Inguinal hernia presents as a bulge in the groin or the inguinal region or in the scrotum. This bulge becomes appreciable while coughing, straining or standing; meaning it is not constant but is variable depending on the intra-abdominal pressure. Most times the bulge disappears on lying down and is rarely painful.

An asymptomatic hernia presents as a swelling in the inguinal region with a sense of aching. There is no actual pain or tenderness when examined and it is seen that the swelling increases with the increase in abdominal pressure. These are the usual characteristics of an asymptomatic inguinal hernia [10]. If the hernia does not reduce or cannot be manipulated into the abdomen via the fascial defect, then it could be an incarcerated hernia. It is often associated with nausea, vomiting and may have symptoms of blocked bowels.

When the blood supply to a part of intestines entangled in the hernia are obstructed, then it is termed as strangulated hernia. In such cases the patient presents with the symptoms of incarcerated hernia accompanied with toxic appearance as a result of toxicity caused due to gut ischemia. The patient might present with nausea/vomiting, fever and chills since a bacterial infection might supervene on the ischemic bowels of a strangulated hernia.

In infants, the lone symptom could be increased irritability, whereas in older children and adults it is presented by dull aching or burning pain that is aggravated by straining or exercise.

• Crying

  In many cases the swelling may only be seen during crying or straining. [hernia.org]

  The bulge in the groin might only be noticed when the child is crying, coughing, or straining during a bowel movement, or it might appear to be larger during these times. Of the newborns who have inguinal hernias, 90% are boys. [my.clevelandclinic.org]

  Management Analgesia (e.g. morphine) Bowel compromised Tender tense swelling with redness and induration, with no impulse on crying in a distressed infant. Resuscitation Urgent surgical consult. [pch.health.wa.gov.au]

  And ask yourself: Is the bulge present when your child is straining, crying, coughing, or standing, but absent when your child is sleeping or resting? This could indicate a reducible hernia. [kidshealth.org]

• Wound Infection

  Wound infection was found higher in Desarda group 18 (19.4%) as compared to darning group 9 (9.7%) (p-value 0.061). [ncbi.nlm.nih.gov]

  Complications The most common complications are wound infections and recurrence of the hernia which occurs approximately 2% of the time. Pediatric Inguinal Hernia (Groin) Doctors and Providers [childrens.com]

  Wound infection. Bladder injury. Intestinal injury. A hydrocele from fluid accumulation in the distal sac usually resolves spontaneously but sometimes requires aspiration. Prognosis This is generally very good, depending on comorbidity. [patient.info]

• Inflammation

  A relationship between inflammation and peritoneal metastasis has been reported; thus, we speculated that local inflammation resulting from chronic stimulus of mesh plugs and peritoneal trauma caused peritoneal metastasis at the repair sites. [ncbi.nlm.nih.gov]

  Icing: Inflammation, swelling, redness, pain in the abdomen or groin are some of the common symptoms of inguinal hernia. [hcah.in]

• Weight Loss

  Weight Loss Surgery is a Big Decision Our specialists provide the expertise and support you need to reach your weight loss goals. [uhhospitals.org]

  In many cases, it is asymptomatic, even though postprandial abdominal pain or, during exercise, nauseas, vomiting, and weight loss could be found. [websurg.com]

  loss Psoas abscess Flank or back pain, fever, inguinal mass, limp, weight loss Sebaceous cyst Soft mass, nontender, more superficial, no change with Valsalva maneuver Testicular torsion Acute onset of pain with a high-riding testis, swelling, very tender [aafp.org]

  Stay at a healthy weight through diet and exercise. Avoid rapid weight loss (such as in crash dieting). [healthlinkbc.ca]

• Inguinal Mass

  Imaging showed large paratesticular mass; radical inguinal excision of testicle, cord, and mass was performed. Pathology showed mixed low-grade and high-grade sarcoma. [ncbi.nlm.nih.gov]

  Inguinal masses that resemble hernias may be the result of adenopathy (infectious or malignant), an ectopic testis, or lipoma. These masses are solid and are not reducible. A scrotal mass may be a varicocele, hydrocele, or testicular tumor. [msdmanuals.com]

  mass; may be enlarging; systemic symptoms or weight loss Psoas abscess Flank or back pain, fever, inguinal mass, limp, weight loss Sebaceous cyst Soft mass, nontender, more superficial, no change with Valsalva maneuver Testicular torsion Acute onset [aafp.org]

• Persistent Cough

  Things that increase the pressure inside the abdomen can increase the risk of this condition, such as being obese, having a persistent cough, straining when opening the bowel or heavy lifting. Inguinal hernias are common. [ada.com]

  Symptoms are most likely to appear after standing for long periods, or when you engage in activities that increase pressure inside the abdomen, such as heavy lifting, persistent coughing or straining while urinating or moving the bowels. [drugs.com]

  Smoking can also predispose you to an Inguinal hernia due to the persistent coughing. Strenuous exertion increases your risk. [scnv.com]

• Respiratory Distress

  Pulmonary BPD/reactive airway disease Premature infants showing signs of respiratory distress and increased work of breathing such as retractions, tachypnea, wheezing, and desaturation may require optimization of their medical therapy. [clinicalpainadvisor.com]

• Dyspnea

  If the patient develops dyspnea and pneumoderma during or after this procedure, a chest radiogram or thoracoabdominal CT should be taken for diagnostic purposes. [giornalechirurgia.it]

• Nausea

  Some patients get crampy abdominal pain, nausea and vomiting or constipation. Abdominal pain, nausea and vomiting are alarming symptoms because they may be a sign of an immediately life threatening complication such as bowel strangulation. [noinsurancesurgery.com]

  An 85-year-old male complained of bowel movement pattern change, abdominal distension and loss of weight, without vomiting but with nausea. [ncbi.nlm.nih.gov]

  This is called an incarcerated hernia and can cause problems such as severe pain, nausea, vomiting, or absence of bowel movements. [my.clevelandclinic.org]

  If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Strangulation. [mayoclinic.org]

• Abdominal Pain

  With small hernias pain may be the only symptom. This pain may be anywhere from the kidney to the testicle. Some patients get crampy abdominal pain, nausea and vomiting or constipation. [noinsurancesurgery.com]

  EMERGENCY Severe lower abdominal pain warrants immediate medical care; it may be a sign of intestinal obstruction or strangulation. [healthcommunities.com]

  INTRODUCTION: Torsion of the omentum is a rare cause of abdominal pain. It is clinically similar to common causes of acute surgical abdomen and is often diagnosed during surgery. [ncbi.nlm.nih.gov]

  Symptoms for a hernia can include the following: Abdominal pain Belly button sticks out ( umbilical hernia only) Discomfort in the groin, especially when bending, coughing or lifting Noticeable bulge in the stomach, scrotum or pubic bone Pain in the groin [childrens.com]

• Abdominal Bloating

  A hernia that cannot be pushed back can be repaired when surgery is convenient unless you have increased pain, redness of the overlying skin, fever, nausea and vomiting, or abdominal bloating. [healthlinkbc.ca]

• Abdominal Mass

  The animation of the surgery shows the placement of the laparoscopic devices, location of the herniated abdominal mass, and placement of mesh graft to strengthen the fascia of the abdominal wall. Caption author (English) Category [youtube.com]

  Patients who present with a history of a severe pain, associated with an inflamed lower abdominal mass should be evaluated emergently for incarceration of abdominal contents within a hernia. [jomi.com]

  The ultrasound scan will allow the doctor to visualize the hernia and to make sure that the bulge is not another type of abdominal mass such as a tumor or enlarged lymph gland. [surgeryencyclopedia.com]

• Intestinal Perforation

  The major complications of an Amyand's hernia include necrotizing fasciitis of the anterior abdominal wall and secondary intestinal perforation. [ncbi.nlm.nih.gov]

• Arthritis

  Septic arthritis in a prosthetic joint (septic arthritis in a native joint is allowed) b. Osteomyelitis c. Endocarditis or myocarditis d. Meningitis, endophthalmitis, or any central nervous system infection 2. [clinicaltrialsregister.eu]

  Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E may need to be stopped temporarily for several days to a week prior to surgery. [sages.org]

  Case 3—Third diagnostic term Four experts gave a third term to describe the diagnosis in case 2: One pubic cleft arthritis, 1 transversus abdominis strain, 1 tear of the posterior inguinal wall and 1 combination of multiple (>2) diagnoses. [bjsm.bmj.com]

• Fear

  In the present case, the individual feared being hospitalised for treatment of his scrotal swelling with potential surgery and the eventual loss of daily income. [ncbi.nlm.nih.gov]

  […] the other hand, surgery has a risk of inguinodynia (10-12%), and this is why males with minimal symptoms are advised to watchful waiting.[25][26] However, if they experience discomfort while doing physical activities or they routinely avoid them for fear [en.wikipedia.org]

  Since the first description by Italian surgeon and anatomist from Pavia, Antonio Scarpa in 1809 [ 1 ] they were feared as a complicated surgical conditions. [intechopen.com]

• Confusion

  Confusion with inguinal hernia can affect prognosis. It increases the risk of thromboembolism as well as preventing the chance of early response. Copyright © 2012. Published by Elsevier B.V. [ncbi.nlm.nih.gov]

  A femoral hernia is rare in kids and can be confused with an inguinal hernia. It consists of tissues that have pushed in alongside an artery into the top of the thigh. It appears as a bulge at the top of the thigh, just below the groin. [kidshealth.org]

  This inguinal hernia is frequently confused with a more benign condition, a communicating hydrocele. What is the difference between an inguinal hernia and a hydrocele? A hydrocele is a fluid filled sac in the groin or scrotum. [healthychildren.org]

  Your child may cry, be fussy or confused, feel sick to his or her stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off. [chp.edu]

• Urinary Retention

  However, postoperative urinary retention (PUR) occurs in up to 22% of patients, resulting in further extraneous treatments.This single institution series investigates whether patient comorbidities, surgical approaches, and anesthesia methods are associated [ncbi.nlm.nih.gov]

• Swelling of the Scrotum

  Symptoms of Inguinal Hernia A lump in the groin area that may be evident only when standing or straining and that disappears when reclining Pain at the site of the lump, especially when lifting a heavy object Swelling of the scrotum Excruciating abdominal [healthcommunities.com]

  Other symptoms may include: pain when coughing, exercising, or bending over burning sensations sharp pain a heavy or full sensation in the groin swelling of the scrotum in men There isn’t one cause for this type of hernia. [healthline.com]

• Dysuria

  The patient endorsed associated symptoms of decreased force of stream on urination, stranguria and hesitancy with slight dysuria. Physical exam showed an effaced umbilicus and phallus with a hidden scrotum estimated to be 30×20×30 cm in size. [ncbi.nlm.nih.gov]

  He denies recent trauma to the area, dysuria or hematuria. On evaluation, his vitals are recorded to be: HR: 106, BP 115/79, O2 100%, Temp 98.8°F. Examination reveals left scrotal swelling and pain with elevation w/o discoloration or bruising. [ultrasoundoftheweek.com]

• Testicular Swelling

  Symptoms of ischemic orchitis include painful testicular swelling and fever commencing 2-3 days after surgery. [65] A study comparing heavyweight and lightweight meshes for laparoscopic inguinal hernia repair in men found that the use of lightweight mesh [emedicine.medscape.com]

The diagnosis is generally made by a thorough physical examination. Usually, laboratory studies are not specific for hernia but some of them can be useful as follows:

• Complete blood count: Results aren’t specific, but leukocytosis with left shift can be seen in case of strangulation.
• Electrolytes, blood urea nitrogen levels (BUN), and creatinine levels must be assessed. In case of patients presenting with nausea and vomiting, it is mandatory to determine their hydration status and these tests are a prerequisite for operating hernia.
• Urinalysis: It helps in ruling out any other genitourinary cause leading to groin pain along with hernia.
• Lactate levels: Raised levels can be due to hypoperfusion but normal levels do not rule out strangulation.

Imaging studies

• Radiography: Chest radiograph taken when the patient is standing straight helps to rule out free air under the diaphragm.
• Flat and upright abdominal radiographs help in diagnosing a small bowel obstruction or to know the portion of bowel that is outside the abdominal cavity. Both these radiographs are helpful in cases of suspicious incarcerated or strangulated hernias.
• CT scan: CT scan of abdomen and pelvis along with oral and intravenous contrast helps in detecting various hernias that are otherwise difficult to diagnose by displaying extracoelomic position of the bowel, bladder or internal reproductive organs [11].
• Ultrasonography: It helps in restricting the differential diagnoses for scrotal masses as well as those beneath the inguinal ligament. It also helps in deciding whether to drain or aspirate a nodal abscess if present.

These imaging studies become necessary when the patient’s body habitus prevents physical examination.

Conservative

A hernia truss helps in keeping the reducible inguinal hernia in the abdomen. It does not cure the condition but if the pads are hard and invade the hernial opening they can lead to scarring and widening of the hole. Due to the pressure, the trusses can cause injury to the skin or bowel and conceal the signs of an incarcerated and strangulated hernia. The truss also increases the chances of complications like strangulation, degeneration of the spermatic cord and the fascial margins. It might lead to enlargement of the defect thereby making the repair tough [12].

Surgical

Herniorrhaphy: In this procedure, an incision is made in the groin region to push the protruding intestine back into the abdomen. Then the weakened or damaged muscle is sewed or strengthened and supported with the help of a synthetic mesh.

Laparoscopic hernioplasty: This is a less invasive procedure where the operation is done via many tiny incisions on the abdomen. This procedure causes minimal discomfort and scarring. It helps the patient to recover faster. It is a good option for those who suffer from recurrence of the hernia after the traditional hernia surgery as the surgeon can bypass the scar tissue formed due to the prior repair. It is a better option for bilateral inguinal hernia.

Hernia surgery is quite safe and effective. It has a good prognosis but depending on the site, size, and technique used, few hernias can recur over a period of time.

Once open surgery is done, the patient can get back to routine activities in a week or two, whereas in case of laparoscopic surgery the recovery is faster. After the surgery, patient should keep away from heavy lifting for few weeks so that the muscle and tissues can recover completely.

Indirect hernia is a congenital hernia irrespective of the patient’s age.

Direct inguinal hernias occur due to increased pressure within the abdomen, aging, stress or strain weakening the abdominal muscles around the inguinal canal, exertion during bowel movements, heavy lifting, obesity, pregnancy, chronic coughing and sneezing, prior surgeries over lower abdomen that may weaken abdominal muscles.

Around 10% of the population develops some form of hernia during their life [1]. From about 1 million abdominal hernia repairs, 770,000 cases are of inguinal hernia repair [2] [3] [4]. A lifetime risk of developing inguinal hernia is more in men i.e. 27% whereas in women is just 3% [5].

Of all the inguinal hernias 50% are indirect whereas 25% are direct [6]. Indirect inguinal hernias are common in premature babies especially those that are born before 32 weeks of gestation [3], whereas direct hernias are seen in older patients due to relaxation of the abdominal wall muscles and thinning of the fascia.

Inguinal hernias are divided into two types - direct and indirect.

Direct: This type of hernia generally occurs due to a fault or weakness in the transversalis fascia region of the Hesselbach triangle in the abdomen. This triangle is formed by the inguinal ligament at the base, inferior epigastric arteries on the lateral side and the conjoint tendon medially [7].

Indirect: The indirect inguinal hernia pursues the tract via the inguinal canal. It is the outcome of a persistent processus vaginalis. Origin of the inguinal canal is within the abdominal cavity, at the opening of the internal inguinal ring, which is nearly midway between the symphysis pubis and the anterior superior iliac spine (ASIS). From here it goes down together with the inguinal ligament to the external inguinal ring present on the medial side of inferior epigastric arteries. The contents of hernia go downwards into the scrotal sac through the passage of the testicle [6] [8] [9].

Rarely inguinal hernias can be prevented, particularly in younger patients. In adults it might be prevented from occurring or recurring by taking following precautions:

• Maintain healthy weight: Overweight causes an increase in the abdominal pressure and thereby increases the risk of developing inguinal hernia. Follow proper diet and exercise regimen to maintain healthy weight. Avoid sudden weight loss by dieting as it leads to weakness of the abdominal muscles due to lack of protein and vitamin intake.
• Quit smoking: Smoking leads to chronic coughing and hence increases the chances of developing hernia.
• Have high fiber diet: This helps in preventing constipation and hence avoids straining while emptying the bowels. Straining for bowels increases the intra-abdominal pressure.
• Take care while lifting heavy weights. While lifting weights bend your knees not the waist.
• Do not depend on a truss: It helps in keeping the hernia in place but does not cure the situation. It can be used for a short time, till you decide about the surgery.

Inguinal hernia is defined as out-pocketing of the contents of the abdominal cavity through the inguinal canal. This protrusion results into a bulge that can be painful especially when one bends over, coughs or lifts heavy objects.

Inguinal hernias can be classified into direct and indirect inguinal hernia depending on the cause of hernia.

Inguinal hernia is a condition that occurs when the contents of abdomen protrude into the inguinal region of the lower abdomen due to a defect or weakness in the abdominal wall.

Birth defects in the abdominal wall cause direct inguinal hernias while aging and stress or strain that weaken the abdominal muscles leads to indirect inguinal hernia. Both these hernias can be repaired by surgical procedures. If the hernias are left untreated, they may lead to strangulation which is a surgical emergency.

Although hernias are difficult to avoid, but various lifestyle changes like maintaining healthy weight, avoiding crash dieting, high fibre diet, avoid smoking etc can help in recurrence. Wearing truss can help keeping the hernia within the abdomen, but it is not the cure. It gives temporary relief from the symptoms and provides greater confidence while performing any physically demanding activities. Just use them for a short time before surgery.

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