Obturator hernia

Changed by Daniel J Bell, 9 Jan 2019

Updates to Article Attributes

Body was changed:

Show markup changes

Obturator hernias are characterised by bowel herniating between the obturator and the pectineus muscles. They are a rare type of abdominal hernia and can be very difficult to diagnose clinically.

Epidemiology

Typically obturator hernias occur in elderly women ^3,42,3 or patients with chronically raised intra-abdominal pressure (e.g. ascites, COPD, chronic cough) ⁴³. It has been suggested that the female predominance of these hernias is the result of pregnancy, which leads to relaxation of the pelvic peritoneum and a wider and more horizontal obturator canal ⁴³.

Clinical presentation

In general obturator, hernias are asymptomatic unless ²¹

they compress the obturator nerve: Howship-Romberg sign(only present in approximately half of cases) ⁴³
contain bowel which incarcerates/obstructs/strangulates

Pathology

The obturator foramen is occluded by the obturator membrane which is pierced anterosuperiorly by the obturator artery, vein and nerve. This neurovascular bundle then travels along a 2-3 cm oblique tunnel, the obturator canal. It is through this deficiency that an obturator hernia occurs. Presumably, due to the sigmoid colon on the left, these hernias are more common on the right ⁴³.

The layers that the hernial neck passes through include:

obturator internus muscle fibres
obturator membrane
obturator externus muscle fibres

The hernia will then lie superficial to obturator externus and deep and inferior to pectineus muscle.

The hernia may contain any of the following:

no more than peritoneum filled with fluid, as seen in patients with ascites
small bowel (most common)
colon ⁴³
appendix
omentum
Meckel diverticulum
ovary/fallopian tube
and even uterus ⁴³

Radiographic features

The diagnosis is readily made on CT/MRI with either fluid or bowel able to be traced along the aforementioned course to lie in the medial upper thigh.

Signs of complication including:

bowel obstruction
strangulation resulting in perforation

Treatment and prognosis

Treatment involves surgery and repair of the hernial orifice.

History and etymology

Howship-Romberg sign is named for the German neurologist, Moritz Heinrich Romberg (1795-1873) ⁵, and British surgeon John Howship (1781-1841) ⁴.

Differential diagnosis

If a hernia contains bowel or can be clearly traced through the obturator foramen, then there are very few alternative diagnoses.

If seen with ultrasound, it may be mistaken for a bursa or acetabular labral cyst.

-<p><strong>Obturator hernias</strong> are characterised by bowel herniating between the obturator and the <a href="/articles/pectineus-muscle">pectineus muscles</a>. They are a rare type of <a href="/articles/abdominal-hernia">abdominal hernia</a> and can be very difficult to diagnose clinically.</p><h4>Epidemiology</h4><p>Typically obturator hernias occur in elderly women <sup>3,4</sup> or patients with chronically raised intra-abdominal pressure (e.g. <a href="/articles/ascites">ascites</a>, <a href="/articles/chronic-obstructive-pulmonary-disease-1">COPD</a>, chronic cough) <sup>4</sup>. It has been suggested that the female predominance of these hernias is the result of pregnancy, which leads to relaxation of the pelvic peritoneum and a wider and more horizontal obturator canal <sup>4</sup>.</p><h4>Clinical presentation</h4><p>In general obturator, hernias are asymptomatic unless <sup>2</sup></p><ul>
-<li>they compress the <a href="/articles/obturator-nerve-1">obturator nerve</a>: <a href="/articles/howship-romberg-sign">Howship-Romberg sign </a>(only present in approximately half of cases) <sup>4</sup>
+<p><strong>Obturator hernias</strong> are characterised by bowel herniating between the obturator and the <a href="/articles/pectineus-muscle">pectineus muscles</a>. They are a rare type of <a href="/articles/abdominal-hernia">abdominal hernia</a> and can be very difficult to diagnose clinically.</p><h4>Epidemiology</h4><p>Typically obturator hernias occur in elderly women <sup>2,3</sup> or patients with chronically raised intra-abdominal pressure (e.g. <a href="/articles/ascites">ascites</a>, <a href="/articles/chronic-obstructive-pulmonary-disease-1">COPD</a>, chronic cough) <sup>3</sup>. It has been suggested that the female predominance of these hernias is the result of pregnancy, which leads to relaxation of the pelvic peritoneum and a wider and more horizontal obturator canal <sup>3</sup>.</p><h4>Clinical presentation</h4><p>In general obturator, hernias are asymptomatic unless <sup>1</sup></p><ul>
+<li>they compress the <a href="/articles/obturator-nerve-1">obturator nerve</a>: <a href="/articles/howship-romberg-sign">Howship-Romberg sign</a> (only present in approximately half of cases) <sup>3</sup>
-</ul><h4>Pathology</h4><p>The <a href="/articles/obturator-foramen">obturator foramen</a> is occluded by the obturator membrane which is pierced anterosuperiorly by the <a href="/articles/obturator-artery">obturator artery</a>, <a href="/articles/obturator-vein">vein</a> and <a href="/articles/obturator-nerve-1">nerve</a>. This neurovascular bundle then travels along a 2-3 cm oblique tunnel, the <a href="/articles/obturator-canal">obturator canal</a>. It is through this deficiency that an obturator hernia occurs. Presumably, due to the <a href="/articles/sigmoid-colon">sigmoid colon</a> on the left, these hernias are more common on the right <sup>4</sup>. </p><p>The layers that the hernial neck passes through include:</p><ul>
+</ul><h4>Pathology</h4><p>The <a href="/articles/obturator-foramen">obturator foramen</a> is occluded by the obturator membrane which is pierced anterosuperiorly by the <a href="/articles/obturator-artery">obturator artery</a>, <a href="/articles/obturator-vein">vein</a> and <a href="/articles/obturator-nerve-1">nerve</a>. This neurovascular bundle then travels along a 2-3 cm oblique tunnel, the <a href="/articles/obturator-canal">obturator canal</a>. It is through this deficiency that an obturator hernia occurs. Presumably, due to the <a href="/articles/sigmoid-colon">sigmoid colon</a> on the left, these hernias are more common on the right <sup>3</sup>. </p><p>The layers that the hernial neck passes through include:</p><ul>
~~-<a href="/articles/colon">colon</a> <sup>4</sup>~~
+<a href="/articles/colon">colon</a> <sup>3</sup>
~~-<li>and even <a href="/articles/uterus">uterus</a> <sup>4</sup>~~
+<li>and even <a href="/articles/uterus">uterus</a> <sup>3</sup>
-</ul><h4>Treatment and prognosis</h4><p>Treatment involves surgery and repair of the hernial orifice. </p><h4>Differential diagnosis</h4><p>If a hernia contains bowel or can be clearly traced through the obturator foramen, then there are very few alternative diagnoses.</p><p>If seen with ultrasound, it may be mistaken for a bursa or <a href="/articles/acetabular-labral-cyst">acetabular labral cyst</a>.</p>
+</ul><h4>Treatment and prognosis</h4><p>Treatment involves surgery and repair of the hernial orifice. </p><h4>History and etymology</h4><p>Howship-Romberg sign is named for the German neurologist, <strong>Moritz Heinrich Romberg</strong> (1795-1873) <sup>5</sup>, and British surgeon <strong>John Howship</strong> (1781-1841) <sup>4</sup>.</p><h4>Differential diagnosis</h4><p>If a hernia contains bowel or can be clearly traced through the obturator foramen, then there are very few alternative diagnoses.</p><p>If seen with ultrasound, it may be mistaken for a bursa or <a href="/articles/acetabular-labral-cyst">acetabular labral cyst</a>.</p>

References changed:

3. Glicklich M, Eliasoph J. Incarcerated obturator hernia: case diagnosed at barium enema fluoroscopy. Radiology. 1989;172 (1): 51-2. <a href="http://radiology.rsna.org/content/172/1/51.abstract">Radiology (abstract)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/2740520">Pubmed citation</a><div class="ref_v2"></div>
4. Bir SC, Kalakoti P, Notarianni C, Nanda A. John Howship (1781-1841) and growing skull fracture: historical perspective. Journal of neurosurgery. Pediatrics. 16 (4): 472-6. <a href="https://doi.org/10.3171/2014.12.PEDS14484">doi:10.3171/2014.12.PEDS14484</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/26186359">Pubmed</a> <span class="ref_v4"></span>
5. Housman B, Bellary SS, Walters A, Mirzayan N, Tubbs RS, Loukas M. Moritz Heinrich Romberg (1795-1873): Early founder of neurology. Clinical anatomy (New York, N.Y.). 27 (2): 147-9. <a href="https://doi.org/10.1002/ca.22112">doi:10.1002/ca.22112</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/22711686">Pubmed</a> <span class="ref_v4"></span>
3. Howship's syndrome from whonamedit.com, the dictionary of medical eponyms. <a href="http://www.whonamedit.com/synd.cfm/1579.html">Howship's syndrome</a><div class="ref_v2"></div>
4. Glicklich M, Eliasoph J. Incarcerated obturator hernia: case diagnosed at barium enema fluoroscopy. Radiology. 1989;172 (1): 51-2. <a href="http://radiology.rsna.org/content/172/1/51.abstract">Radiology (abstract)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/2740520">Pubmed citation</a><div class="ref_v2"></div>

ADVERTISEMENT: Supporters see fewer/no ads

{"current_user":null,"inclusions":[{"imageId":48778096,"studyId":null,"caseSlug":null,"caption":"Case 1","thumbnail":"https://prod-images-static.radiopaedia.org/images/48778096/7d4d760a3c46de12ded545f3784b18_big_gallery.jpeg","isStack":false,"diagnosticCertainty":null},{"imageId":45444982,"studyId":74612,"caseSlug":"obturator-hernia-causing-small-bowel-obstruction","caption":"Case 2","thumbnail":"https://prod-images-static.radiopaedia.org/images/45444982/f61664fae6af9edc4307a176d20e84_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":1346574,"studyId":14830,"caseSlug":"obturator-hernia-2","caption":"Case 3","thumbnail":"https://prod-images-static.radiopaedia.org/images/1346574/20bd4d9e7e5f6730c51dd2d010d47c_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":33927809,"studyId":63614,"caseSlug":"incarcerated-obturator-hernia-1","caption":"Case 4","thumbnail":"https://prod-images-static.radiopaedia.org/images/33927809/2827db4c7a3997894e4c8cce5e5080_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52198047,"studyId":86293,"caseSlug":"obstructed-obturator-hernia","caption":"Case 5","thumbnail":"https://prod-images-static.radiopaedia.org/images/52198047/8c6e3acca2707ef01845bc421a510a_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52917856,"studyId":91766,"caseSlug":"obturator-hernia-incarcerated","caption":"Case 6","thumbnail":"https://prod-images-static.radiopaedia.org/images/52917856/4dc25956434f246341b7ddfdaeffce_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":54575236,"studyId":103969,"caseSlug":"incarcerated-obturator-hernia-3","caption":"Case 7","thumbnail":"https://prod-images-static.radiopaedia.org/images/54575236/69_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":60437169,"studyId":129628,"caseSlug":"obturator-hernia-15","caption":"Case 6","thumbnail":"https://prod-images-static.radiopaedia.org/images/60437169/5fb5778c791168d50b13506f1db237afafce1da6edb92a1d8afb115e17c20fb1_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"}],"ddx_inclusions":[],"lang":"us"}