Case history/examination:
A 22-year-old man complained of sudden and severe abdominal pain while sleeping and was brought to our hospital via ambulance. He was writhing in pain during hospital admission, but denied nausea or constipation. A medical interview revealed no medical or surgical history. A physical examination revealed a tender flat abdomen with maximal tenderness in the upper abdomen. Intestinal peristalsis was normal. There was no rebound tenderness or abdominal rigidity.
A blood test showed an elevated white cell count (12,300/μL) but no elevated C-reactive protein (0.0 mg/dL). All the other parameters were normal. A radiograph indicated a soft part shadow, approximately 13 cm in size, in the genital area (Figure 1). On examining his genital area, we found a large, irreducible, non-tender right scrotum (Figure 2). He did not notice it and denied lower abdominal pain. We, therefore, suspected inguinal hernia. Computed tomography confirmed external inguinal hernia. Manual delivery was a failure; therefore, emergency surgery was performed.
Inguinal hernias have a variety of clinical presentations: a painless bulge in the groin region, scrotum pain, anteromedial hip pain, and groin or abdomen pain.1 The median patient age for inguinal hernia in adults is 50–69 years,2 mostly affecting men, with a few uncommon occurrences in women or young men, as in our patient. The genital area must therefore be carefully examined in such clinical presentations. In our patient, a radiograph helped in the diagnosis of inguinal hernia. We conclude that special attention must be paid to the genital area on a radiograph for patients presenting with abdominal pain, as described in the case above.