A congenital indirect inguinal hernia commonly presents with a mass or swelling in the groin that is witnessed by the parents in the first few months of life. The parents may report that the swelling appears with straining or crying only to disappear at rest. There may be a story of it increasing in size during the course of the day - presumably due to the accumulation of peritoneal fluid while erect. A lump may have been witnessed in both groins and specific enquiry must be made about bilateral swelling.
As with adults, the child should be examined while standing. With boys, the scrotum should be examined to deduce whether the mass extends into it. If a scrotal mass is present, the examiner must determine whether it is possible to get above it. If it is possible to get above the mass, then it is unlikely to be a hernia. While examining the scrotum, it is vital to establish that both testicles are present.
Ascending in males, the cord is palpated. A thickened cord relative to the contralateral side is a fair sign that a hernia may be present. The groin is examined as there may be an obvious mass. The contralateral side should be examined. The mass may reduce with gentle pressure or exhibit a cough impulse. In the absence of a mass in a young child and in the presence of a good history from the mother, it is a reasonable step to make a diagnosis of a congenital indirect inguinal hernia and proceed to exploration.
Girls with clinical features of an inguinal hernia should raise suspicions about the child's genotypic sex, particularly if bilateral swellings have been reported. For example, testicular feminization syndrome may be present. The child with a tender, fixed groin swelling with or without abdominal pain and vomiting should rapidly proceed to theatre with a presumed diagnosis of bowel strangulation.
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