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Hernia Examination for MRCS Part B: Standing, Supine and the Cough Impulse

By Dr Richard Miller, MBChB FRCS with the MRCS Part B Questions Team · Reviewed 15 September 2026

In brief

Examine a groin hernia standing first, then supine: inspect, ask the patient to cough, palpate the lump, decide whether you can get above it and whether it is reducible, and locate it against the pubic tubercle.

Examine a groin hernia with the patient standing first, because a small hernia disappears when they lie down. Inspect both groins, ask the patient to cough, palpate the lump and the inguinal regions, then repeat the whole sequence supine and locate the lump against the pubic tubercle.

Key takeaways

An inguinal hernia lies superomedial to the pubic tubercle; a femoral hernia lies inferolateral to it.
A cough impulse is an expansile bulge felt over the lump when the patient coughs, and it is the sign that makes a groin lump a hernia.
You cannot get above a hernia that descends into the scrotum, and you can get above a primary scrotal swelling.
StatPearls notes it is not essential to distinguish direct from indirect on examination because the repair is the same.
Femoral hernias are commoner in women and carry the highest risk of strangulation of any groin hernia.

How is this station marked in MRCS Part B?

A physical examination station is marked out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication, and professionalism carry 4 marks each. The examiner also gives the station a separate global rating of pass, borderline or fail.

Two things follow from that split. More than half the marks sit outside your knowledge of the condition, so a silent, technically correct examination scores poorly. And you are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

How do I start the hernia examination?

Gel your hands where the examiners can see, introduce yourself, explain what you propose to do and gain consent. Expose the patient from nipples to knees in principle, and cover the genitalia while you are not examining them.

The GMC is explicit that examinations of the genitalia are intimate examinations, so explain what the examination involves, tell the patient they can ask you to stop at any time, and offer a chaperone.

Why does the patient stand first?

Gravity brings the hernia out. A hernia that reduces on lying flat may be invisible if you start with the patient on the couch.

Stand the patient up and look at both groins from the front, then from the side.
Look for previous inguinal or abdominal scars, and for an obvious swelling.
Ask the patient to cough and watch both groins for a bulge appearing.

What is a cough impulse and how do I elicit it?

A **cough impulse** is a palpable expansile bulge transmitted to a lump when intra-abdominal pressure rises. Place your fingers flat over the lump or over the inguinal region, warn the patient, and ask them to turn their head away and cough.

Palpate both inguinal regions with the patient coughing, even when the lump is obviously on one side, because a second hernia on the other side is a common finding and a common miss.

How do I characterise the lump itself?

Site, size, shape, surface and consistency.
Whether you can get above it, which separates a groin hernia extending into the scrotum from a primary scrotal swelling.
Whether it is reducible, and whether it reduces spontaneously on lying down or needs gentle pressure.
Whether it extends into the scrotum or labium.
Its position relative to the pubic tubercle, which is the landmark that separates inguinal from femoral.

Find the pubic tubercle deliberately by tracing the tendon of adductor longus upwards, and say out loud which side of it the lump lies on.

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

By the pubic tubercle. An inguinal hernia emerges superomedial to it, and a femoral hernia emerges inferolateral to it and below the inguinal ligament.

The distinction matters because the risks differ. StatPearls records strangulation as the commonest serious complication of a femoral hernia, with the highest strangulation rate of the groin hernias, and femoral hernias being about four times more likely in women.

Can I distinguish a direct from an indirect inguinal hernia?

Not reliably. The anatomical definition is clear: an indirect hernia passes through the deep ring lateral to the inferior epigastric vessels, and a direct hernia pushes through the transversalis fascia in Hesselbach's triangle, medial to those vessels.

Clinical Methods describes reducing the hernia and occluding the deep ring, then feeling whether the bulge returns at the fingertip or against the side of the finger. Say that you would attempt it, and say that the definitive distinction is made at operation.

How do I complete the hernia examination?

Lie the patient down, inspect and palpate both groins again, and repeat the cough impulse.
Attempt gentle reduction if the hernia has not reduced spontaneously.
Examine the scrotum and the contralateral side.
Offer an abdominal examination to look for causes of raised intra-abdominal pressure such as ascites, a mass or chronic cough.
Cover the patient, thank them, and present your findings.

What is the examiner marking, and what goes wrong?

The station carries 20 marks and a global rating, and the Intercollegiate professionalism domain is being scored here as hard as the technique.

Examining only supine, so a small reducible hernia is never seen.
Examining only the symptomatic side.
Locating the lump against the femoral pulse instead of the pubic tubercle.
Forcing reduction of a tender, irreducible lump rather than recognising possible strangulation.
Not offering a chaperone or not explaining the examination before exposing the patient.

MRCS Part B Questions has a hernia examination station with a marked checklist at /Sample-Questions. Reviewed and updated 15 September 2026.

Key evidence

Clinical Methods, 3rd edition: Inguinal Canal and Hernia Examination — NCBI Bookshelf (1990)
Femoral Hernia — StatPearls, NCBI Bookshelf (2023)
Inguinal Hernia — StatPearls, NCBI Bookshelf (2023)
Intimate examinations and chaperones — General Medical Council (2024)

FAQ

What does a hernia cough impulse actually feel like?

It feels like a soft expansile push against the flat of your fingers, arriving at the moment the patient coughs and settling immediately afterwards. A transmitted pulsation moves your fingers in one direction only, whereas a true impulse expands the lump. If you feel nothing, ask the patient to stand and cough again before calling it absent.

Does the absence of a cough impulse exclude a hernia?

No. An incarcerated or strangulated hernia is irreducible and characteristically has no cough impulse, and that combination with tenderness is the finding you must not miss. Say aloud that a tense, tender, irreducible groin lump with no impulse is a surgical emergency.

Where exactly is the pubic tubercle?

It is the small bony prominence at the lateral end of the pubic crest, about 2 to 3 cm from the midline. The reliable way to find it in the station is to trace the tendon of adductor longus upwards from the medial thigh until you reach bone, rather than pressing blindly in the groin.

Should I examine the scrotum as part of a hernia examination?

Yes, or at least offer it. A groin swelling that extends into the scrotum is an inguinoscrotal hernia, and a scrotal swelling you can get above is not a hernia at all. Treat it as an intimate examination, explain it and offer a chaperone.

Do I need to name the type of hernia to pass?

You need to name it as inguinal or femoral, using the pubic tubercle, and to say whether it is reducible. You do not need to commit to direct or indirect, because the repair is the same and the distinction is made at operation. Saying so demonstrates judgement rather than uncertainty.

The MRCS Part B Questions Team

Written and maintained by doctors who have sat and scored well at this interview, and reviewed against the current published guideline in each case. Guidance changes — check the source before you rely on a threshold.

Last reviewed 15 September 2026

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