A 62-year-old Hispanic woman comes to the office with complaints of a sense of heaviness and discomfort in her right groin. Her discomfort is worse with standing and coughing, and is relieved by lying flat. She also noticed a painful bulging mass at the same site two days ago, which resolved spontaneously after two hours. She has a past medical history of breast cancer and chronic bronchitis. She had a left mastectomy at age 48 and two cesarean sections at 28 and 33 years of age. She smokes a pack of cigarettes daily. On examination and Valsalva maneuver, you find a right-sided femoral hernia that is easily reducible. There is no evidence of incarceration or strangulation. Which of the following is the most appropriate next step?

Question

A 62-year-old Hispanic woman comes to the office with complaints of a sense of heaviness and discomfort in her right groin.  Her discomfort is worse with standing and coughing, and is relieved by lying flat.  She also noticed a painful bulging mass at the same site two days ago, which resolved spontaneously after two hours.  She has a past medical history of breast cancer and chronic bronchitis.  She had a left mastectomy at age 48 and two cesarean sections at 28 and 33 years of age.  She smokes a pack of cigarettes daily.  On examination and Valsalva maneuver, you find a right-sided femoral hernia that is easily reducible.  There is no evidence of incarceration or strangulation.  Which of the following is the most appropriate next step?

Quizplus · Accepted Answer

Explanation: A hernia is a small area of weakness or defect in the overlying muscular or fibrous wall through which abdominal contents pass. Groin hernias are either inguinal or femoral hernias. The most common presentation is the dull sensation of heaviness or discomfort that is more pronounced with prolonged standing or straining (increased intraabdominal pressure). These are easily reducible in most cases, and symptoms are relieved with lying flat. A dreaded complication is incarceration or strangulation. It occurs when a tight constriction ring forms around the herniated contents and the hernia then becomes irreducible. Patients typically present with a constant pain that gets worse over time. If left untreated, it leads to necrosis and gangrene of the contents, and can be life-threatening. A femoral hernia is much more predisposed to strangulation than an inguinal hernia. The effective treatment for all types of hernias is surgical repair. Risks of delaying the surgery are mainly those related to incarceration and strangulation. much more surgical repair (Choices A and B) Observation alone is not appropriate in patients with a femoral hernia. The risk of strangulation is the greatest in the early stages and with small hernias. (Choice D) Abdominal binders are only useful for symptomatic relief in patients with large incisional or umbilical hernias. These are not used for patients with femoral hernias. The only nonsurgical therapy for groin hernias is the use of a truss for symptom relief, but this is generally discouraged. (Choice E) Narcotic analgesics may mask the clinical features of strangulation. These should not be prescribed for long-term management of femoral hernias. Educational objective: The primary treatment for all types of hernias is surgical repair.

A 62-Year-Old Hispanic Woman Comes to the Office with Complaints