abdominal contents to protrude below the inguinal ligament into the femoral canal. Educational objective: Direct inguinal hernias occur most commonly in older men due to weakness of the transversalis fascia. They protrude medial to the inferior epigastric vessels into the Hesselbach triangle and pass only through the superficial inguinal ring with no direct route to the scrotum.

A 62-Year-Old Man Comes to the Physician Due to Intermittent