Inguinal hernia

Overview

An inguinal hernia occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. The resulting bulge can be painful, especially when you cough, bend over or lift a heavy object. However, many hernias do not cause pain.

An inguinal hernia isn't necessarily dangerous. It doesn't improve on its own, however, and can lead to life-threatening complications. Your doctor is likely to recommend surgery to fix an inguinal hernia that's painful or enlarging. Inguinal hernia repair is a common surgical procedure.

Symptoms

Inguinal hernia signs and symptoms include:

• A bulge in the area on either side of your pubic bone, which becomes more obvious when you're upright, especially if you cough or strain
• A burning or aching sensation at the bulge
• Pain or discomfort in your groin, especially when bending over, coughing or lifting
• A heavy or dragging sensation in your groin
• Weakness or pressure in your groin
• Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum

Signs and symptoms in children

Inguinal hernias in newborns and children result from a weakness in the abdominal wall that's present at birth. Sometimes the hernia will be visible only when an infant is crying, coughing or straining during a bowel movement. He or she might be irritable and have less appetite than usual.

In an older child, a hernia is likely to be more apparent when the child coughs, strains during a bowel movement or stands for a long period.

Signs of trouble

If you aren't able to push the hernia in, the contents of the hernia may be trapped (incarcerated) in the abdominal wall. An incarcerated hernia can become strangulated, which cuts off the blood flow to the tissue that's trapped. A strangulated hernia can be life-threatening if it isn't treated.

Signs and symptoms of a strangulated hernia include:

• Nausea, vomiting or both
• Fever
• Sudden pain that quickly intensifies
• A hernia bulge that turns red, purple or dark
• Inability to move your bowels or pass gas

When to see a doctor

Seek immediate care if a hernia bulge turns red, purple or dark or if you notice any other signs or symptoms of a strangulated hernia.

See your doctor if you have a painful or noticeable bulge in your groin on either side of your pubic bone. The bulge is likely to be more noticeable when you're standing, and you usually can feel it if you put your hand directly over the affected area.

Causes

Some inguinal hernias have no apparent cause. Others might occur as a result of:

• Increased pressure within the abdomen
• A preexisting weak spot in the abdominal wall
• Straining during bowel movements or urination
• Strenuous activity
• Pregnancy
• Chronic coughing or sneezing

In many people, the abdominal wall weakness that leads to an inguinal hernia occurs prior to birth when a weakness in the abdominal wall muscle doesn't close properly. Other inguinal hernias develop later in life when muscles weaken or deteriorate due to aging, strenuous physical activity or coughing that accompanies smoking.

Weaknesses can also occur in the abdominal wall later in life, especially after an injury or abdominal surgery.

In men, the weak spot usually occurs in the inguinal canal, where the spermatic cord enters the scrotum. In women, the inguinal canal carries a ligament that helps hold the uterus in place, and hernias sometimes occur where connective tissue from the uterus attaches to tissue surrounding the pubic bone.

Risk factors

Factors that contribute to developing an inguinal hernia include:

• Being male. Men are eight times more likely to develop an inguinal hernia than are women.
• Being older. Muscles weaken as you age.
• Being white.
• Family history. You have a close relative, such as a parent or sibling, who has the condition.
• Chronic cough, such as from smoking.
• Chronic constipation. Constipation causes straining during bowel movements.
• Pregnancy. Being pregnant can weaken the abdominal muscles and cause increased pressure inside your abdomen.
• Premature birth and low birth weight. Inguinal hernias are more common in babies who are born prematurely or with a low birth weight.
• Previous inguinal hernia or hernia repair. Even if your previous hernia occurred in childhood, you're at higher risk of developing another inguinal hernia.

Complications

Complications of an inguinal hernia include:

• Pressure on surrounding tissues. Most inguinal hernias enlarge over time if not repaired surgically. In men, large hernias can extend into the scrotum, causing pain and swelling.
• Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, the contents can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas.
• Strangulation. An incarcerated hernia can cut off blood flow to part of your intestine. Strangulation can lead to the death of the affected bowel tissue. A strangulated hernia is life-threatening and requires immediate surgery.

Prevention

You can't prevent the congenital defect that makes you susceptible to an inguinal hernia. You can, however, reduce strain on your abdominal muscles and tissues. For example:

• Maintain a healthy weight. Talk to your doctor about the best exercise and diet plan for you.
• Emphasize high-fiber foods. Fruits, vegetables and whole grains contain fiber that can help prevent constipation and straining.
• Lift heavy objects carefully or avoid heavy lifting. If you must lift something heavy, always bend from your knees — not your waist.
• Stop smoking. Besides its role in many serious diseases, smoking often causes a chronic cough that can lead to or aggravate an inguinal hernia.

Diagnosis

A physical exam is usually all that's needed to diagnose an inguinal hernia. Your doctor will check for a bulge in the groin area. Because standing and coughing can make a hernia more prominent, you'll likely be asked to stand and cough or strain.

If the diagnosis isn't readily apparent, your doctor might order an imaging test, such as an abdominal ultrasound, CT scan or MRI.

Treatment

If your hernia is small and isn't bothering you, your doctor might recommend watchful waiting. Sometimes, wearing a supportive truss may help relieve symptoms, but check with your doctor first because it's important that the truss fits properly, and is being used appropriately. In children, the doctor might try applying manual pressure to reduce the bulge before considering surgery.

Enlarging or painful hernias usually require surgery to relieve discomfort and prevent serious complications.

There are two general types of hernia operations — open hernia repair and minimally invasive hernia repair.

Open hernia repair

In this procedure, which might be done with local anesthesia and sedation or general anesthesia, the surgeon makes an incision in your groin and pushes the protruding tissue back into your abdomen. The surgeon then sews the weakened area, often reinforcing it with a synthetic mesh (hernioplasty). The opening is then closed with stitches, staples or surgical glue.

After the surgery, you'll be encouraged to move about as soon as possible, but it might be several weeks before you're able to resume normal activities.

Minimally invasive hernia repair

In this procedure requiring general anesthesia, the surgeon operates through several small incisions in your abdomen. The surgeon may use laparoscopic or robotic instruments to repair your hernia. Gas is used to inflate your abdomen to make the internal organs easier to see.

A small tube equipped with a tiny camera (laparoscope) is inserted into one incision. Guided by the camera, the surgeon inserts tiny instruments through other small incisions to repair the hernia using synthetic mesh.

People who have a minimally invasive repair might have less discomfort and scarring after surgery and a quicker return to normal activities. Long-term results of laparoscopic and open hernia surgeries are comparable.

Minimally invasive hernia surgery allows the surgeon to avoid scar tissue from an earlier hernia repair, so it might be a good choice for people whose hernias recur after open hernia surgery. It also might be a good choice for people with hernias on both sides of the body (bilateral).

As with open surgery, it may be a few weeks before you can get back to your usual activity level.

Preparing for your appointment

You'll likely start by seeing your primary care provider. Here's some information to help you get ready for your appointment.

What you can do

Make a list of:

• Your symptoms, including when they started and how they may have changed or worsened over time
• Key personal information, including recent life changes and family medical history
• All medications, vitamins or supplements you take, including doses
• Questions to ask your doctor

Take a family member or friend along, if possible, to help you remember the information you get.

For an inguinal hernia, some basic questions to ask your doctor include:

• What's the most likely cause of my symptoms?
• What tests do I need?
• What treatments are available and which one do you recommend for me?
• If I need surgery, what will my recovery be like?
• I have other health conditions. How can I best manage these conditions together?
• What can I do to prevent another hernia?

Don't hesitate to ask other questions you may have.

What to expect from your doctor

Your doctor is likely to ask you several questions, such as:

• When did your symptoms begin?
• Have your symptoms stayed the same or gotten worse?
• Do you have pain in your abdomen or groin? Does anything make the pain feel worse or better?
• What physical activity do you perform on your job? What other physical activities do you regularly engage in?
• Do you have a history of constipation?
• Have you had a previous inguinal hernia?
• Do you or did you smoke? If so, how much?

What you can do in the meantime

Get emergency medical care if you develop nausea, vomiting or fever or if your hernia bulge turns red, purple or dark.