Hernia or Psoas?

Wow, I wish all my patients came with such thorough and insightful histories. Thank you for that!

Well, you hit every single point that I usually tackle during the detailed hernia questionnaire that we go through during consultation (you can find a copy of it on my website if you don’t believe me!). You pretty much said “Yes” to everything on our list: pain at the groin that radiates up and around to the back and down the upper thigh, worse with sitting and standing, best with lying flat, associated nausea and bloating, notably worse with bull bladder and pain lingers after a bowel movement. Exercise does not make it worse, as most exercises do not cause an increase in abdominal pressure.

You do have a risk factor of hernia: family history. And we have noticed that a female link is stronger than a male link.

Ultrasounds for hernias must be done as a dynamic study. That means, standing, coughing, walking around. It should never be done while lying flat. That would likely result in a “false negative” study, that is, a report that says there is no hernia, when in fact there is one. In our study, we found that for small hernias, 50% of the time, the ultrasound was falsely negative. It is possible that this is because of technique more than the ultrasound quality itself.

If there is no actual bulge at your groin area, but your symptoms are suggestive of an inguinal hernia, then you fall into the category of an occult or hidden hernia. This is most likely to be found among women. In these circumstances, I recommend an ultrasound, and if that is not diagnostic, then a dynamic MRI. We have noted in our studies that the dynamic portion of the MRI pelvis is actually highly important in helping diagnose small occult hernias. A flat MRI pelvis may be adequate in many situations.

So, based on this assessment, which, granted, is based on your story, without any review of your films or any examination…

I do recommend that you seek a hernia specialist for your situation. You can start with a general surgeon who has interest in hernias, but most are not in tune with the concept of occult hernias among women, and so you may need to be patient and seek another consultant if the first one does not provide you with an answer to help rid you of your pain.

I am not familiar with specialists in Alberta. You can first try the Americas Hernia Society website (www.americanherniasociety.org) to see if any members live in your Province. The Shouldice Clinic in Ontario is another option, and I am in contact with them to discuss the concept of occult hernias among women.