How do you tell an inguinal hernia from a femoral hernia?

By their relationship to the pubic tubercle. An inguinal hernia appears above and medial to the pubic tubercle; a femoral hernia appears below and lateral to it. Femoral hernias are commoner in women and strangulate earlier because the femoral canal is narrow.

What does a tender, irreducible hernia mean?

It suggests strangulation, meaning the blood supply to the contents of the hernia is compromised. With vomiting or absolute constipation it also indicates obstruction. Both require urgent surgical assessment, and the hernia should not be forcibly reduced.

Hernia and the groin — a guide for medical students

Written and clinically reviewed by Dr. Mohammed Maree, consultant minimally invasive and bariatric surgeon, Al-Makassed Hospital, Jerusalem, and Assistant Professor of Surgery, Al-Quds University. Last updated 6 October 2026.

A hernia is a protrusion of a viscus, or part of one, through a defect in the wall that normally contains it. Almost everything a student needs follows from one idea: a hernia is a problem of contents, and the danger is not the lump but what is inside it.

Three questions, in this order

Question	Answer	What it means
Does it go away when you lie down, or can you push it back?	Yes	Reducible — elective referral
	No, not any more	Incarcerated — it has become irreducible
Is it painful or tender now?	Yes	Suspect strangulation — the blood supply to the contents is compromised
Have you vomited, or stopped passing wind?	Yes	Obstruction — the hernia contains bowel, and this is a tonight problem

Why the groin is examined in a patient with obstruction

A patient referred with vomiting and a distended abdomen may never mention the lump in their groin, because it has been there for years and has never caused trouble. An obstructed femoral hernia in an older woman is small, often missed, and strangulates early because the femoral canal is narrow and unforgiving. If you do not look, you do not find it — this is the examination step most often skipped.

Direct, indirect and femoral

The distinction matters less at the bedside than textbooks imply, because the operation is largely the same, but the reasoning is worth knowing.

Indirect inguinal — through the deep ring, down the inguinal canal, along the path of the descending testis. Can reach the scrotum. The commoner type, and the type in young men.
Direct inguinal — pushes forward through a weak posterior wall, medial to the inferior epigastric vessels. Rarely reaches the scrotum. Typically older men.
Femoral — below and lateral to the pubic tubercle, through the femoral canal. Commoner in women, and the one most likely to strangulate.

The landmark that separates them clinically is the pubic tubercle: inguinal hernias appear above and medial to it, femoral hernias below and lateral.

Surgical pearl

Never ask a patient to reduce a tender, irreducible hernia for you, and do not force it yourself. Reducing strangulated bowel back into the abdomen returns dead bowel to a place where you can no longer see it.