Treating a hernia used to be a simple 1-2-3 approach. A man noticed a bulge in his groin, his doctor diagnosed it as a hernia, and a surgeon repaired it.
Now the process is more complex. Rather than three steps, there are three questions you need to ask:
- Should the hernia be repaired?
- Which repair is best?
- What type of anesthesia should be used?
Men and Groin Hernias
A hernia is when one of the body's structures protrudes through an abnormal opening in tissues. Hernias can develop in many areas of the body.
A groin hernia is called an inguinal hernia. It occurs when part of the intestine or the fatty tissue that surrounds the bowel bulges through a weak spot in the abdominal wall. A man has a 27% chance of developing a groin hernia at some time in his life.
For most men, the term hernia is shorthand for a hernia in the groin. Groin hernias are nine times more common in men than women. Men are more likely to lift heavy objects. This increases abdominal pressure and puts stress on the groin tissues. (For both men and women coughing, obesity and constipation with straining to move the bowels are factors that can increase abdominal pressure; pregnancy is an additional factor for women.)
How Does an Inguinal Hernia Develop?
When the testicles begin to develop early in fetal life, they are near the kidneys, high up at the back of the abdomen. At about 17 weeks of fetal development, the testicles start to descend through the abdomen to the groin. By about 28 weeks, the third trimester of pregnancy, they pass down to the scrotum through the inguinal canal. As they pass into the scrotum, they leave an opening behind.
In most cases, this inguinal canal will close by the time of birth. If the closure is defective, however, it remains a weak area that may later become a hernia.
The most common type of inguinal hernia is the indirect inguinal hernia. It develops later in life from a defect present at birth. As tissues weaken with age, indirect inguinal hernias are most common in older men.
The other type of groin hernia is the direct inguinal hernia. It is not caused by an inborn defect. Aging is an even stronger risk factor for this type of groin hernia. It is acquired over time as tissues weaken.
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What Are the Symptoms?
Most men with hernias develop two symptoms:
- A dull pain or ache
- A bulge in the groin or scrotum
At first, the bulge comes and goes. It is only noticeable when a man strains or stands, but not while he's lying down. Hernias that come and go are called reducible hernias. They can be uncomfortable or unsightly, but they're not serious.
An incarcerated hernia, on the other hand, do not come and go. It is more likely to be painful and can develop a complication called strangulation. This occurs when pressure interferes with the bowel's blood supply. Strangulated hernias are very painful. A person develop nausea, vomiting, abdominal bloating and fever. Strangulated hernias need immediate surgery. Fortunately, these complications are uncommon with inguinal hernias.
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How Is a Groin Hernia Diagnosed?
Even in this age of high-tech medicine, a careful physical exam will detect most hernias.
Most doctors will ask the patient to stand for the exam. The doctor will first look at the groin and scrotum, then feel for a bulge in these areas. If gravity does not bring out the bulge, the doctor places his finger at the base of the scrotum, then asks his patient to cough or strain. As abdominal pressure increases, the abdominal contents will bulge through the opening and tap on the doctor's finger.
Ultrasound can sometimes detect a hernia very early when there's just a bulge but no discomfort. A physical examination and an ultrasound together will also detect other conditions that may be confused with hernias. These include enlarged groin lymph nodes, fluid in the testicular sack (a hydrocele), cysts or inflammation of the epididymis, a twisted testicle (torsion, a urologic emergency) and testicular cancer.
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Do I Need Surgery?
When a hernias causes discomfort and interferes with daily life, surgery is the way to go. Young physically active men are also generally wise to choose surgery, even if their hernias are painless.
But men who have few symptoms can choose to wait and see if they develop discomfort that requires surgery. However, surgery is more risky as you get older. But these risks are uncommon. Men who choose waiting avoid post-operative complications, including a substantial likelihood of pain and a small chance of the hernia coming back.
Based on new studies, many men may now decide "if it's not broken (painful), don't fix it."
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Which Surgery Is Best?
The first hernia repair, or herniorrhaphy, took place in 1887. For nearly 100 years, surgeons simply used sutures to bring the separated tissues together. But this puts the tissues under tension and they pull apart in up to 7% of patients. The hernia may then come back.
Now, surgeons use only two types of surgeries to repair groin hernias.
- Tension-free repair – In the early 1980s, Dr. Irving Lichtenstein developed a way to repair hernias without putting tissues under tension. Surgeons close the defect with a sheet of mesh. It can be done as outpatient surgery under local or spinal anesthesia. Because patients experience less pain and there is a lower risk of the hernia returning, tension-free repair has quickly became the favored operation.
- Laparoscopic surgery – This newer rival burst onto the scene in the early 1990s. Whereas open repairs require a four- to six-inch incision in the groin, the laparoscopic repair requires only three half-inch incisions in the abdomen. First, the surgeon inflates the abdomen with carbon dioxide. Next, he inserts a thin fiber-optic tube (laparoscope) through the incisions. While watching through a video camera, he then inserts instruments that he uses to pull the intestinal contents back into place and to staple a mesh patch over the defect. Inflating the abdomen is painful, so laparoscopic surgery requires general anesthesia. It also requires specialized equipment and extra training, so it is more expensive than open surgery.
Laparoscopic surgery produces less post-operative pain and gets you back to work faster (two to three days versus one to two weeks) than the open repair. But because the operation is tricky, you'll need a surgeon with lots of laparoscopic experience to get these good results.
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General or Local Anesthesia?
It's the simplest of the three questions. If you have a laparoscopy, you'll need general anesthesia. Open surgery can be done with local, spinal or general anesthesia. However, randomized clinical trials report that local anesthesia produces less post-operative pain and fewer problems with urination. Still, if you and your doctors have a reason to choose general or spinal anesthesia, they are also reasonable options.
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Medicine has come a long way from days when doctors made a diagnosis and decided on the treatment plan with little or no discussion with the patient. There are lots of good treatment options. Good communication is the key to making a good choice. Find out your options and what your surgeon does best. Talk it over with family and friends, and ask for a second opinion if you are torn.
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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.