Hernia
A hernia is internal contents pushing out through a weak point in the muscular wall that ought to hold them in.
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A hernia is internal contents pushing out through a weak point in the muscular wall that ought to hold them in. Nearly always the abdomen and the groin are involved: a layer of fat, and sometimes a loop of bowel, squeezes through a gap in the wall, and a soft bulge appears on the outside. One clarification is worth making: the same word is used for a slipped disc in the spine, but that is a different story and is not covered here. This page is about hernias of the abdominal wall — why they appear, what can happen to them and when waiting is not an option.
Where the weak point comes from
The abdominal wall works as a firm corset of muscles and tendinous sheets that keeps the contents in during any strain. But the corset has places that are thinner to begin with: the canal in the groin down which the testicle descends in boys, the ring at the navel where the cord passed through, the narrow femoral canal under the groin ligament. Add to those any place where the wall has been cut during an operation.
A second player is then needed: pressure from within. It rises with every cough, every strain on the toilet and every load lifted. If those episodes repeat over years, the weak place stretches until the contents of the abdomen slip into it. That explains the list of things that push someone towards a hernia: a chronic cough, particularly in smokers; stubborn constipation; difficulty passing urine with an enlarged prostate; heavy physical work; excess weight; pregnancy; fluid collecting in the abdomen; and age, with which tissues lose their strength. Smoking also acts directly, worsening the quality of the collagen those tendinous sheets are built from. The inborn quality of connective tissue counts too, and that is what explains hernias in young, slim people who have never lifted anything.
The types and where they come out
- Inguinal: the commonest, mostly in men. The bulge appears in the groin and sometimes descends into the scrotum.
- Femoral: below the groin crease and more often in women. It is uncommon, but its canal is narrow and rigid, so it strangulates more readily than any other. That is why it is usually repaired without delay.
- Umbilical: around the navel. In babies it is almost the norm, since the ring closes by itself over the first years of life and needs no interference. In an adult it never closes on its own.
- Incisional: at an old scar on the abdomen, where the wall healed weakly.
- Epigastric: on the midline between the navel and the breastbone, usually small but tender.
- Spigelian: rare, at the edge of the straight abdominal muscle; it is treacherous because it hides between the layers of the wall and may not bulge outwards at all.
- Hiatus hernia stands apart: there part of the stomach slides up into the chest, there is no visible lump, and what troubles the person is heartburn.
What a person notices
The classic picture is a soft swelling that appears on standing, coughing or straining and goes away on lying down. Many people first find it in the shower or come across it by chance with a hand. It may not hurt at all. When it does hurt, it is usually a dragging ache that builds by the end of the day, after long hours on the feet or heavy work; with small hernias the reverse is common, and they ache more than large ones because the contents get pinched in a narrow opening.
Over time the bulge mostly grows, but unevenly: it can stay the same for years and then enlarge within a couple of months. Growing is not in itself a cause for alarm, whereas a change in behaviour is: if it stops going back in and stays visible while you lie down, that is worth discussing with a doctor without waiting for pain.
When it becomes a matter of hours
The main danger of a hernia is that the trapped tissue can be squeezed in the narrow opening. The blood supply is cut off and the tissue starts to die; if it is bowel that is trapped, an obstruction is added to that. Both situations need surgery straight away.
Call an ambulance — across Europe the number is 112 — or go to the emergency department at once if:
- the hernia has suddenly become sharply painful;
- the bulge has gone hard, will not go back and stays put when you lie down;
- vomiting starts and the abdomen swells;
- stools and wind stop passing;
- the skin over the bulge turns red or dusky;
- there is fever, a racing pulse and sudden weakness.
Two practical notes. First, a hard and painful hernia must not be forced back in: that can push an already dying loop into the abdomen where the surgeon will not find it. Second, until you have been examined it is better not to eat or drink, since it saves time if an operation turns out to be needed.
The examination and the decision
In the great majority of cases the diagnosis is made with the hands. The doctor examines the groin and abdomen with the patient standing, not only lying — lying down, a small hernia simply disappears — and asks for a cough: a characteristic impulse is felt under the fingers. An ultrasound scan is needed when there is no visible bulge but there is groin pain, or when it is unclear whether the hernia is inguinal or femoral. A CT scan earns its place in incisional and unusual hernias, to establish the size of the defect before any repair.
Then the main question is settled: operate now or watch. Several things are weighed up:
- the type of hernia — a femoral one is almost always repaired without delay, whereas an inguinal one allows waiting;
- what is inside it — a loop of bowel carries more risk than fat alone;
- how much it interferes with life — pain and restriction matter more than size;
- general health, because with serious other illness the risk of anaesthesia may outweigh the benefit.
Watching is a legitimate choice for a small, painless inguinal hernia, and the person is not left to it alone: the signs of strangulation are explained and a review is arranged. Two things are worth being clear about. In an adult a hernia does not heal over, and no exercise will close it. And the truss some people wear for years does not treat anything: it merely holds the bulge in, and worn long enough it can rub the skin and complicate the eventual operation.
How a hernia is repaired
The point of the operation is always the same: put the contents back and reinforce the weak part of the wall. It is done by two routes. Open surgery, through a cut directly over the hernia, often under local or spinal anaesthetic. And keyhole surgery, through several small openings under general anaesthetic; it is technically harder but easier to recover from and convenient when there are hernias on both sides or when one has come back. In adults the defect is usually closed with a mesh, which takes the strain and markedly lowers the chance of recurrence. In children no mesh is used: closing the canal is enough.
Most people go home on the day of surgery or the next morning. Walking is allowed straight away; driving, once you can brake hard without pain; office work is resumed within a week or two, and heavy work as agreed with the surgeon. Moderate dragging discomfort, swelling and bruising near the wound in the first weeks are normal.
The risks are worth asking about beforehand, because they feed into the decision. The hernia can come back. Fluid may collect under the skin, a bruise may form, and less often the wound becomes infected. Chronic groin pain stands apart: it affects a proportion of those operated on and comes from irritation of the nerves, and it is precisely why a symptomless inguinal hernia is by no means always rushed to theatre.
What is in your hands
A hernia cannot be got rid of on your own, but lowering the pressure inside the abdomen and keeping it from growing is entirely realistic, and the same measures prepare you for an operation if one becomes necessary.
- Sort out constipation: fibre, water, movement and gentle laxatives if needed. Years of straining on the toilet are one of the main reasons a hernia enlarges.
- Treat a chronic cough and stop smoking: that works both through the pressure and through the strength of the tissues.
- If the urinary stream is weak and you have to strain, see a doctor — the prostate can be treated, and the abdominal wall benefits along the way.
- Lose weight gradually. Crash diets achieve nothing, whereas a few kilograms less noticeably eases the load on the wall.
- When lifting, bend the knees, keep the load close to the body and do not hold your breath. There is no need to give up exertion altogether; the technique is what counts.
- After abdominal surgery, respect the timescales you were given: a good share of incisional hernias comes from going back to heavy work too soon.
Online consultation
Remotely it is easy to settle what you are dealing with and how urgent it is. The doctor will ask how the bulge behaves, whether it goes back in, what happens on coughing and exertion, will ask to see the area on camera and will explain whether this looks like a hernia or rather an enlarged lymph node, a lipoma or a separation of the abdominal muscles after childbirth. The same appointment covers whether to go for surgery now or watch instead, how to prepare for the operation, what to do about pain and swelling afterwards and when to return to sport. The signs of strangulation listed above are not dealt with through a screen: with those you go straight to the emergency department.
This material is for information only and does not replace medical advice.
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