An inguinal hernia is when a part of the intestine or other soft tissue bulges through a weak spot in the lower abdomen near the groin, which can appear as visible lumps or bulges in the groin or scrotum area. Inguinal hernias are the most prevalent type of hernias, accounting for approximately 70% of all hernias.1 Inguinal hernias can cause discomfort or pain, which can occur after bouts of coughing, heavy lifting, or bending. In severe cases, inguinal hernias can become trapped or strangulated, which requires immediate medical attention. Diagnosis by a healthcare professional through a physical exam, and sometimes imaging tests is recommended. The main treatment is surgery to push the hernia back and strengthen the weak area. It's important to address an inguinal hernia promptly to relieve symptoms and prevent complications.
Types of inguinal hernia
There are two main types of inguinal hernias:1
- Direct inguinal hernia: This type occurs when abdominal contents, such as the intestine, protrude through a weak spot in the abdominal wall in the inguinal canal. Direct inguinal hernias typically develop due to age-related weakening of the abdominal muscles, such as in adulthood
- Indirect inguinal hernia: It is the most prevalent type of hernia, which can be present from birth. While it can affect all genders, it is more frequently observed in those assigned male at birth. This is due to the fact that the testicles originate in the abdomen and descend through an opening in the groin area to reach the scrotum. If this opening fails to close properly at birth, a hernia may develop. In those assigned females at birth, inguinal hernias can occur if reproductive organs or the small intestine push through a weakened area in the abdominal muscles near the groin
The specific type of hernia is determined during diagnostic evaluation.
Causes of inguinal hernia
While some inguinal hernias have no clear cause, certain factors can increase the risk of developing one.3 These factors include:
- Ageing: As people age, the abdominal muscles naturally weaken, making them more susceptible to hernias
- Congenital factors: Some individuals are born with a predisposition to inguinal hernias due to a congenital defect in the abdominal wall, such as a failure of the inguinal canal to close properly
- Constipation: Straining during bowel movements can be one of the causes
- Pre-existing weakness or previous hernia: Individuals with a weakened abdominal wall or a history of hernias or hernia repair are at a higher risk
- Raised abdominal pressure: Caused by persistent coughing, heavy lifting, obesity, or pregnancy, as examples
- Weakened abdominal wall: Creating a vulnerability in the inguinal region, allowing tissues to push through and form a hernia
It's important to note that these factors can increase the risk of developing an inguinal hernia, but not everyone with these risk factors will necessarily develop one.
Signs and symptoms of inguinal hernia
Small hernias can move back and forth through the abdominal opening without causing any noticeable symptoms. For larger hernias, it may be possible to gently push the hernia back into the abdomen. Inguinal hernias can present with various signs and symptoms, including:2,4
- A noticeable bulge or lump in the groin or scrotum is a common sign of an inguinal hernia. A protrusion that becomes more prominent when you exert pressure and diminishes when you recline
- Changes in the bulge: A hernia that becomes trapped or strangulated may appear tender, firm, or discoloured. These signs indicate a serious condition and require urgent medical evaluation
- Discomfort, pain or aching sensation in the groin area which may worsen during activities, such as straining or exercising
- Hip discomfort
- Nausea and vomiting: In certain cases, an inguinal hernia can become trapped or strangulated (known as incarcerated), leading to severe pain, nausea, and vomiting. This requires immediate medical attention
- Some individuals with an inguinal hernia may experience a dragging or heavy sensation in the groin area as if something is pulling down
- Testicular swelling and pain
- Weakness or pressure sensation in the groin
It's important to note that not all inguinal hernias cause symptoms, especially in their early stages. If any signs or symptoms are present, it is recommended to seek medical attention for proper diagnosis and appropriate management.
Management and treatment for inguinal hernia
The management and treatment of inguinal hernias typically involve the following approaches:1,2
- Surgical repair:6 The primary treatment for inguinal hernias is surgical repair. There are two main approaches:
- Open hernia repair: This procedure involves making an incision near the groin to push the protruding tissue back into place and reinforce the weakened area with sutures or mesh. It is a traditional approach and may require a longer recovery period
- Laparoscopic hernia repair: In this minimally invasive technique, small incisions are made, and a camera and specialized instruments are used to guide the repair from inside the abdomen. The transabdominal preperitoneal procedure (TAPP) involves repairing the hernia through an intraperitoneal approach, while the total extraperitoneal procedure (TEP) is completed without entering the peritoneal cavity. It generally results in smaller incisions, reduced scarring, bilateral hernia repair, large hernia defects, reduced postoperative pain, and a faster recovery time. However, they require expertise and have higher costs
- Watchful waiting:7 If the hernia is small, not causing significant symptoms, and not at risk of becoming trapped or strangulated, a watchful waiting approach may be adopted. Regular monitoring and lifestyle modifications may be recommended
The choice of surgical procedure depends on various factors, including the size and type of hernia, the individual's overall health, and the surgeon's expertise.
Recovery after surgery:
After undergoing inguinal hernia surgery, it is important to adhere to the guidelines provided by your healthcare provider for a smooth recovery. Here are some recommended approaches:
- Keep your surgical wound clean and dry as instructed by your healthcare team
- Maintain a healthy and balanced diet to minimize the risk of constipation
- Refrain from exerting yourself, such as lifting heavy objects, bending over, or straining during bowel movements
In general, you can anticipate resuming light activities and non-manual labour work after approximately two weeks. It typically takes about six weeks to achieve a complete recovery.
Diagnosing an inguinal hernia typically involves a combination of medical history, physical examination, and sometimes imaging studies.1 The summary of the diagnosis process for an inguinal hernia includes:
- Imaging studies: In some cases, when a hernia cannot be visually observed externally, the healthcare provider may recommend imaging studies to confirm the diagnosis or assess the hernia more accurately. Commonly used imaging modalities include ultrasound, which can help visualize the hernia and assess its contents, and sometimes imaging studies like CT scans may be ordered for complex cases or to rule out other conditions
- Medical history: Such as patient's symptoms, presence of a bulge or discomfort in the groin area. They may inquire about factors that could contribute to the development of a hernia, such as a history of heavy lifting, chronic cough, or previous abdominal surgeries
- Physical Examination: The healthcare provider will look for a visible or palpable bulge that may become more prominent when the patient coughs, strains, or stands up. The examination may involve feeling the groin area to detect the presence of a hernia and determining its size, location, and reducibility (whether it can be pushed back into place)
Complications of inguinal hernias can include the following:5
- Bowel obstruction: In some cases, the hernia may cause a blockage in the intestine, leading to bowel obstruction. This can cause symptoms such as severe abdominal pain, bloating, constipation, and vomiting
- Incarceration: This occurs when the hernia becomes trapped and cannot be pushed back into the abdomen. It may cause discomfort, pain, and the inability to manually reduce the hernia
- Increased pressure: When there is greater pressure on the tissues surrounding the hernia, inguinal hernias tend to enlarge if they are not treated surgically. In men, larger inguinal hernias can extend into the scrotum, resulting in swelling and discomfort
- Recurrence: Despite surgical repair, there is a possibility of hernia recurrence, especially if the repair was not performed adequately or if there are underlying factors that predispose to hernia formation
- Strangulation: This is a more serious complication where the blood supply to the herniated tissue is cut off, leading to tissue ischemia (lack of blood flow) and potential tissue death. Strangulated hernias require immediate medical attention
It is important to seek medical attention if you experience symptoms of complications associated with an inguinal hernia, as prompt diagnosis and treatment can help prevent further complications and ensure optimal outcomes.
To summarise, inguinal hernias can occur in both sexes, although they are far more common in those assigned males at birth. Inguinal hernia often presents with painful or tender lumps in the groin which may be accompanied by nausea and vomiting. If you suspect an inguinal hernia is the cause of discomfort, seeking confirmation and possible treatment from a registered healthcare professional is recommended due to there being a risk of further complications.
- Hammoud M, Gerken J. Inguinal hernia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Jun 29]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK513332/
- Jenkins JT, O’Dwyer PJ. Inguinal hernias. BMJ [Internet]. 2008 Feb 2 [cited 2023 Oct 10];336(7638):269–72. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223000/
- Öberg S, Andresen K, Rosenberg J. Etiology of inguinal hernias: a comprehensive review. Frontiers in Surgery [Internet]. 2017 [cited 2023 Oct 10];4. Available from: https://www.frontiersin.org/articles/10.3389/fsurg.2017.00052
- Chiow AKH, Chong CK, Tan SM. Inguinal hernias: a current review of an old problem. Proceedings of Singapore Healthcare [Internet]. 2010 Sep [cited 2023 Oct 10];19(3):202–11. Available from: http://journals.sagepub.com/doi/10.1177/201010581001900306
- Chowbey PK, Pithawala M, Khullar R, Sharma A, Soni V, Baijal M. Complications in groin hernia surgery and the way out. J Minim Access Surg [Internet]. 2006 Sep [cited 2023 Oct 10];2(3):174–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999781/
- [cited 2023 Oct 10]. Available from: https://academic.oup.com/bjs/article/109/3/244/6460252
- Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence. Archives of Surgery [Internet]. 2012 Mar 1 [cited 2023 Oct 10];147(3):277–81. Available from: https://doi.org/10.1001/archsurg.2011.914