Inguinal hernia

An inguinal hernia develops when fat, tissue or a loop of the bowel pokes through a weakness in your lower abdominal muscles into a passage called the inguinal canal. It can occur on the left or right side of your groin. This can cause discomfort or pain, especially when you cough, sneeze, bend over or lift a heavy object. 

Inguinal hernias are quite common and affect men and women. In men, the inguinal canal contains the spermatic cord (nerves, blood vessels and reproductive structures that supply the testes) and in women, it contains the round ligament of the womb. 

Inguinal hernias affect men eight times more often than women. Inguinal hernias are also more likely when you’re older.

Babies born with a weakness in their abdominal muscles can develop an inguinal hernia in childhood or later in life. This is sometimes referred to as an indirect inguinal hernia.

An inguinal hernia won’t go away on its own and in itself is not necessarily dangerous. However, it can lead to life-threatening complications and therefore needs treatment to repair it ie surgery.

Inguinal hernias do not usually cause persistent pain but often cause discomfort or pain when you cough, sneeze, bend over or lift a heavy object. You may first notice a hernia after straining yourself eg lifting a heavy object.

Inguinal hernia symptoms include:

• An ache, burning, discomfort, pain or a heavy or dragging sensation in your groin around the bulge
• A bulge (hernia) in your groin area that is more noticeable when you are standing up, particularly when you cough or strain — it may disappear when lying down
• Hip pain 
• In men, painful and/or swollen testicles if the bulge descends into the scrotum
• Weakness or pressure in your groin

Occasionally, a hernia can become trapped (incarcerated) and/or the blood supply cut off (strangulated). Strangulated hernias are more common with small hernias or femoral hernias. 

Incarcerated inguinal hernias and strangulated inguinal hernias require urgent medical treatment as they can be life-threatening. If you notice any of the following symptoms you should therefore seek immediate medical attention: 

• A change in the colour of your hernia eg turning red, purple or darker
• Difficulties passing stools and/or passing wind
• High temperature
• Nausea and vomiting
• Sudden (acute), intense pain

If you notice a lump in your groin area, see your GP. To diagnose an inguinal hernia, your GP will ask about your symptoms, your medical history and examine your stomach and groin. They might ask you to stand for this examination and also ask you to cough — coughing often makes the hernia more noticeable and easier to examine.

To confirm a diagnosis, your GP may refer you to a consultant or, occasionally, for further tests, such as an ultrasound scan or MRI scan.

Some inguinal hernias occur for no apparent reason. However, any condition that increases the pressure in your abdomen and/or weakens any part of your abdominal wall increases your risk of developing an inguinal hernia. You are therefore more likely to develop an inguinal hernia if you:

• Are affected by constipation — straining when passing stools can cause an inguinal hernia
• Are pregnant — pregnancy weakens the abdominal muscles 
• Have a family history of inguinal hernias
• Have a chronic (long-term) cough, possibly as a result of smoking
• Have a pre-existing weakness in the abdominal wall or have previously had an inguinal hernia or hernia repair surgery — up to one in 10 hernias return after treatment
• Regularly lift or push heavy loads

Getting older also increases your risk as your abdominal muscles weaken over time. You are at particular risk if you have previously had abdominal surgery or injured your abdomen. 

Sometimes an inguinal hernia is present from birth. This occurs when the lining of the abdomen (peritoneum) doesn’t close properly, causing a weakness in the abdominal wall.

Men are eight times more likely to develop an inguinal hernia than women. Ageing is also a major risk factor as your abdominal muscles weaken over the years. Other risk factors include: 

• Being born prematurely or with a low birth weight
• Being caucasian
• Being overweight or obese
• Having a chronic cough eg caused by smoking
• Having a family history of inguinal hernias eg a parent or sibling with the condition
• Having chronic constipation — this makes you strain when passing stools which increases the pressure in your abdomen

In women, pregnancy increases your risk of an inguinal hernia because it increases the pressure in your abdomen and weakens your abdominal wall.

Previous abdominal surgery or injury, as well as previous hernia surgery or a past inguinal hernia, even in childhood, also increases your risk.

Having cystic fibrosis increases your risk of developing an inguinal hernia too. 

• Bowel obstruction — when part of your bowel becomes trapped in the inguinal canal, causing nausea, vomiting and stomach pain
• Increased pressure on the tissues around your hernia — inguinal hernias tend to get bigger if they are not surgically repaired; in men, large inguinal hernias can descend into the scrotum, causing swelling and pain
• Strangulated hernia — when a trapped hernia (incarcerated hernia) cuts off blood supply to part of your bowel, which can cause this tissue to die; this is a life-threatening condition that needs emergency surgery 

If an inguinal hernia is not causing you pain or discomfort, your doctor may suggest postponing your inguinal hernia repair surgery. In children, your doctor may try manually pushing the hernia to reduce its size before surgery.

Inguinal hernia repair is a common surgical procedure. It involves returning the fat, tissue or loop of bowel, which created the hernia, to your abdomen. During surgery, your surgeon will also strengthen your abdominal muscles with a special mesh.

An inguinal hernia can be repaired using open surgery or laparoscopic (keyhole) surgery. Your surgeon will discuss which option is best for you, taking into consideration your inguinal hernia symptoms and your general health. It can be carried out under local anaesthetic with sedation or general anaesthetic. It is usually performed as a day case so you can return home on the same day as your surgery.

Following surgery, inguinal hernia recovery is relatively quick and you will be encouraged to move around as soon as possible. You should be able to return to work after about two weeks or slightly longer if your job is strenuous. Most people make a full recovery within six weeks. 

Open inguinal hernia repair

Open hernia repair can be carried out under local anaesthetic with sedation or general anaesthetic. Your surgeon will cut into your groin and push the protruding tissue into your abdomen. The weakened part of your abdominal wall will be reinforced with a synthetic mesh that is sewn in — this is called a hernioplasty. Your cut is then sewn together with stitches or staples, or is held together with surgical glue. 

Over time, the synthetic mesh will be incorporated into your abdominal muscle. 

Laparoscopic inguinal hernia repair

Laparoscopic surgery is minimally invasive as it uses smaller cuts. However, it is always carried out under general anaesthetic. Your surgeon will make several small cuts into your abdomen and inflate your abdomen with gas — this makes it easier to see your organs using a thin, telescope-like tube with a light and a camera on the end (laparoscope) which will be inserted via one of the cuts. Next, your surgeon will insert tiny, surgical instruments through the other small cuts to repair the hernia and sew reinforcing synthetic mesh in place. 

Laparoscopic inguinal hernia repair causes less discomfort and scarring and has a faster recovery time than open inguinal hernia surgery. If you have previously had open inguinal hernia surgery and your hernia returns, laparoscopic inguinal hernia repair helps your surgeon avoid scar tissue from this past surgery. This approach is also preferable if you have inguinal hernias on both sides of your body (bilateral hernias). 

Follow the advice from your care team on how to recover following your surgery. Make sure you: 

• Avoid straining yourself eg avoid lifting heavy objects, bending over or straining when passing stools
• Follow a healthy, balanced diet to reduce your risk of constipation
• Keep your wound clean and dry — follow the instructions given by your care team on how to do this

In most cases, you should be able to return to light activities and work that does not involve manual labour in around two weeks. You can usually expect a full recovery in around six weeks.

If you have a weakness in your abdominal wall from birth, you can’t change this. However, you can reduce your risk of developing an inguinal hernia by avoiding putting too much strain on your abdominal muscles and tissues. To do this: 

• Avoid lifting heavy objects and if you have to, make sure you lift them carefully by bending your knees and holding the object close to your body
• Eat lots of high-fibre foods to reduce your risk of constipation eg fruits, vegetables and whole grains
• Maintain a healthy weight — you can speak to your GP about an exercise plan and for dietary advice
• Quit smoking — smoking increases your risk of a large number of diseases but also increases your chances of developing a chronic cough that can cause an inguinal hernia