Inguinal hernia
and Carola Felchner, science journalistClemens Gödel is a freelancer for the medical team.
More about the expertsCarola Felchner is a freelance writer in the medical department and a certified training and nutrition advisor. She worked for various specialist magazines and online portals before becoming a freelance journalist in 2015. Before starting her internship, she studied translation and interpreting in Kempten and Munich.
More about the experts All content is checked by medical journalists.An inguinal hernia (inguinal hernia, inguinal hernia) occurs when layers of the abdominal wall "break through" the inguinal canal. A palpable swelling forms, which can often be pushed inwards. Most of the patients are male. An inguinal hernia in women or girls is less common. Read more about the topic here: What exactly is an inguinal hernia? How can an inguinal hernia be recognized? How is he treated?
ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. K40
Inguinal hernia: brief overview
- Important symptoms: Visible and palpable swelling in the groin area, pulling and possibly pain, which increase under load
- Cause: weak point in the abdominal wall (congenital or acquired)
- Risk factors: e.g. violent pressure (sneezing, coughing, straining when defecating, lifting heavy loads, etc.), chronic cough (e.g. with COPD or smoking), obesity, autoimmune connective tissue diseases (collagenoses), male gender
- Possible complications: entrapment (incarceration)
- Treatment: An inguinal hernia with symptoms is usually operated on. If the inguinal hernia shows little or no symptoms in men, the hernia can be observed and the hernia can be observed ("watchful waiting").
Inguinal hernia: symptoms
Even if the name suggests something else: In the case of an inguinal hernia (hernia inguinalis), no bone is broken, but tissue in the groin area is pierced - the so-called inguinal canal. This tubular connection between the abdominal cavity and the outer pubic region runs obliquely from the back to the front. Blood and lymph vessels as well as the spermatic cord in men and one of the mother ligaments in women run in this channel.
If this inguinal canal is pierced in an inguinal hernia, this can be recognized by a visible and / or palpable swelling in the groin area, which can often be pushed inwards. Sometimes the genital region is also affected by the inguinal hernia: in women, swelling can occur in the area of the labia and in men on the scrotum.
In most cases, the inguinal hernia symptoms (women & men) show up on the right side.
Inguinal hernia: pain
In many cases, the hernia does not cause pain. Those affected are more likely to report an indefinite feeling of pressure or pulling. Sometimes they also complain about stomach pain or a foreign body sensation in the groin area.
When inguinal hernia pain occurs, it can reach the testicles or the labia. If the abdominal pressure increases, the symptoms increase. This happens, for example, in the following situations:
- cough
- Sneeze
- Pressing, for example when defecating or exercising
- Lifting heavy loads
- Long walking or standing
On the other hand, the inguinal hernia symptoms subside at rest and when lying down. So if someone is more likely to experience pain when lying down / at night, it is usually not a hernia. Instead, for example, a hip joint or muscle disease may be behind it.
Both pain and swelling increase with exertion. In the case of particularly intense and painful hernia signs, tissue can already be trapped. Then you should see a doctor immediately!
Pinched inguinal hernia: warning symptoms!
In rare cases, intestinal parts (such as loops of intestine) become trapped in an inguinal hernia. These are then no longer adequately supplied with blood and can die. The symptoms of an inguinal hernia with entrapment are much more intense, for example:
- Strong pain
- Reddening of the affected area
- Nausea and vomiting
If someone shows such symptoms, it is necessary to alert a doctor immediately. There is a risk of an intestinal obstruction (ileus) and dangerous peritonitis! The incarceration may be followed by life-threatening blood poisoning (sepsis). Fever, circulatory disorders, unnatural sleepiness and confusion as well as palpitations can occur.
Severe pain with an inguinal hernia is an indication of (dangerous) complications. Go to the doctor immediately!
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"Not every hernia has to be operated on immediately"
Three questions for
Dr. med. Joachim Conze,
Specialist in surgery and visceral surgery -
1
Why do men especially get an inguinal hernia?
Dr. med. Joachim ConzeThis is due to the development of the testicles. The gonads develop in the body and migrate through the groin into the scrotum - this is then the weak point. Overall, it is assumed that one in five men can develop an inguinal hernia. There is a noticeable increase in families, that is, if the father or grandfather had an inguinal hernia, the chances of it happening are higher.
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2
Do you always have to have an operation?
Dr. med. Joachim ConzeThat was previously thought. It is now known that the risk of entrapment in men with a non-painful (asymptomatic or less symptomatic) hernia is less than one percent. If there is only a small protrusion and there are no other complaints, active waiting, the "watchful waiting", is also possible. This means that there is a check-up every six to nine months, and of course immediately if there are any complaints.
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3
Can I prevent an inguinal hernia?
Dr. med. Joachim ConzeThat's the mean thing: You can't do anything preventively. The inguinal canal is a connective tissue structure that cannot be trained like a muscle. There is nothing that has been shown to help preventively. Discomfort in the groin is common, it is important that you then have a hernia specialist look over it.
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Dr. med. Joachim Conze,
Specialist in surgery and visceral surgeryDr. med. Joachim Conze heads the Dr. Conze in Munich. He is a founding member of the German Hernia Society (DHG) and was on the EHS board for many years.
Inguinal hernia symptoms in children
Recognizing an inguinal hernia in children is not always easy. Often the parents accidentally discover the visible swelling in the groin or genital area when they bathe, dress or undress their child. As in adults, most children have an inguinal hernia on the right. But there are also children who have the hernia on the left or on both sides.
If a baby with an inguinal hernia lies relaxed on their back, the swelling may also go away. Conversely, it can increase if the child cries, coughs or presses.
The bulge is mostly painless. But it can also be accompanied by pulling pains. If you press it, the child can react sensitively. The inguinal hernia is likely to be trapped if:
- Increased and apparently baseless crying (especially babies and toddlers)
- Great unrest
- Redness of the swelling
- Refusal to eat or drink (baby)
- Nausea and vomiting
- Flatulence and bloating
- fever
In the event of such symptoms, take the child to the hospital immediately or call the emergency doctor!
In girls, the hernial sac can often also contain the ovaries and fallopian tubes (ovarian hernia). In this case, doctors will also operate immediately, provided the ovary does not slide back into the abdomen by itself.
Don't push too often on an inguinal hernia. It could contain delicate parts, like an ovary. Frequent pressing could cause permanent damage here.
Inguinal hernia: causes and risk factors
The abdomen is largely closed and lined with a fine skin, the peritoneum. It houses organs such as the stomach, liver and intestines. The organs are pulled down by gravity. Plates and strands of connective tissue hold them in place. Nevertheless, there is a certain amount of pressure, especially in the lower abdominal area.
The inguinal canal also feels this pressure. Especially when lifting heavy loads, sneezing, coughing or straining (e.g. when defecating), the abdominal organs press on the inguinal canal. Usually it can withstand the strain - thanks to the strong muscles, ligaments and tight connective tissue that surround it.
If the pressure becomes too great, however, a gap arises in the groin tissue (hernial portal): The peritoneum bulges outward like a sack at this point. That is why one speaks of a hernial sac. Sometimes parts of the intestines (mostly parts of the intestine) - enclosed by the hernial sac - pass through the gap and out of the abdominal cavity (hernial contents).
This happens with an inguinal hernia
Indirect inguinal hernia
Most patients have an indirect inguinal hernia: Here the hernial sac passes laterally through the inguinal canal and can penetrate to the scrotum or the labia.
In many cases, the indirect inguinal hernia is congenital: it is based on an inguinal canal that is not completely closed. In the development of the fetus, the inguinal canal is lined with peritoneum. This normally regresses by the time of birth and closes completely by the end of the second year of life at the latest. If this does not happen, a congenital indirect inguinal hernia often develops. Babies, children and young people are most commonly affected, boys more often than girls.
More rarely, an indirect inguinal hernia does not develop until later in life (acquired indirect inguinal hernia). The reason is a weak connective tissue. This causes the abdominal wall to turn out and the inguinal hernia runs within the inguinal canal.
Direct hernia
In contrast, the direct inguinal hernia is acquired. It arises at a weak point in the wall of the inguinal canal. The hernial sac pushes itself directly through the abdominal wall, so it does not reach the genital region. Various factors can favor this wall weakness and thus the direct hernia (such as operations or various diseases: see below). Most often, adults develop this form of inguinal hernia. Women are rarely affected, but older men are particularly often affected.
Testicular hernia
In men, the hernial sac sometimes extends into the testicles. Doctors speak of a scrotal hernia (testicular hernia, scrotum = scrotum). The testicular hernia is typically one of the indirect inguinal hernias. In women, the special shape usually affects the labia, which is why doctors also refer to this inguinal hernia as a labial hernia.
Risk factors
There are various factors that favor an inguinal hernia, for example because they are associated with a weak connective tissue (e.g. old age, genetic predisposition, connective tissue diseases) or increase the pressure in the abdomen (e.g. during pregnancy, chronic constipation, constant coughing).
Here is a list of important risk factors for inguinal hernia:
- Older age
- Male gender
- Chronic cough (e.g. in COPD)
- Smoking (promotes coughing and weak connective tissue)
- Chronic constipation
- Cases of inguinal hernia in the family (up to 8 times higher risk, suggests a genetic predisposition to an inguinal hernia)
- Already suffered a hernia
- Injuries to the abdominal wall
- Obesity
- Ascites
- Collagenoses (group of autoimmune diseases of connective tissue)
In children, an umbilical hernia (omphalocele) or an intestinal prolapse (gastroschisis) can increase the pressure in the abdomen. The possible consequence of this is an inguinal hernia. Children born prematurely are also more prone to an inguinal hernia.
During pregnancy, the extra weight placed on the groin can cause a hernia.
Inguinal hernia: examinations and diagnosis
If you suspect an inguinal hernia, see a doctor quickly. The first point of contact is usually the family doctor or the pediatrician. Inguinal hernias are usually treated by specialized surgeons.
First, the doctor will collect the medical history in a so-called anamnesis interview. For example, he can ask the following questions:
- What complaints do you have?
- Do you have swelling in the groin area? Does it sometimes disappear, for example when lying down?
- Do you feel pain? Where exactly do these occur?
- Do the symptoms get worse under stress, e.g. when lifting heavy loads or when coughing?
- Has anyone in your family ever had a hernia?
- Have you ever had an operation on your stomach or groin?
Physical examination
When performing a physical examination for an inguinal hernia, the doctor usually first asks the patient to stand up straight. He then palpates the patient's groin to detect any swelling. He can also instruct the patient to cough or tense the abdominal muscles, which increases pressure in the abdomen. This usually increases the swelling in an inguinal hernia.
The doctor can repeat the palpation examination with the patient lying down. He also focuses on the genitals. The hernial sac may extend into the testicles (scrotal hernia, testicular hernia) or the labia (labial hernia).
Usually, the doctor examines both the left and right groin regions. It is not uncommon for an inguinal hernia to occur on both sides.
The examiner also checks whether the contents of the hernia can be pushed back into the abdomen with the fingers. If that works, there is a so-called repositionable inguinal hernia. However, if the doctor cannot push the contents of the hernia back into the correct position, the inguinal hernia is irreversible.
A rectal examination may also be necessary to clarify a suspected hernia. The doctor feels the last part of the rectum with a finger. In addition to palpation, the doctor will also listen to the swelling with a stethoscope. Under certain circumstances, he can perceive intestinal noises. This suggests that there are intestinal parts in the hernial sac.
The typical swelling in the groin region is often enough for the doctor to make the inguinal hernia diagnosis. If not, imaging tests will follow.
Imaging
If the physical examination does not clearly indicate an inguinal hernia, the doctor can examine the corresponding region using ultrasound (lying down and standing). In this way, he can also assess how severe the inguinal hernia is and how urgently it needs to be treated. It also helps rule out other diseases that can cause swelling in the groin area.
Other imaging methods are rarely necessary (e.g. in patients with obesity = obesity). This can then be, for example, a magnetic resonance tomography (MRT).
Exclusion of other diseases
Sometimes other diseases can also be behind a supposed hernia. These so-called differential diagnoses include, for example, enlarged lymph nodes in the groin area (e.g. in lymph gland cancer). They can cause swelling similar to that of an inguinal hernia.
Testicular tumors or testicular cancer, in turn, can look similar to a scrotal hernia. They are often less painful and only slowly but steadily increase in size. In addition, the testicles feel hardened in cancer.
Especially in athletes, a suspected inguinal hernia often turns out to be a so-called soft groin (athlete's groin or footballer's groin). As with an inguinal hernia, those affected have pain in the groin area, which is often aggravated when coughing, sneezing or pressing. The sporting activity (sprinting, shooting balls and stopping with the inside of the foot, etc.) can namely overload the muscles and tendons in the groin area as well as the inguinal canal and lead to small injuries - a soft groin is created.
A bump also occurs in the event of a water break (hydrocele). However, it is a bulging, elastic protrusion in the course of the spermatic cord that cannot be moved. In the ultrasound, the water break can usually be seen clearly as a kind of ball.
In addition, the vein network in the testicle can expand, called a varicocele (varicose vein hernia). Here, too, the testicles swell, pain is rather rare. Sometimes you can see the enlarged vessels from the outside, which are usually easy to feel.
Under certain circumstances, a suspected hernia in a man (boy) turns out to be a testicle located in the groin (undescended testicle).
When is a hernia an emergency?
An inguinal hernia is an emergency when there are signs of entrapment. These include, for example, severe pain with nausea and vomiting. In this case you should call a doctor or an emergency doctor immediately! As a result of the entrapment, the organ parts in the hernial sac can die off, as the blood circulation is squeezed off. Doctors call this complication inguinal hernia incarceration.
General information on inguinal hernia treatment
An inguinal hernia in children is usually treated by a doctor, because the inguinal hernia does not heal on its own. In addition, there is always the risk of abdominal tissue becoming trapped - the younger the patient, the more often.
According to the guidelines of the European Hernia Society (EHS), an inguinal hernia in women should always be operated on, even if it does not cause any symptoms. There could also be a fracture of the thigh (femoral hernia, femoral hernia). A femoral hernia can also cause pain and possibly swelling in the groin area, but it is often difficult to identify clearly. The dangerous thing about her is that she gets trapped (incarcerated) in up to 30 percent of the cases. Since women are much more likely to have a fractured leg than men, doctors usually operate on a (supposed) hernia in women.
An inguinal hernia in a man that shows no symptoms and does not progress (i.e. does not enlarge) has also been operated on for a while. The reason was the risk of entrapment. According to a new study, this risk is only low. That is why experts now recommend "watchful waiting" in such cases.
Some people who have already had an inguinal hernia operation later get an inguinal hernia again (recurrent inguinal hernia). Doctors then decide on a case-by-case basis about the time and type of the next operation.
The following applies to all hernia patients - if the intestines are trapped, an operation must be carried out immediately!
Inguinal hernia surgery
An inguinal hernia operation is one of the routine interventions. Various surgical techniques are used. A distinction is made between:
- Open procedure: Here the doctor makes a larger incision and relocates the contents of the hernia back into the abdomen. Then he either uses an artificial net or uses the surrounding connective tissue and muscles to avoid relapse.
- Minimally invasive procedures: These surgical procedures require several small incisions. The doctor always puts in a net for stabilization. The pain is often not as persistent as after open surgery.
The doctor decides on a case-by-case basis which method is most suitable in each individual case. The currently valid guidelines generally recommend surgical methods in which a net is inserted. The relapse rate is then lower.
You can read more about the process of an inguinal hernia operation and the possible complications in the article Inguinal hernia - OP.
By the way: Although still available for sale, so-called hernia ligaments are no longer used for inguinal hernia treatment.These belt-like supports were tied from the outside over the respective hernia. However, wearing it can weaken the abdominal wall and make subsequent surgery more difficult.
Inguinal hernia: disease course and prognosis
Most hernias are harmless. However, entrails can be pinched at any time. Doctors speak of incarceration. The patient then has to be operated on within a few hours, because a jammed bowel loop can lead to further complications, such as:
- Intestinal obstruction (ileus)
- The intestinal wall breaks open so that the contents (feces) emerge (perforation)
- Dangerous inflammation of the peritoneum (peritonitis)
- Life-threatening blood poisoning (sepsis)
Depending on the location, the hernia can also interrupt the blood supply to the testicles or ovaries. Without treatment, the reproductive organs are damaged.
Most of the inguinal hernia operations proceed without complications. Sometimes, however, there is a relapse later (relapse), i.e. a new inguinal hernia forms.
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