Inguinal hernia
Inguinal hernia | |
---|---|
Diagnostic method | Based on symptoms, medical imaging[1] |
Treatment | Conservative, surgery[1] |
Frequency | 27% (males), 3% (females)[1] |
Deaths | 59,800 (2015)[4] |
An inguinal hernia or groin hernia is a
Risk factors for the development of a hernia include:
Groin hernias that do not cause symptoms in males do not need to be repaired. Repair, however, is generally recommended in females due to the higher rate of
In 2015 inguinal, femoral and abdominal hernias affected about 18.5 million people.[10] About 27% of males and 3% of females develop a groin hernia at some time in their life.[1] Groin hernias occur most often before the age of one and after the age of fifty.[2] Globally, inguinal, femoral and abdominal hernias resulted in 60,000 deaths in 2015 and 55,000 in 1990.[4][11]
Signs and symptoms
Hernias usually present as bulges in the groin area that can become more prominent when coughing, straining, or standing up. The bulge commonly disappears on lying down. Mild discomfort can develop over time. The inability to "reduce", or place the bulge back into the abdomen usually means the hernia is 'incarcerated' which requires emergency surgery.
As the hernia progresses, contents of the abdominal cavity, such as the intestines, can descend into the hernia and run the risk of being pinched within the hernia, causing an
Pathophysiology
In males, indirect hernias follow the same route as the descending
Inguinal hernias mostly contain
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Illustration of an inguinal hernia.
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Different types of inguinal hernias.
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Inguinal fossae
Diagnosis
There are two types of inguinal
In the case of the female, the opening of the
Type | Description | Relationship to inferior epigastric vessels | Covered by internal spermatic fascia? | Usual onset |
---|---|---|---|---|
Direct inguinal hernia | Enters through a weak point in the fascia of the abdominal wall ( Hesselbach triangle ) |
Medial | No | Adult |
Indirect inguinal hernia | Protrudes through the inguinal ring and is ultimately the result of the processus vaginalis failing to close after the testicle's passage during the embryonic stage |
Lateral | Yes | Congenital / Adult |
Inguinal hernias, in turn, belong to groin hernias, which also includes femoral hernias. A femoral hernia is not via the inguinal canal, but via the femoral canal, which normally allows passage of the common femoral artery and vein from the pelvis to the leg.
In Amyand's hernia, the content of the hernial sac is the appendix.
In
Clinical classification of hernia is also important according to which hernia is classified into
- Reducible hernia: is one which can be pushed back into the abdomen by putting manual pressure to it.
- Irreducible/Incarcerated hernia: is one which cannot be pushed back into the abdomen by applying manual pressure.
Irreducible hernias are further classified into
- Obstructed hernia: is one in which the lumen of the herniated part of intestine is obstructed.
- Strangulated hernia: is one in which the blood supply of the hernia contents is cut off, thus, leading to ischemia. The lumen of the intestine may be patent or not.
Direct inguinal hernia
The direct inguinal hernia enters through a weak point in the fascia of the abdominal wall, and its sac is noted to be medial to the inferior epigastric vessels. Direct inguinal hernias may occur in males or females, but males are ten times more likely to get a direct inguinal hernia.[15]
A direct inguinal hernia protrudes through a weakened area in the
When a patient develops a simultaneous direct and indirect hernia on the same side, it is called a pantaloon hernia or saddlebag hernia because it resembles a pair of pants with the epigastric vessels in the crotch, and the defects can be repaired separately or together. Another term for pantaloon hernia is Romberg's hernia.
Since the abdominal walls weaken with age, direct hernias tend to occur in the middle-aged and elderly. This is in contrast to indirect hernias which can occur at any age including the young, since their etiology includes a congenital component where the inguinal canal is left more patent (compared to individuals less susceptible to indirect hernias).[16][17] Additional risk factors include chronic constipation, being overweight or obese, chronic cough, family history and prior episodes of direct inguinal hernias.[15]
Indirect inguinal hernia
An indirect inguinal hernia results from the failure of embryonic closure of the
In the male fetus, the
The deep inguinal ring, which is the beginning of the inguinal canal, remains as an opening in the fascia transversalis, which forms the fascial inner wall of the spermatic cord. When the opening is larger than necessary for passage of the spermatic cord, the stage is set for an indirect inguinal hernia. The protrusion of peritoneum through the
In an indirect inguinal hernia, the protrusion passes through the deep inguinal ring and is located lateral to the inferior epigastric artery. Hence, the conjoint tendon is not weakened.
There are three main types
- Bubonocele: in this case the hernia is limited in inguinal canal.
- Funicular: here the processus vaginalis is closed at its lower end just above the epididymis. The content of the hernial sac can be felt separately from the testis which lies below the hernia.
- Complete (or scrotal): here the processus vaginalis is patent throughout. The hernial sac is continuous with the tunica vaginalis of the testis. The hernia descends down to the bottom of the scrotum and it is difficult to differentiate the testis from hernia.
In the female, groin hernias are only 4% as common as in males. Indirect inguinal hernia is still the most common groin hernia for females. If a woman has an indirect inguinal hernia, her internal inguinal ring is patent, which is abnormal for females. The protrusion of peritoneum is not called "processus vaginalis" in women, as this structure is related to the migration of the testicle to the scrotum. It is simply a hernia sac. The eventual destination of the hernia contents for a woman is the
Medical imaging
A physician may diagnose an inguinal hernia, as well as the type, from
When assessed by
On axial
Differential diagnosis
Differential diagnosis of the symptoms of inguinal hernia mainly includes the following potential conditions:[23]
- Femoral hernia
- Epididymitis
- Testicular torsion
- Lipomas
- Inguinal adenopathy (Lymph nodeSwelling)
- Groin abscess
- Saphenous vein dilation, called Saphena varix
- Vascular aneurysm or pseudoaneurysm
- Hydrocele
- Varicocele
- Undescended testes)
Management
Conservative
There is currently no medical recommendation about how to manage an inguinal hernia condition in adults, due to the fact that, until recently,
Surgical
Surgical correction of inguinal hernias is called a
Constipation after hernia repair results in strain to evacuate the bowel causing pain, and fear that the sutures may rupture. Opioid analgesia makes constipation worse. Promoting an easy bowel motion is important post-operatively.
Surgical correction is always recommended for inguinal hernias in children.[30]
Emergency surgery for incarceration and strangulation carry much higher risk than planned, "elective" procedures. However, the risk of incarceration is low, evaluated at 0.2% per year.
Epidemiology
A direct inguinal hernia is less common (~25–30% of inguinal hernias) and usually occurs in men over 40 years of age.
Men have an 8 times higher incidence of inguinal hernia than women.[35]
See also
- Birkett hernia
References
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- ^ ISBN 978-1-4511-8850-9.
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- ^ a b "Direct Inguinal Hernia". University of Connecticut. Archived from the original on April 27, 2012. Retrieved May 6, 2012.
- ^ James Harmon M.D. Lecture 13. Human Gross Anatomy. University of Minnesota. September 4, 2008.
- ^ "Hernia: Treatment, Types, Symptoms (Pain) & Surgery".
- ^ "UOTW #16 - Ultrasound of the Week". Ultrasound of the Week. 2 September 2014. Retrieved 27 May 2017.
- ^ "UOTW #40 - Ultrasound of the Week". Ultrasound of the Week. 9 March 2015.
- PMID 23939566.
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- ^ PMID 21415178.
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- ^ Inguinal Hernia Archived 2007-09-27 at the Wayback Machine
- ^ "Inguinal Hernia". UCSF Pediatric Surgery. Archived from the original on 2020-10-26. Retrieved 2018-11-15.
- ^ PMID 16418463.
- ^ Simons MP, Aufenacker TJ, Berrevoet F, Bingener J, Bisgaard T, Bittner R, et al. (2017). World guidelines for groin hernia management (PDF).
- ^ Brooks D. "Overview of treatment for inguinal and femoral hernia in adults". www.uptodate.com. Retrieved 2017-11-19.
- PMID 21299930.
- ^ "Inguinal hernia". Mayo Clinic. 2017-08-11.
External links
- Indirect Inguinal Hernia - University of Connecticut Health Center
- Media related to Inguinal hernia at Wikimedia Commons