What Is a Hernia?
Treatment of hernia may incorporate wearing a truss or surgical belt and having surgery.
If a person feels a lump in the abdomen, it could be a hernia. The lump may be soft, small, and painless, or it may feel a little painful and swollen. The lump might even be able to be pushed back in, only to pop out again later.
When the hernia occurs in the groin, it is called an inguinal hernia. Hernias occur when part of an abdominal organ, such as the intestine, bowel, or bladder, or fatty tissue in the abdomen pushes through a weak spot or tear in the abdominal muscles. The contents of the lump or bulge may be intestine or fatty tissue. Sometimes this lump in the abdominal wall is referred to as an outpouching. Hernias usually occur in areas where the abdominal wall is weakened or thinner, either because the location is already weaker or is made weaker due to a previous intervention such as a surgical procedure. If the pressure inside the abdomen increases, as with a cough or lifting a heavy object, the hernia can appear.
Many people have abdominal hernias. As much as 10% of the population develops some type of hernia during life. More than a half million hernia operations are performed in the United States each year.
Many people do not seek treatment. Hernias might never worsen, but if a hernia is not taken care of, it can become larger and cause a medical emergency as tissue becomes trapped in the outpouching, loses its blood supply, and dies. (This is called a strangulated hernia.)
Some people have no discomfort at all. However, some hernias can become painful, when the intra-abdominal pressure is increased (which happens when you cough or lift a heavy object). Sometimes coughing or lifting can cause the hernia in the first place.
Hernia repair is one of the most common types of surgery in the United States. At one time, a hernia operation was a major procedure. Now, inguinal (groin) hernias are often repaired using laparoscopy. This is a technique in which instruments are inserted into the abdomen through several small incisions or cuts. Recovery is often quick without complications.
What Are the Different Types of Hernias?
Hernias of various types can develop in men and women.
- Inguinal or groin hernia: The most common type, inguinal hernias occur in about 2% of men in the United States. These hernias are divided into two different types, direct and indirect. Both occur in the area where the skin crease at the top of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both types of hernias are treated the same way.
- Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during pre-birth development and descends from the abdomen into the scrotum. This pathway normally closes before birth but remains a possible place for a hernia. Sometimes the hernial sac may protrude into the scrotum. An indirect inguinal hernia may occur in people of any age but becomes more common as people age.
- Direct inguinal hernia: The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in a place where the abdominal wall is naturally slightly thinner. It rarely protrudes into the scrotum. Unlike the indirect hernia, which can occur in people of any age, the direct hernia almost always occurs in middle-aged and elderly people because the abdominal walls weaken with age.
Other types of abdominal hernias include the following:
- Femoral hernia: The femoral canal is where the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) to be pushed into the canal. A femoral hernia causes a bulge below the inguinal crease in roughly the middle of the thigh. Rare and usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (cannot be pushed back in the abdominal cavity) and strangulated (tissue becomes trapped and may lose blood supply, a medical emergency).
- Umbilical hernia: These common hernias (accounting for 10%-30% of all hernias) are often seen in babies at birth as a lump at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn't close completely. If small (less than ½ inch), this type of hernia usually closes gradually by itself by 2 years of age. Larger hernias and those that do not close by themselves usually require surgery when the child is 2-4 years of age. Even if the area is closed at birth, umbilical hernias can appear later in life because this anatomic area remains a weaker place in the abdominal wall than other areas. Umbilical hernias can also appear in elderly people and middle-aged women who had children. Obesity is an additional risk factor.
- Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall that must heal on its own. This flaw can create an area of weakness where a hernia may develop. This occurs after a portion of all abdominal surgeries, although some people are more at risk. After open surgical repair, incisional hernias have a high rate of returning months or years after the procedure. However, in expert hands, minimally invasive surgical repair has a low recurrence rate.
- Spigelian hernia: This rare hernia occurs along the lateral (outer) edge of the rectus abdominus muscle, which is several inches to the side of the middle of the abdomen.
- Obturator hernia: This extremely rare abdominal hernia happens mostly in women. This hernia protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen). No bulge appears, but the hernia can act like a bowel obstruction and cause nausea and vomiting. As there is no bulge and the pain can often be diffuse, this is a difficult hernia for the health-care provider to diagnose.
- Epigastric hernia: Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, epigastric hernias are usually composed of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered. This type of hernia occurs mainly in men and in people 20-50 years of age.
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What Causes a Hernia?
Weakness in the abdominal wall may have been present since birth. But this weakness may not cause problems until later in life.
Hernias have other causes:
- Surgery in the area that creates a weakness in the muscles because of incomplete healing
- Incision from surgery itself creating a weak spot (the bigger the incision, the higher the chance to develop an incisional hernia)
- Family history
- Premature birth
- Previous hernia (People who have a hernia on one side may develop a hernia on the other side of the abdomen.)
Some conditions may increase the pressure against the abdominal cavity and cause a muscle to tear and a hernia to form or make a hernia worse:
- Lifting heavy objects (Some strenuous jobs can cause hernias over time.)
- Strenuous physical activity
- Coughing from smoking or other lung conditions
- Sneezing (allergies)
- Straining during a bowel movement (with constipation) or urination
- Fluid in the abdominal cavity (ascites)
What Are Hernia Symptoms and Signs?
For a person with no symptoms, the doctor may discover a lump in the groin or abdomen during a medical exam. Most commonly, people with hernias notice a lump or tenderness and pressure or pain upon bending, coughing, or straining. The lump may be easier to feel when the person stands up. This is a sign of a reducible hernia, meaning it can be pushed back into the abdomen. When a person stands, the lump sticks out noticeably because of the pull of gravity.
Other symptoms of a hernia include the following:
- A heavy feeling in the groin or abdomen
- Pain and swelling in the scrotum (men)
- Pain with a bowel movement or during urination
- Pain when lifting or moving something heavy
- Pain later in the day, especially if you have been standing a lot
In children, a parent may notice a lump when the baby cries or coughs or strains for a bowel movement.
An irreducible hernia cannot be pushed back inside. Any time a hernia cannot be reduced, you should contact your health-care provider. Sometimes these types of hernias can become strangulated. The tissue, usually intestine, can become trapped and the blood supply cut off. If this happens, pain, tenderness, and symptoms of a bowel obstruction (nausea and vomiting) develop. The person may develop a fever. This is a medical emergency that requires immediate surgery to repair the hernia.
Even if a person has no major symptoms, to avoid complications, the hernia should be discussed with a doctor.
When Should Someone Seek Medical Care for a Hernia?
If a person discovers a hernia or has symptoms that suggest he or she might have a hernia, the person should consult a doctor. Hernias, even those that ache, if they are not tender and easy to reduce (push back into the abdomen), are not surgical emergencies, but all hernias have the potential to become serious. Referral to a surgeon should generally be made so that a person can have surgery by choice (called elective surgery) and avoid the risk of emergency surgery should the hernia become irreducible or strangulated.
If you already have a hernia and it suddenly becomes painful, tender, and irreducible (cannot be pushed it back inside), you should go to the emergency department. Strangulation (cut off blood supply) of the intestine within the hernia sac can lead to gangrenous (dead) bowel in as little as six hours.
What Specialists Treat Hernias?
Hernias are usually diagnosed by your primary care provider, including family practitioners, internists, and pediatricians. If surgery or further evaluation is needed, you will be referred to a general surgeon.
Questions to Ask the Doctor When You Have a Hernia
What type of hernia do I have?
What is the plan to take care of it?
Can I just wait and see if my hernia gets worse?
What should I do if suddenly my hernia feels painful and swollen or gets larger?
What type of surgical repair (laparoscopic repair or open repair) can I have?
What Exams and Tests Do Health Care Professionals Use to Diagnose a Hernia?
A doctor will perform a physical exam.
- If a person has an obvious hernia, the doctor will not require any other tests to make the diagnosis (if the person is healthy otherwise).
- If a person has symptoms of a hernia (dull ache in the groin or other body area or pain with lifting or straining but without an obvious lump), the doctor may feel the area while increasing abdominal pressure (having you stand or cough). This action may make the hernia able to be felt. If a person might have an indirect inguinal hernia, the doctor will feel for the potential pathway and look for a hernia by inverting the skin of the scrotum with his or her finger.
- The doctor may order an X-ray, ultrasound, or CT scan.
The doctor will ask questions about the hernia:
- When was it first noticed (unless the doctor discovered the hernia during a physical exam)?
- Does the lump come and go? Can it be pushed back inside?
- Has the lump grown larger or painful?
- What activities give you discomfort from the hernia?
Your doctor may recommend surgery and refer you to a surgeon for the procedure.
What Is the Treatment for a Hernia?
Hernia Home Remedies
In general, all hernias are candidates for surgical repair unless you are unable to have surgery because of other medical conditions. If surgery is not possible or delayed, a person can wear a truss or surgical belt (available at medical supply stores or some drugstores) to hold the bulge of the hernia in. This will only work for certain hernias. A truss is like tightly fitting elastic underwear that keeps the area of the hernia flat. It keeps the hernia from protruding, but a truss is not a cure.
Gently push the hernia back into your abdomen. This may be easiest while lying down. If you cannot push the hernia back into your abdomen, it may have become trapped in the abdominal wall. This is a medical emergency. Seek emergency medical care.
Practice these techniques:
- If you become constipated easily and strain for bowel movements, add fiber to your diet so you do not have to strain.
- Ask your doctor to treat coughs so you are not coughing and causing your hernia to bulge.
- Avoid any activity that could increase abdominal pressure, such as lifting heavy items.
Medical Treatment for Hernias
For small hernias that cause no pain, you and your doctor may decide to watch and wait. Any hernia that seems to grow and cause pain may require surgery.
Treatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated.
- In general, all hernias should be repaired to avoid the possibility of future intestinal strangulation.
- If a person has medical conditions that would make surgery unsafe, the doctor may not repair the hernia but will monitor it closely.
- Rarely, the doctor may advise against surgery because of the special condition of your hernia.
- Some hernias have or develop very large openings in the abdominal wall, and closing the opening is not possible because of its large size.
- These kinds of hernias may be treated without surgery, perhaps using abdominal binders.
- Some doctors feel that the hernias with large openings have a very low risk of strangulation and that surgery is not needed if the person is relatively symptom-free.
- All acutely irreducible hernias need emergency treatment because of the risk of strangulation.
- An attempt to reduce (push back) the hernia will generally be made, often with medicine for pain and muscle relaxation. If unsuccessful, emergency surgery is needed. If successful, treatment depends on the length of the time that the hernia was irreducible.
- If the intestinal contents of the hernia had the blood supply cut off, dead (gangrenous) bowel is possible within hours.
- In cases where the hernia has been strangulated for an extended time, surgery is performed to check whether the intestine has died and to repair the hernia.
- In cases in which the length of time that the hernia was irreducible was short and gangrenous bowel is not suspected, the person may be discharged.
- Because a hernia that becomes trapped and difficult to reduce has a dramatically increased risk of doing so again, if you have had an irreducible hernia, you should have surgery sooner rather than later.
- Occasionally, your doctor may decide that the long-term irreducible hernia is not a surgical emergency. These hernias, having passed the test of time without signs of strangulation, may be repaired by scheduled surgery.
What Medications Treat a Hernia?
There are no medications to treat a hernia directly. The doctor may prescribe medications to reduce the risk of worsening a hernia (such as a stool softener or cough medicine).
How Do Physicians Repair Hernias?
Hernias can be repaired with two types of surgery.
- Traditional: During traditional hernia repair, the abdominal wall is opened during the operation, the protruding tissue is moved back into the abdomen, and the abdominal wall is closed and the weak area reinforced with synthetic mesh. The person may be given general anesthesia and stay overnight in the hospital. The person will have an incision and several stitches.
- Laparoscopy: Many times the surgery can be done through laparoscopy. This type of surgery is less invasive than traditional hernia repair. With laparoscopy, tiny fiber-optic instruments are inserted into the abdomen through small surgical openings. The person may have several small surgical openings. A video camera is inserted into one opening, which guides the surgeon who is manipulating the instruments in the other openings. The person is given general anesthesia, so he or she is asleep during the procedure. However, recovery is much shorter with this less invasive surgery. The person may even go home the same day.
Following the surgery, the doctor will advise the patient on these issues:
- The person may be given pain medications.
- Tenderness, swelling, and some bleeding are possible.
- Depending on the type of surgery to repair the hernia, the person may slowly return to regular activities.
- Lifting or any activity that would put a strain on the surgical area should be avoided.
- When the person can resume driving, sexual activity, and work are items to discuss with the doctor.
Call the doctor if, after surgery, any of these problems develop:
- Excessive tenderness or swelling
- Difficulty urinating
- Excessive bleeding
- Redness in the area of the incision
- Severe or increasing pain
What is a hernia?
What Follow-up Care Is Necessary After Hernia Surgery?
Resume regular activities as the doctor advises and ability permits.
It Possible to Prevent a Hernia?
A person can do little to prevent areas of the abdominal wall from being weak or becoming weak, which can potentially become a site for a hernia.
However, people can reduce the pressure on the abdominal wall to prevent a hernia from bulging through a weak spot (or prevent a hernia from becoming worse) by following these lifestyle practices:
- Lose weight if overweight.
- Eat high-fiber foods with plenty of whole grains and fruits and vegetables to prevent constipation and straining with bowel movements. Drink plenty of water. Ask a doctor about using a stool softener.
- Learn how to lift heavy objects or simply do not lift them at all.
- Stop smoking. Smoking can cause coughing, which can make a hernia worse.
- Control allergies to avoid sneezing in excess.
- Exercise to strengthen the abdominal muscles.
What Are the Risks and Complications Associated With Hernias?
- Risk of strangulation: In considering when to have a reducible hernia operated on, it is important to know the risk of strangulation.
- The risk varies with the location and size of the hernia and the length of time it has been present.
- Inguinal hernias, the most common type of hernia, have been the most intensively studied. For direct and indirect inguinal hernias, the risk of strangulation is 2.8% for the first three months, increasing to 4.5% over two years.
- Femoral hernias, although rare, are especially prone to strangulation.
- In general, hernias with large sac contents and a relatively small opening are more likely to become strangulated.
- Hernias are more likely to become irreducible in the first few weeks than over months or years, but even hernias that have been present for many years may become irreducible.
- Complications of surgery: Some people who undergo surgical hernia repair will have complications.
- These are short-term and usually treatable.
- The hernia that comes back after the initial surgical repair has a greatly increased risk of returning if operated on again.
- Complications include the following:
- Recurrence (most common)
- Inability to urinate
- Wound infection
- Fluid build-up in the scrotum (called hydrocele formation)
- Scrotal hematoma (bruise)
- Testicular damage on the affected side (rare)
Fitzgibbons, Jr., R.J., and R.A. Forse. "Clinical Practice. Groin Hernias in Adults." N Engl J Med 372.8 Feb. 19, 2015: 756-763.