Original Article

Value of Ultrasonography in the Diagnosis of Inguinal Hernia –

A Retrospective Study
Wertigkeit der Sonographie in der Diagnostik der Leistenhernie –
eine retrospektive Studie

Authors
Tanja Maisenbacher1, Wolfgang Kratzer1, Andrea Formentini2, Julian Schmidberger1, Tanja Kaltenbach1,
Doris Henne-Bruns2, Tilmann Graeter3, Andreas Hillenbrand2

Affiliations allowing us to assess the accuracy of negative ultrasound find-

1 Department of Internal Medicine I, University Hospital ings as well.
Ulm, Germany Results The findings on ultrasonography were positive in 248
2 Department of General and Visceral Surgery, University patients and negative in 78 patients. In addition to 201 oper-

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Hospital Ulm, Germany
3 Department of Diagnostic and Interventional Radiology,
University Hospital Ulm, Germany
Key words
ultrasonography, inguinal hernia, diagnostics,
retrospective study
received 19.09.2017
accepted 16.05.2018
Bibliography
DOI https://doi.org/10.1055/a-0637-1526
Published online: 2018
Ultraschall in Med
© Georg Thieme Verlag KG, Stuttgart · New York
ISSN 0172-4614
Correspondence
Prof. Wolfgang Kratzer
Department of Internal Medicine I, University Hospital Ulm,
Albert-Einstein-Allee 23, 89081 Ulm, Germany
Tel.: ++ 49/7 31/50 04 47 30
Fax: ++ 49/7 31/50 04 46 20
wolfgang.kratzer@uniklinik-ulm.de
ABSTR AC T
Purpose The diagnosis of an inguinal hernia is usually made
clinically. Precise imaging appears to be necessary when the
clinical examination is inconclusive. The aim of this study was
to determine the diagnostic value of ultrasonography for
inguinal hernias and whether it influences the decision for or
against surgery.
Materials and Methods This study was a single-center retro-
spective study carried out from January 2012 to December
2016. All 326 patients had undergone ultrasound scanning
of the groin as part of the diagnostic workup. Besides surgical
findings being the gold standard, follow-up data and alterna-
tive ultrasound diagnoses were considered as references,
ated patients, we were able to validate a further 40 patients
by means of a questionnaire and the alternative ultrasound di-
agnoses. The correlation with all three references resulted in a
sensitivity of 97 %, a specificity of 77 %, a positive predictive
value of 95 %, and a negative predictive value of 87 %.
Conclusion Ultrasonography is an accurate method for eval-
uating inguinal hernias. High sensitivity makes it particularly
suitable for ruling out an inguinal hernia when the findings
are negative. An ultrasound scan carried out in addition to
clinical examination can therefore help to determine the right
indication for surgical intervention.
Z US A M M E N FA SS U N G
Ziel Leistenhernien werden primär klinisch diagnostiziert.
Eine genaue Bildgebung erscheint notwendig, wenn die kli-
nische Untersuchung kein eindeutiges Ergebnis liefert. Ziel
dieser Studie war es, die Wertigkeit der Sonografie in der Di-
agnostik von Leistenhernien zu bestimmen und deren Einfluss
in der Entscheidungsfindung für oder gegen eine Operation
herauszuarbeiten.
Material und Methoden Es handelte sich bei dieser Studie
um eine retrospektive Studie, die als Single-Center-Studie
von Januar 2012 bis Dezember 2016 durchgeführt wurde.
Untersucht wurden 326 Patienten, die zur differentialdiag-
nostischen Abklärung eine Ultraschalluntersuchung der Leiste
erhalten hatten. Neben Operationsbefunden als Goldstandard
wurden Angaben aus einem Follow-up und alternative sono-
grafische Diagnosen als Referenz betrachtet, um den Stellen-
wert der Sonografie bei negativen Ultraschallbefunden mög-
lichst genau einschätzen zu können.
Ergebnisse Die Sonografie war bei 248 Patienten positiv und
bei 78 Patienten negativ. 201 Patienten wurden operiert und
weitere 40 Patienten konnten durch einen Fragebogen und
die alternativen sonografischen Diagnosen validiert werden.
Die Korrelation mit diesen Referenzen ergab eine Sensitivität
von 97 %, eine Spezifität von 77 %, einen positiv prädiktiven
Wert von 95 % und einen negativ prädiktiven Wert von 87 %.

Maisenbacher T et al. Value of Ultrasonography… Ultraschall in Med

 Original Article
Schlussfolgerungen Die Sonografie stellt eine sehr genaue
Methode für die Evaluierung von Leistenhernien dar. Mit einer
hohen Sensitivität eignet sie sich bei einem negativen Ultra-
schallbefund insbesondere gut zum Ausschluss einer Leisten-
Introduction
Surgical procedures for inguinal hernia were the second most
common surgeries performed on men treated as inpatients in
Germany in 2015 [1] and represent a high cost factor for the
healthcare system [2]. In the presence of the classic constellation
of symptoms and signs, the diagnosis of an inguinal hernia can
usually be made clinically. However, if the clinical examination is
inconclusive, questions arise as to whether an inguinal hernia is
really the cause of the symptoms and which diagnostic investiga-
tions should then be carried out. In such cases, noninvasive ima-
ging is required for a reliable diagnosis and appropriate treat-
ment. Ultrasonography is the method most frequently used in
routine clinical practice to assess an inconclusive clinical examina-
tion of the groin. It has the advantage of being a noninvasive,
readily available, cost-effective modality with the possibility of dy-
namic real-time demonstration of soft tissues, without exposure
to ionizing radiation [3, 4]. Its disadvantages, however, include
the fact that the results depend greatly on the examiner and that
it is difficult to perform adequately in obese patients [5, 6]. There
is good evidence that ultrasonography can identify clinically palp-
able inguinal hernias very accurately [7]. On the other hand, stud-
ies on occult inguinal hernias are less clear-cut [3 – 5, 8 – 10].
The aim of the present study was to determine the diagnostic
value of ultrasonography for inguinal hernias. In this context, we
aimed to evaluate the role of ultrasonography in the diagnostic al-
gorithm of inguinal hernias and work out a proposal for the manage-
ment of the individual patient, subject to the ultrasound findings.
Materials and methods
The present study was a single-center retrospective follow-up
study, conducted from January 2012 to December 2016. The local
Ethics Committee approved the study (application no. 46/16).
By means of a database search, we found 551 ultrasound
examinations carried out in the Central Ultrasound Unit between
January 2012 and April 2016, with the query or finding of an ingu-
inal hernia. Generally, we included patients who had undergone
ultrasound scanning of the groin with subsequent surgery or the
option to participate in the follow-up. After applying the inclusion
and exclusion criteria, the study population consisted of 326 pa-
tients (▶ Fig. 1). Most patients were referred by the surgical de-
partment after clinical examination. Therefore, there has been a
preselection of patients resulting in mainly clinical equivocal cases
being sent to the ultrasound unit.
hernie. Eine zusätzlich zur klinischen Untersuchung durchge-
führte Sonografie kann daher die korrekte Indikation und
Entscheidung für eine chirurgische Intervention vereinfachen.
Scanning technique
All patients were initially examined on the symptomatic side in a
supine position. If necessary, the patient was also examined
standing up, in order to enhance any ultrasound evidence of an
inguinal hernia. For orientation the examination started with a
convex transducer with 1 – 6 MHz. First, the transducer was
placed in a slightly oblique section between the anterior superior
iliac spine and the pectineal line of the pubis. The inferior epigas-
tric artery served as a landmark for the deep inguinal ring. The in-
guinal canal was then assessed in cross section, i. e. in the anato-
mical sagittal axis. Each plane was assessed at rest and with raised
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intra-abdominal pressure (Valsalva maneuver, coughing, or strain-
ing) to demonstrate any transient inguinal hernias that were com-
pletely reduced at rest and therefore could not be seen earlier.
Any widening of the inguinal canal was taken to be pathological,
whereas movement of the spermatic cord under pressure was
considered physiological. These steps were then repeated using a
high-resolution linear transducer with 5 – 12 MHz.
An inguinal hernia was diagnosed by fulfilling one or more of
the following criteria on ultrasound scanning:
1. Evidence of a hernial gap and/or hernial sac
2. Typical movements of the intestine and/or fatty structures in
the hernial gap and sac during a Valsalva maneuver
3. Reduction of the hernial contents
4. Evidence of an incarcerated hernia
If an inguinal hernia was demonstrated, its contents, the size of
the gap, and the size of the hernial sac were ascertained whenever
possible (▶ Fig. 2 – 5).
Study schedule
Clinical data, ultrasound scan findings, and operation reports
were gathered retrospectively from the electronic patient re-
cords. To ensure a clear distinction, a positive cough impulse on
physical examination was not considered to be a clinically palp-
able hernia but was classified and recorded separately. Data were
then collected prospectively from a follow-up by means of a ques-
tionnaire. We contacted all patients who, according to our infor-
mation, had not yet had surgery. The questionnaire asked for de-
tails of weight, height, occupation, concomitant diseases,
medication, and previous surgeries, as this information could pro-
vide evidence of other possible causes of the symptoms. More-
over, the patients were asked about surgeries for inguinal hernias,
including the date, place, and findings, in order to identify pa-
tients who had undergone surgery at another hospital, possibly
even as an emergency. In addition, we asked whether the symp-
toms in the groin had persisted, their duration, site, and nature,
and if there was any association with particular situations.
Maisenbacher T et al. Value of Ultrasonography… Ultraschall in Med

▶ Fig. 1 Selection of the study population (BMI = Body Mass Index).
▶ Fig. 2 Ultrasound image of an inguinal hernia (BL = hernial gap
measuring 8 mm, hernial sac measuring 46 × 21 mm).
▶ Fig. 3 Inguinal hernia left type A to Gai [18].
Maisenbacher T et al. Value of Ultrasonography… Ultraschall in Med
▶ Fig. 4 Inguinal hernia left type B to Gai [18].
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▶ Fig. 5 Inguinal hernia left type C to Gai [18].
Reference standard
Besides taking the surgical findings as the gold standard to con-
firm an inguinal hernia, the findings from follow-up and alterna-
tive ultrasound diagnoses were considered as further references
for determining the accuracy of ultrasonography, especially with
negative findings.
Whenever available, an operation report was used as the refer-
ence. Patients who participated in the follow-up were grouped ac-
cording to their ultrasound findings and answers to the question-
naire. If no inguinal hernia had been seen on ultrasound scanning
and the patient was symptom-free at follow-up, this was counted
as “no inguinal hernia” and therefore a “true negative”. It was as-
sumed that the symptoms experienced at the time of the ultraso-
nography were most likely due to another cause. We also attemp-
ted to determine this cause. When patients with negative
ultrasound findings reported persistent symptoms, we could not
draw any firm conclusions purely from the symptoms themselves.
If another possible cause of the symptoms could be identified
from the history in these cases, we also deemed these patients
to be “true negatives”. If no other possible cause was found, the
patients were not included in determining the value of ultrasono-
 Original Article
▶ Table 1 Follow-up constellations (negative = no inguinal hernia, positive = inguinal hernia, CE = clinical examination).
ultrasound persistent symptoms at follow-up
negative no
negative yes
positive no
positive yes
ultrasound surgery in another hospital
negative yes
positive yes
graphy. Patients with an inguinal hernia diagnosed on ultrasound
who were asymptomatic at follow-up could not be classed as clear
true or false positives and were therefore not taken into consid-
eration in determining the value either. Patients with an inguinal
hernia seen on ultrasound and persistent symptoms were alloca-
ted to the group of true positives.
Alternative ultrasound diagnoses were taken as a further refer-
ence in patients who had not had surgery and did not participate
in follow-up, as an inguinal hernia seemed unlikely in these
patients.
Statistical analysis
The patient data were first analyzed descriptively. The sensitivity,
specificity, positive predictive value (PPV), negative predictive val-
ue (NPV), and positive and negative likelihood ratio (LR) were cal-
culated separately for each of the reference standards using a
2 × 2 contingency table. Data were not complete for all patients.
The calculations were therefore based on the available data.
Results
The studied patient population consisted of 266 men (81.6 %) and
60 women (18.4 %). This gave a male:female ratio of about 4.5:1.
The mean age ± standard deviation was 54.67 ± 17.67 years with a
range of 18 to 94 years at the time of ultrasound scanning. The
mean body mass index (BMI) was 26.1 kg/m² (± 4.25 kg/m²), with
a minimum of 15.2 kg/m² and a maximum of 49.3 kg/m².
On clinical examination, about 6 % of the patients were asymp-
tomatic, while 87 % reported symptoms (missing data in 7 %). For
symptomatic patients the main reason presenting to the hospital
was pain (in over 80 %). Symptoms were localized to the groin in
most cases (87 %), with a slight predominance on the right side.
Ultrasound showed an inguinal hernia in 248 patients (76 %).
Surgery was carried out on 201 patients (62 %) including 8 pa-
tients who stated having had surgery elsewhere on the follow-up
number of patients valuation
11 5 true negative
6 with other causes of symptoms true negative
12 5 not possible
7 with other causes of symptoms true negative
7 4 not possible
3 asymptomatic at the time of CE not possible
9 true positive
number of patients valuation
1 false negative
(included in the calculation with reference standard surgery)
7 true positive
(included in the calculation with reference standard surgery)
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questionnaire. Of the inguinal hernias confirmed at surgery, 39 %
were on the left, 41 % on the right, and 17 % bilateral (no informa-
tion given in the operation report in 3 %). Indirect inguinal hernias
were the most common, followed by direct and recurrent inguinal
hernias. Correlation with surgical findings revealed ten false-posi-
tive and five false-negative ultrasound findings.
The ultrasound scans offered an alternative diagnosis to ingu-
inal hernia in 13 of the patients who did not have surgery. These
findings included swollen lymph nodes (n = 5), musculoskeletal
causes (n = 2), gastrointestinal causes (n = 3), an ovarian cyst
(n = 1), an incisional hernia (n = 1) and an abdominal wall hernia
in the lower abdomen (n = 1).
47 patients participated in the follow-up. A total of 23 patients
had a positive ultrasound finding, and 24 had a negative ultrasound
finding. 8 out of 47 patients had surgery in another hospital. From
the patients with positive US finding (n = 23), 9 without surgery
had persistent symptoms, the other 7 were asymptomatic. From
the patients with negative ultrasound (n = 24), 12 showed persistent
symptoms and 11 patients had no symptoms (▶ Fig. 6, ▶ Table 1).
From the information given in the questionnaires, we were able to
identify other possible causes of the symptoms in 13 of the patients
who had no evidence of an inguinal hernia on ultrasound: musculos-
keletal (n = 7), gastrointestinal (n = 3), urological (n = 1), and pre-
vious surgery (n = 2) (▶ Fig. 6, ▶ Table 1).
Correlation with one of the references was possible in 241 of
the 326 patients (201 patients with surgery, 27 patients validated
through follow-up and 13 patients with alternative ultrasound di-
agnoses). This gave a sensitivity of 97 %, specificity of 77 %, PPV of
95 %, NPV of 87 %, positive LR of 4.29 and negative LR of 0.033.
The operation rate for the whole study population was 62 %.
When looking at the rate of operation based on clinical findings,
surgery was performed in 62 out of 66 patients (94 %) with clini-
cally palpable inguinal hernias, 15 out of 17 (88 %) with a positive
cough impulse, and 124 of 243 (51 %) with a negative clinical ex-
amination. The rate based on ultrasound findings was 78 % when
an inguinal hernia was demonstrated on ultrasound and 10 % with
Maisenbacher T et al. Value of Ultrasonography… Ultraschall in Med
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▶ Fig. 6 : Study flowchart (US = ultrasound)

negative ultrasound findings. When the clinical examination was provided initial information for the preoperative assessment of
negative but the ultrasonography positive, 120 out of 170 pa- whether mesh would be required to close the gap. The hernia con-
tients (71 %) had surgery. tents and size of the gap also seem to be useful in assessing the
urgency of an operation, as large gaps and the absence of bowel
in the hernial sac present a much lower risk of incarceration [12].
Discussion False-positive findings on ultrasound examination occur espe-
cially with lipomas of the spermatic cord or the round ligament
Ultrasonography seems to be unnecessary in patients with a palp-
and with lymphadenopathy [6, 10]. The reasons for the false-posi-
able inguinal hernia, because the indication for surgery can usual-
tive findings in our study were seven femoral hernias, one abscess,
ly be determined clinically (▶ Fig. 7). In such cases ultrasonogra-
and one varicocele. The reasons for false-negative findings include
phy provides only limited additional information and the use of
a lack of patient cooperation in the Valsalva maneuver, a poor ex-
imaging resources may be criticized as being inefficient, even
amination technique, and slight or only intermittent herniations
with a mixed study population [11]. However, as our patients
[6, 10]. Another possible cause is too much pressure applied to
were selected retrospectively, any effects of this study on the re-
the transducer, which can reduce an inguinal hernia or prevent
ferral practice at the time can be ruled out. On this basis, it can be
the bulge from forming [6]. Three recurrent inguinal hernias may
argued that the results from a mixed population most likely re-
be possible reasons for our false negatives, because assessment
flect the real clinical situation. The reasons for referring patients
can be difficult due to implanted mesh and its reflections.
with palpable inguinal hernias for ultrasound could not be deter-
The sensitivity found in this study was 97 %, which is in agree-
mined retrospectively in all cases. The request forms for these pa-
ment with other recent studies [9, 13]. There was a greater differ-
tients usually queried the size of the hernial gap/sac and its con-
ence in the PPV of 95 %, compared with the figures of 70 % found
tents. The size of the hernial gap measured on ultrasound

Maisenbacher T et al. Value of Ultrasonography… Ultraschall in Med

 Original Article

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▶ Fig. 7 : Diagnostic algorithm (US = ultrasound)

by Light et al. and Alabraba et al. [8, 10]. Differences can be attrib- Role of ultrasonography in the diagnostic algorithm
uted to the methodology, with the selection of the patient popu- (▶ Fig. 7)
lation probably being largely responsible [5, 10, 11]. Studies on
The high sensitivity of ultrasonography means that it is well suited
clinically palpable inguinal hernias, such as Bradley et al. [7],
to rule out an inguinal hernia when the findings are negative.
showed the highest sensitivity and PPV. The ultrasound technique
Accordingly, patients with an unremarkable clinical examination
and the various transducers used may also offer an explanation
and negative ultrasound findings can be treated conservatively
[11]. The lower resolution and “poorer” hardware and software
(▶ Fig. 7). Besides ruling out an inguinal hernia, an ultrasound
in the older studies may also be relevant in this context.
examination can help to identify other causes of the symptoms
The specificity of 77 % in the present study is slightly lower than
in these patients and guide treatment in the right direction.
the 82 – 100 % found in other studies [6, 7, 9, 14]. Only three stud-
With only a few false-positive findings, a high PPV, and a speci-
ies have reported the NPV, with figures of 85 – 100 % [6, 7, 14]. Dif-
ficity of 77 %, surgery can be recommended for patients with an
ferences in the specificity and the NPV can be explained mainly by
inguinal hernia detected on ultrasound. However, the results of
the choice of reference standards, as under- or overestimation of
the present study also show that about one quarter of patients
these two values is possible, depending on the reference standard
with positive ultrasound findings did not undergo surgery. In only
used. Furthermore, differences may also be attributed to the dif-
a few patients we were able to determine a direct cause, such as a
ference in the number of validated negative ultrasound findings.
high surgical risk, patient preference, or symptomatic improve-
A large number seems to be associated with a higher specificity
ment. An alternative explanation might be the increasing use of
and a higher NPV.
a watchful waiting strategy. This approach is thought to be safe
in men with only minimal or no symptoms, given the low risk of
incarceration and the high incidence of chronic postoperative

Maisenbacher T et al. Value of Ultrasonography… Ultraschall in Med

pain [15]. According to two studies, however, more than half the
patients managed in this way developed symptoms and ultimate-
ly required surgery [16, 17]. It would therefore be of interest to
improve the selection of patients who would benefit from watch-
ful waiting before actually engaging in this therapeutic option. In
this situation, ultrasonography may be useful to assess the risk of
complications from the contents of the hernia, the size of the her-
nial gap, and the type of hernia (▶ Fig. 3 – 5) [18]. However, this
therapeutic approach is not to be recommended in women, as
femoral hernias are more common in females and have a higher
risk of incarceration [15]. Consequently, the preoperative differ-
entiation of inguinal hernia from femoral hernia would be mean-
ingful but, according to the literature, neither clinical examination
nor other diagnostic tests have delivered reliable results [19].
Femoral hernias were responsible for 70 % of the false-positive
findings in our study, which supports the earlier observations.
Positive and negative LRs show that the probability of an ingu-
inal hernia being present changes less with a positive ultrasound
result than with a negative finding. This allows us to assume that
ultrasonography is more useful to rule out an inguinal hernia than
to confirm one.
Limitations of the study concern the diagnostic reference
standard, for which the only confirmed gold standard is surgery.
Surgical exploration of all patients would be required to assess
the value of ultrasonography precisely. As this obviously cannot
be justified on ethical grounds, the figures for specificity and the
NPV in particular have to be considered as merely indicative.
Ultrasonography is an imaging procedure, which means that the
findings have to be interpreted. Knowledge of the ultrasound
findings therefore has an effect on the surgeon’s decision to oper-
ate and thus on the use of the reference standard (information
bias). As a result, the same reference standard was not used for
all patients. Patients with positive and negative ultrasound find-
ings were validated in different ways and with differing quality
(verification bias). A slight overestimation of the sensitivity was
therefore to be expected but was accepted in return for better
estimation of the specificity and the NPV.
Conclusion
Our results show that ultrasonography is a time-saving, noninvasive,
examination that provides reliable findings in the diagnostic investi-
gation of inguinal hernias. With its high sensitivity, negative ultra-
sound findings seem particularly useful in ruling out inguinal hernias.
Apart from cases where the clinical examination is inconclusive,
ultrasonography may also be indicated in patients with clinically
palpable hernias when the urgency of surgical interventions and the
need for a mesh implant have to be assessed. The role of ultrasound
in the search for other possible causes of symptoms in the groin
should likewise not be underestimated. Our results indicate that
ultrasonography should be an integral component of the diagnostic
algorithm when an inguinal hernia is suspected.
Conflict of Interest
The authors declare that they have no conflict of interest.
Maisenbacher T et al. Value of Ultrasonography… Ultraschall in Med
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