Hernia

Hernia

What is a hernia?

Most common in the abdomen, a hernia can also develop in the bellybutton (navel), upper thigh or groin areas of the body. A hernia develops when an organ (sometimes even fatty tissue) forces through an opening or weakened area in muscles and connective tissues (fascia) that would normally hold it in place.

A hernia can develop in a short space of time or over prolonged periods. This generally depends on the underlying cause. Sometimes a hernia is present at birth (birth defect), and at other times develops due to strain and weakness later on in life.

Typically, the majority of hernias are not initially life-threatening, but they do not naturally resolve themselves (go away on their own). Medical intervention is likely necessary and may sometimes require a surgical procedure to prevent potentially serious complications, which can become life-threatening.

Causes and types of hernia

What are the common causes of a hernia?

  • Muscle weakness: Impaired function which can result in the development of a hernia include signs such as chronic coughing, congenital defects whereby the abdominal wall or inguinal ring does not close properly in the womb, age, damage due to surgery or as a result of injury.
  • Strains / pressures in the body: In combination with muscle weaknesses, strains which can also result in a hernia include pregnancy, constipation, diarrhoea, ascites (presence of fluid in the abdomen), sudden weight gain, persistent coughing, sneezing pressure (experienced persistently), obesity, effects of smoking, poor nutrition and lifting heavy objects.

What are the different types of hernia?

Illustration of an inguinal hernia

Based on their predominant causes, hernias are classified as the following types:

  • Inguinal hernia: The most common of all, up to 70% of cases are inguinal hernias. This type occurs when a portion of the intestines or bladder is forced through a weakened area or tear in the lower abdominal wall (also known as the inguinal canal) near the groin. This hernia type is common amongst men affecting the spermatic cord which passes between the abdomen and scrotum area, and holds up testicles. A male’s testicles descend through the inguinal canal soon after birth. Naturally, the canal closes on its own. If not, it creates a weakened area which may be more susceptible to hernia. The inguinal canal in females holds the uterus in place. The hernia (bulge) that develops can be painful, particularly when bending over, lifting heavy objects or even coughing. Complications as a result of the bulge getting larger and more painful can be life-threatening if not effectively treated. Surgery is often recommended in this instance.
  • Hiatal hernia: This type of hernia occurs when a portion of the stomach pushes through an opening in the diaphragm (hiatus) and into the chest. The diaphragm is the muscle responsible for helping a person to breathe, supporting breath through the inhaling and exhaling function. The hiatus is a natural opening allowing the oesophagus (‘food tube’) to connect to the stomach. The diaphragm is located between organs in your chest and abdomen, separating these areas of the body. A common complication of this type of hernia is GERD (gastroesophageal reflux disease). Many hernias of this type can be treated with medication and self-care methods (being mindful of what you eat which may cause reflux). Where the hernia is particularly large, surgery may be required.
  • Umbilical hernia: This type of hernia affects infants younger than 6 months of age, as well as young children. It can also affect women who are obese or those who have carried many children (had multiple pregnancies). With this type, the intestines push through the abdominal wall in the area of the bellybutton (navel). A sign this has happened is a visible bulge near the bellybutton. This bulge which causes a pronounced protruding bellybutton, is even more visible when a child or baby is crying. This type of hernia is mostly regarded as harmless. If the hernia doesn’t appear to resolve by the time a child is 4 years of age, seek medical attention. It is also possible that this type of hernia may require surgical intervention.
  • Incisional hernia: This type is a common complication following an abdominal surgical procedure. A healing scar can serve as weakened tissue, which intestines can push through causing a hernia at (or near) the site of incision. This type is commonly seen with inactivity following surgery, especially if a person is overweight or elderly.
  • Femoral hernia: This type is common in ladies who are either obese or pregnant. A hernia develops when a portion of the intestine is forced through the canal carrying the femoral artery near the upper thigh. This type is also known as femorocele.

Ilustration of an umbilical hernia

What are the signs and symptoms?

All types of hernia result in a bulge or bump at the site of an affected area. Common symptoms according to type of hernia include:

  • Inguinal hernia: A lump on either side of the pubic bone (the area where the thigh and groin area meet). This lump or bulge can be felt in the area when standing upright. Other symptoms include pain or discomfort in the lower abdomen, an ache or burning sensation at the site of the lump, and a feeling of heaviness in the abdomen or groin (accompanied by pressure or weakness). Males may experience pain and swelling in their testicles when the hernia descends into the scrotum. Babies and children may show signs of a hernia when crying, straining during a bowel movement or coughing. Babies and children may also experience a loss of appetite and show signs of irritability.
  • Hiatal hernia: Difficulty swallowing, acid reflux or heartburn, belching (burping), black stools (faeces), vomiting blood and chest or abdominal pain.
  • Umbilical hernia: A bulge or protruding bellybutton can be seen and felt most often when a baby is crying or displaying signs of strain such as coughing. The bulge may seem to disappear when the baby is lying down or begins to calm. Adults will experience abdominal discomfort. Pain, vomiting, bulge tenderness and swelling or discolouration are all red flags needing medical attention.
  • Incisional hernia: Signs include a bump or bulge on the surgical incision scar, visible protrusion, infection, fever, pain or discomfort, redness or inflammation and foul-smelling drainage.
  • Femoral hernia: Small-to-moderate sized hernias typically don’t cause obvious symptoms. Larger hernias begin to cause discomfort and pain (particularly when standing, straining in any way or lifting heavy objects) and are also typically visible in the groin area (near the upper thigh). Pain is often noted on the hip bone as a result. Strangulation (obstruction of the intestines restricting blood flow) can occur and cause severe stomach and sudden groin pain, as well as nausea and vomiting.

Diagram showing hiatal (hiatus) hernia

Diagnosing and treating hernia

How is a diagnosis made?

At your consultation, your doctor may ask you series of questions to gain a better understanding of your symptoms, as well as to determine the best means of diagnosis and treatment.

Typical questions can include:

  • How long ago did you first start experiencing symptoms or notice something unusual?
  • What is the nature of your symptoms?
  • Do you experience them occasionally or on a continuous basis?
  • How would you describe your symptoms - mild or severe?
  • Have you tried anything that has provided symptom relief?
  • Has anything seemingly made your symptoms worse?

Hernias are typically diagnosed according to their type and severity, and treated accordingly.

A hernia can be diagnosed in the following ways:

  • Inguinal hernia: Diagnosed through a physical exam as the bulge is generally visible. Your doctor will ask you to stand upright. A hernia is generally more prominent in this position and will be easy enough to see with the naked eye. If necessary, your doctor will ask you to cough or act as if straining the body (for instance reaching for something or attempting to lift something heavy). This will also cause the bulge to protrude. If for any reason the bulge is not clearly visible and your doctor strongly suspects a hernia or wishes to check for (or rule out) other conditions, an imaging test may be recommended. These can include an abdominal ultrasound, MRI or CT scan. All of these provide detailed images which can help to make a definite diagnosis.
  • Hiatal hernia: This type is often diagnosed when a doctor performs tests to try and determine a cause of heartburn, reflux or upper abdominal pain. Tests can include an eosphagram / barium swallow, blood testing (checking blood count and for signs of anaemia), endoscopy (generally a gastroscopy), or manometry (a catheter which is passed through the nose, down the oesophagus and into the stomach, and measures pressure of movement).
  • Umbilical hernia: A doctor will perform a physical exam and sometimes include an imaging test (CT scan or abdominal ultrasound).
  • Incisional hernia: This type of hernia will be diagnosed in a similar way to an inguinal hernia.
  • Femoral hernia: Your doctor will try and feel the bulge through a physical exam. He or she will also recommend an abdominal ultrasound in order to make a diagnosis. If necessary, an imaging test can also be used to show the weakened or torn muscle gap, and the protruding tissue.

Treatment

Treatment of a hernia may or may not be entirely necessary. Your doctor will determine the size of your hernia during the physical examination, as well as through various tests. If unnecessary to intervene, your doctor may merely monitor you, requesting follow-up appointments, to check for potential signs of enlargement and other developing complications.

General treatment for hernia involves:

  • Lifestyle and dietary changes: Your doctor may suggest that you be mindful of what you eat (avoiding spicy and tomato-based foods that cause heartburn and acid reflux) and take care not to consume heavy meals. Other tips you may be given include not lying down or bending following a meal, and maintaining a healthy weight. Smoking habits should also be stopped. Often, such changes can help alleviate hernia related discomfort. If not, surgery to correct a hernia may be recommended.
  • Medication: Not all types of hernia need be treated with medication. A hiatal hernia can be treated with prescription or over-the-counter medication that helps to relieve stomach acid and its associated symptoms. In this instance, antacids, proton pump inhibitors and H-2 receptor blockers are commonly recommended.
  • Surgery: Pain is a strong sign that the hernia has reached a stage which can’t necessarily be managed with medications and lifestyle adjustments. A hernia can increase in size and due to the forceful nature of tissue pushing through muscles and other connective tissues, it can cause intense pain. Surgery may then become necessary to alleviate pain by repairing holes or weakened areas (closing the opening) with surgical mesh. Depending on the surgeon and the nature of your hernia, surgery may be performed as either open surgery through an incision or laparoscopically through much smaller incisions. In the case of laparoscopic surgery, a surgeon will perform the procedure with a tiny camera and miniaturised surgical tools, making a few small incisions. This is sometimes a favoured procedure as it is less damaging to surrounding tissues, but a hernia can recur and it isn’t always a suitable option for some body locations (such as near the scrotum of a male). Open surgery will result in a longer recovery period. You may be immobile for up to 6 weeks during recovery.

Open hernia surgery

Who is at greater risk?

You may be more susceptible to developing a hernia if:

  • You have a chronic cough
  • You are a smoker (often linked to a chronic cough)
  • You are overweight or obese
  • You experience chronic constipation
  • You have experienced a hernia before or had a hernia repair (surgery)
  • You have a family history of hernias
  • You have been diagnosed and treated for cystic fibrosis
  • You are 50 years of age or older and are at higher risk for a hiatal hernia and muscle loss in general
  • You are pregnant or have had multiple pregnancies
  • You are male (this may make you more susceptible to inguinal hernias)
  • Infants and premature babies with low birth weights (at higher risk of umbilical hernias)

Common complications

When hernias develop, they are typically small in size. Size can increase. When this happens, they can become quite painful.

Enlargement can also result in complications of obstruction in the bowel or the intestine becoming trapped in the abdominal wall. Obstructions (also known as an incarcerated hernia) can lead to severe pain, constipation, vomiting and nausea, as well as the inability to pass gas or have a bowel movement. Building pressure in the affected area of the body can also cause damage to nearby tissues, resulting in more pain and swelling.

A trapped intestine is also known as strangulation whereby blood flow is restricted. This in turn can lead to an infection of intestinal tissue (intestinal tissue may begin to ‘die’ – this is also known as gangrene). When this happens, immediate medical care or surgery is necessary as it can be life-threatening.

Complications related to an umbilical hernia are not common. Problems can arise when the protruding abdominal tissue becomes incarcerated (trapped) and is unable to move (or be moved) back into the abdominal cavity. This results in a complication whereby blood supply is reduced, thus causing pain and tissue damage in the navel area. If blood flow is completely restricted, strangulation occurs. Immediate medical intervention (often emergency surgery) is necessary in this instance.

FAQs

Is it possible to get a hernia after having a C-section to deliver my baby?

A C-section, also known as a caesarean, is a birth delivery option which involves making an incision in a woman’s abdomen and uterus in order to retrieve a baby ready to be born. The development of a hernia as a result is a possible complication, although not all that common.

Studies have noted that women who have a midline incision (a cut that runs vertically / up and down the abdomen) may be more susceptible to developing an incisional hernia. Hernias do not appear to be as common among women who have transverse (horizontal / side to side) incisions. An incisional hernia will likely develop within the first year following the procedure to deliver a baby.

Common symptoms and signs of this following a caesarean delivery include an abdominal bulge in the area where the incision was made (at or close to the site of the scar) and loose skin around the abdomen which may become dimpled or dented. Other signs include pain and discomfort which continues beyond the normal recovery period after the surgery (C-section), constipation, nausea and vomiting.

Hernias that do develop can happen within a few months and up to a year post birth. A woman may notice a hernia more when she is standing upright, involved in some form of physical activity, coughing or trying to lift objects above her head.

A hernia is often noticeable (visible with the naked eye), but sometimes is diagnosed when a doctor is checking for other conditions which also cause similar stomach and digestive issues. These include a possible abscess, uterine rupture, wound infection, haematoma, or abdominal wall endometriosis. Tests may involve an ultrasound or CT scan to make a diagnosis. Imaging tests will pick up any obstructions, such as that of a hernia.

An incisional hernia will generally be treated with surgical repair. Symptoms typically need to be in advanced stages for surgery to be considered – the hernia is large in size and causing severe pain or discomfort, or is incarcerated and restricting blood flow.

Medications aren’t likely to be prescribed as a hernia can’t be shrunk or reduced in size. Surgery is typically the most effective way to treat it. Few repair procedures result in a recurring hernia. This is especially true for women not wishing to have another baby. If a woman wishes to conceive and carry a baby again, and her symptoms aren’t too severe, a doctor may postpone surgery as there is a risk of recurrence with another pregnancy and delivery.

What is the difference between a direct and indirect hernia?

Of the various types of hernias, inguinal hernias are the most commonly diagnosed. These types are often labelled as ‘direct’ or ‘indirect’.

  • Direct hernia: A hernia that develops in adults who have experienced rapid weight gain (due to pregnancy or otherwise) or following injury.
  • Indirect hernia: A hernia that is congenital (a baby is born with this complication).

Both can result in a visible bulge (when standing upright or straining) on either side of a person’s groin (pelvic area). Enlargement of this hernia usually causes pain which alerts a person to seek medical assistance. A baby will respond to pain by crying.

In the case of a direct hernia, muscle tissue which weakens can happen over a period of time. Unnecessary strain or pressure can result in tearing. An indirect hernia does not necessarily occur as a result of weakened or torn tissue. Instead the inguinal ring (an area of abdominal muscle tissue) fails to close-up before birth (while still in the womb).

The ring allows a boy’s testicles to drop into the scrotum before closing (soon after birth). For both male and female babies, if the ring remains open, the risk is higher for the occurrence of a hernia.

Diagnosis and treatment will involve a physical exam and sometimes testing to confirm the development of a hernia and the best course of treatment.

Illustration of a herniated diskWhat is a herniated disk?

A herniated disk is also commonly referred to as a ‘slipped disk” or ‘ruptured disk’ and typically occurs in the lumbar spine (lower back area) or cervical spine (neck area). A disk is essentially a rubbery cushion (with a soft centre) situated between the vertebrae (individual bones) that make up the spine. The soft, jelly-like centre can sometimes become forced through a tear in the disk exterior, which is tougher or harder in consistency.

Signs and symptoms of a herniated disk are sensations of numbness, tingling or weakness experienced in a person’s arm or leg (typically if the herniated disk has occurred in the lower back area), and also a degree of pain (sometimes in the shoulders, buttocks, thighs and calves) due to damage caused to nearby nerves in the body. Pain may be described as ‘shooting’, especially when a person coughs or sneezes. A person may also describe their pain as ‘moving’ as they themselves move into different positions (standing, sitting, lying down).

A herniated disk often occurs along with gradual age-related disk regeneration (natural wear and tear). As we age, our spinal disks naturally lose a little of their water content, making them more flexible and thus more susceptible to tears or ruptures (even with minor bodily strains or twists).

A doctor will diagnose a herniated disk via a physical exam (checking for muscle strength, walking ability, reflexes and a person’s ability to feel sensations as a result of touch, pinpricks and other types of vibration). Tests may be recommended and include CT scans, MRI, X-rays, myelogram (shows the condition of the spinal cord and nerves) or an electromyogram (measuring how electrical impulses are moving along the body’s muscle tissues).

Treatment may involve prescribed medications, physical therapy or surgery. Sometimes alternative methods may be recommended in the way of acupuncture, massage, yoga and chiropractic methods which can all help alleviate symptoms of pain and discomfort.

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