Inguinal Hernia

What is inguinal hernia?

If a tissue or organ protrudes through a weak spot in the groin structure, causing the groin or scrotum to protrude, which may feel painful or bulging, and it retracts normally when lying down, and bulges when standing or exerting force, it may be inguinal hernia.

In general, it is easy to confuse groin hernia with the inguinal hernia because the protrusions are located on both sides of the lower abdomen and inner thighs, close to the sexual organs. In fact, groin hernia is a general term for a hernia protrusion that occurs in the area, including inguinal hernia (occurs in the weak spot of groin structure which is located on upper inner side) and femoral hernia (occurs in the weak spot of groin structure which is located on lower lateral side).

About 90% of hernias in adults are inguinal hernia. It is the most common, and occurs in 90% of men.

According to the cause and structure, inguinal hernia can be classified as::

  • Indirect Hernia
  • Direct Hernia

Indirect Hernia:

Before men are born, the testis will descend from the inguinal canal on the abdominal wall to the scrotum and position itself, thus leaving the inguinal ring. If that area is not completely closed, or the closure isn’t tight enough, the intra-abdominal organs (intestines, etc.) may protrude from this gap and cause bulging and pain at a certain point in time, which is called indirect hernia. Infants, children, adolescents and youth (below 25 years old) are mostly diagnosed with indirect hernia. The unique characteristic of this condition is that there will be a hernia sac which is prolapsed down from the peritone-um along the inguinal canal, and looks like a large balloon (abdominal cavity) with a bulging small balloon (hernia sac). The organs in the abdominal cavity such as the small intestine and abdominal omentum are often prolapsed into the hernia sac, and gradually drop into the scrotum. This hernia sac is often connected to the abdominal cavity, and the ascites will also flow into the hernia sac, so it will often combine with scrotum and accumulate water.

99% of inguinal hernia in females is indirect hernia. Similar to indirect hernia in males, the hernia sac extends from the abdominal pelvis along the groin to the labia majora (equivalent to male scrotum) through the round ligament of uterus (equivalent to male spermatic cord). It also causes the groin to bulge.

Direct hernia:

Direct hernia, just as its name implies, is a hernia that protrudes directly from the muscle layer of the groin. The aging, weakening, or defect of the abdominal wall of the groin causes the organs in the abdominal cavity to bulge, which occurs mostly in middle-aged and elderly men.

The inguinal hernia that occurs in adults, whether it is indirect hernia or direct hernia, mostly takes place because the groin is the lowest point of the body trunk. When exerting force on the abdomen and increasing the load, the force is transmitted downward to the groin which is the lowest point of the trunk. The groin on both sides of the lower abdomen is like an “inverted triangle”. When the body’s trunk strength is transmitted downward, the strength is transmitted to both sides of the top of “inverted triangle”. If the supporting structure is not strong enough, the structure will be easily destroyed, causing ejection of the internal organs and formation of a hernia. The male’s “inverted triangle” is sharper, and the female’s “inverted triangle” is flatter. Therefore, in terms of structural angle, inguinal hernia in adults is more likely to occur in males than females.

The incidence of inguinal hernia:

  1. According to public health statistics in the US, an average of one in every four men have had hernia in their lifetime.
  2. In Taiwan, 10% of men aged 70 years old or above suffer from inguinal hernia.
  3. In Taiwan, the incidence of hernia in infants and adolescents is 7%, and the proportion of males and females is similar.
  4. In Taiwan, the probability of adult inguinal hernia in males is nine times that of females.

What causes inguinal hernia?

1. Indirect hernia:

Before men are born, the testis will descend from the inguinal canal on the abdominal wall to the scrotum by pushing out the peritoneum and position itself. Normally, the ca-nal will close and disconnect with the abdominal cavity. If the canal that the testis de-scends from is not completely closed due to genetics, premature birth, or unexplained reasons or the closure is not tight enough, it becomes a weak spot in the connection be-tween the abdominal cavity. The intra-abdominal organs (intestines, etc.) may protrude from this gap and cause bulging and pain after birth or at a certain point in time (from infanthood to adulthood and old age), which is called indirect hernia.

99% of inguinal hernia in females is indirect hernia. Similar to indirect hernia in males, the hernia bag extends from the abdominal pelvis along the groin to the labia majora (equivalent to male scrotum) through the abdominal cavity along the round ligament of uterus (equivalent to male spermatic cord). It also causes the groin to bulge, forming hernia.

2. Direct hernia:

Direct hernia, just as its name implies, is a hernia that protrudes directly from the muscle layer of the groin. The aging, weakening, or defect of the abdominal wall of the groin causes the organs in the abdominal cavity to bulge, which occurs mostly in middle-aged and elderly men.

The inguinal hernia that occurs in adults, whether it is indirect hernia or direct hernia, mostly takes place because the groin is the lowest point of the body trunk. When exert-ing force on the abdomen and increasing the load, the force is transmitted downward to the groin which is the lowest point of the trunk. The groin on both sides of the lower abdomen is like an “inverted triangle”. When the body’s trunk strength is transmitted downward, the strength is transmitted to both sides of the top of “inverted triangle”. If the supporting structure is not strong enough, the structure will be easily destroyed, causing ejection of the internal organs and formation of a hernia. The male’s “inverted triangle” is sharper, and the female’s “inverted triangle” is flatter. Therefore, in terms of structural angle, inguinal hernia in adults is more likely to occur in males than females.

Causes of inguinal hernia

“Main cause” plus “predisposing factor(s)“

Main cause:

The congenital weak spot of the groin structure; incomplete closure of the inguinal ca-nal or incomplete or weakened supporting structure of the muscle group of the ab-dominal wall of the groin.

Predisposing factor(s):

Increasing long-term abdominal pressure, such as being overweight, frequent heavy lifting, coughing or excessive exertion, prostatic hyperplasia in males causing long-term overexertion of force on the abdomen for urination, or long-term constipation causing long-term overexertion force on the abdomen for defecation, may be factors contrib-uting to hernia. Hernia often occurs in adult females during pregnancy due to a con-genital weak spot of the groin structure and increased abdominal pressure during preg-nancy.

What are the symptoms of inguinal hernia?

The main symptom of inguinal hernia is a protrusion in the groin or scrotum that feels like a round lump. This lump may suddenly appear after lifting heavy objects, cough-ing, bending over, exerting force, or laughing, or it may take several weeks or months to form. Some hernias will feel painful, but some will not feel painful even if there is a lump. If a tissue or organ protrudes through a weak spot in the groin structure, causing the groin or scrotum to protrude, which may feel painful or bulge, and it will retracts normally when lying down, and bulges when standing or exerting force, it may be in-guinal hernia. Sometimes the patients will feel that there will be no groin swelling in the morning when they get up, and the inguinal hernia will occur in the afternoon or when they feel tired at work.

Hernia may cause protrusion, which is sometimes accompanied by a heavy, falling, dragging or even burning sensation in the affected area. These symptoms will slow down when lying down.

The clinical course of inguinal hernia:

The prolapsed organs gradually increase in volume and cause pain, and the gap of her-nia gets bigger. The tissues of the prolapsed organs increase, the disease becomes more complicated, and the complications accumulate (such as intestinal adhesion, large intes-tine slippage, testis which have atrophied due to long-term compression or adhesion of the hernia organs, and ovaries which are stuck in the hernia sac and chronically atro-phied). This kind of hernia usually leads to discomfort. The patient ignores the im-portance of medical treatment because the patient is accustomed to the body’s “hernia state” and the complications of hernia gradually accumulate and change. Therefore, it is advisable to seek medical treatment as soon as possible.

Emergency risk of inguinal hernia:

If the inguinal hernia is not surgically treated, it may lead to excessive collapse of the herniated organ and tissue due to sudden exertion. The blood supply of the herniated organ and tissue in the gap in the abdominal wall is blocked by the pressure, causing incarcerated hernia and severe pain. The blood is unable to transport oxygen to the tis-sue through circulation, causing ischemic necrosis of the displaced organ, and will be life-threatening. At this time, immediate treatment or surgery is required. The prime time for emergency treatment of “incarcerated hernia” is six hours. If the prime time has passed, it may be necessary to cut off the intestines and rejoin them due to intestinal ne-crosis.

When the patient suddenly feels severe pain in the inguinal hernia, abdominal pain, and even nausea and vomiting, it may be because part of the intestines are stuck in the her-nia bag. If you have hernia and these symptoms occur, seek medical attention immedi-ately.

How to diagnose inguinal hernia?

The doctor can tell if there is any hernia from your symptoms and a physical examina-tion.

In general, this protrusion is easily diagnosed by palpation. The doctor can ask the pa-tient to exert force on the stomach during palpation, and then feel the protrusion of in-guinal hernia through continuous contraction and relaxation to establish a diagnosis.

The accuracy for other methods of diagnosis of hernia is not high. For example, X-ray is suitable for viewing the bone, and unsuitable for viewing the soft tissue of groin. If the soft tissue of groin is viewed with ultrasound or even nuclear magnetic resonance, it is difficult to distinguish the hernia since the inguinal hernia is not obvious when patient is lying down during the examination.

How to treat inguinal hernia?

Apart from a small number of neonatal hernias, there is an opportunity of a hernia self-closing before an infant is 1 year old due to the small stomata. Most inguinal hernias will not heal by itself and can only be treated with surgery.

If the hernia has not been cured, the prolapsed organs will gradually increase in volume and cause pain, and the gap of hernia will get bigger. The tissues of the prolapsed or-gans will increase, the disease will become more complicated, and the complications will accumulate (such as intestinal adhesion, large intestine slippage, testis which have atrophied due to long-term compression or adhesion of the hernia organs, and the ova-ries are stuck in the hernia bag and chronically atrophied). This kind of hernia usually leads to late discomfort. The patient ignores the importance of medical treatment be-cause the patient is accustomed to the body’s “hernias state” and the complications of hernia gradually accumulate and change. Therefore, it is advisable to seek medical treatment as soon as possible.

Inguinal hernia classification and treatment principles

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