Inguinal Hernia

An inguinal hernia happens when tissue from inside your belly pushes through a weak spot in your lower abdominal wall into your groin area, creating a noticeable bulge that may cause discomfort or pain.

Table of contents

• What is an inguinal hernia?
• Types of inguinal hernias
• Who is affected?
• Signs and symptoms
• What causes inguinal hernias?
• Risk factors
• How is it diagnosed?
• Treatment options
• Possible complications
• Prevention tips
• Recovery after surgery

What is an inguinal hernia?

An inguinal hernia occurs when abdominal tissue, such as belly fat or a loop of intestines, bulges through an opening in your lower abdominal wall.^[1] This is the wall that separates your abdomen from your groin. The hernia appears in a passageway called the inguinal canal (a channel that runs down either side of your pelvis into your sex organs), which is why these hernias are also called groin hernias.^[2]

The resulting bulge can be painful, especially when coughing, bending over, or lifting a heavy object. However, many hernias do not cause pain.^[1] An inguinal hernia isn’t necessarily dangerous, but it doesn’t get better on its own and can lead to life-threatening complications.^[1]

Inguinal hernias are the most common type of hernia. Up to 75% of all hernias are inguinal hernias.^[2] In the United States, 1.6 million groin hernias are diagnosed annually, and 700,000 are repaired surgically.^[4]

Types of inguinal hernias

There are two main types of inguinal hernias, based on how they develop:^[2]

Direct inguinal hernia: A direct inguinal hernia penetrates directly through the wall of your inguinal canal. This type of hernia occurs in adults over time, from a combination of weakening abdominal muscles and chronic pressure on the muscle wall.^[2]

Indirect inguinal hernia: An indirect inguinal hernia enters your inguinal canal through the top. This usually occurs because of a birth defect. In some fetuses, the opening to their canal doesn’t close all the way during development in the uterus.^[2]

Who is affected?

For reasons of anatomy, inguinal hernias usually affect males by a ratio of 10:1.^[2] The lifetime prevalence of groin hernias is 27% in men and 3% in women.^[4] Around 25% of males will have an inguinal hernia during their lifetime, compared to 2% of females.^[2]

In males, the testicle begins above the lower abdominal wall and descends through the inguinal canal into the scrotum. The place where the testicle passes through is more susceptible to a hernia because it’s a preexisting opening, which is more easily reopened. Sometimes, it doesn’t close all the way during development in the first place.^[2]

In females, the inguinal canal is narrower and begins under the abdominal wall. It carries the round ligament that supports the uterus, and this tough ligament helps to reinforce the muscle wall.^[2] However, women with a connective tissue disease (a condition affecting the tissues that support organs and other structures) may be more susceptible to hernias.^[2]

Direct (acquired) inguinal hernias are more common in middle-aged and older men. Indirect inguinal hernias affect up to 4.5% of children, including 2% of baby boys and 1% of baby girls. Premature babies are up to 30% more likely to get one.^[2] Inguinal hernias occur in 7 percent of boys and almost 1 percent of girls. In children born prematurely, up to 25 percent will have inguinal hernias.^[7]

Signs and symptoms

The main symptom of an inguinal hernia is a bulge in the groin or scrotum. It often feels like a round lump.^[6] Common inguinal hernia symptoms include:^[1]

• A bulge in the area on either side of the pubic bone, which becomes more obvious when upright, especially when coughing or straining
• A burning or aching sensation at the bulge
• Pain, discomfort or pressure in the groin, especially when bending over, coughing or lifting
• Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum

The bulge may form over a period of weeks or months, or it may appear suddenly after an activity that strains the groin.^[6] The hernia may also cause swelling and a feeling of heaviness, tugging, or burning in the area of the hernia. These symptoms may get better when you lie down.^[6] Patients may report having symptoms only at the end of the day or after prolonged activity and that the bulge disappears when they are lying flat.^[4]

Up to one-third of patients have no symptoms.^[4]

Symptoms in children

Inguinal hernias in newborns and children result from a weakness in the abdominal wall that’s present at birth. Sometimes the hernia will be seen only when a baby is crying, coughing or straining during a bowel movement. The baby might be irritable and have less appetite than usual.^[1] In an older child, a hernia is likely to be more noticeable when the child coughs, strains during a bowel movement or stands for a long period.^[1]

Signs of trouble

You should seek immediate medical care if:^[6]

• Your child has an inguinal hernia that can’t be pushed back into the belly with gentle pressure
• You or your child has an inguinal hernia that suddenly becomes painful or can’t be pushed back in
• You have new or worse belly pain
• You are vomiting
• You cannot pass stools or gas
• The area over the hernia turns red or becomes tender

If a loop of the intestine is trapped very tightly in the hernia, the blood supply to that part of the intestine can be cut off (strangulated hernia, which means tissue is trapped and its blood supply is blocked), causing tissue to die. A strangulated hernia is a medical emergency that requires immediate surgery.^[6] Signs of a strangulated inguinal hernia include nausea and vomiting, and intense abdominal or groin pain that keeps getting worse, and the groin mass turns red or purple.^[13]

What causes inguinal hernias?

Most inguinal hernias happen because an opening in the muscle wall does not close as it should before birth, leaving a weak area in the belly muscle.^[6] Pressure on that area can cause tissue to push through the belly and bulge out. Belly muscles that are torn or weakened can also cause the condition.^[6]

In male fetuses, the testicles develop in the back of the abdomen just below the kidney. As the fetus develops, the testicle descends from this location into the scrotum, pulling a sac-like extension of the lining of the abdomen with it. If the abdominal wall does not fully close, a hernia will result.^[7]

Although girls do not have testicles, they do have an inguinal canal, so they can develop hernias as well. It is often the fallopian tube and ovary that fall into the hernia sac.^[7]

In adults, causes of direct inguinal hernias include:^[8]

• A weak spot in your abdominal wall
• Pressure inside your abdomen
• Straining when going to the bathroom
• Doing strenuous activities and lifting heavy things
• Pregnancy
• Coughing and sneezing a lot

Risk factors

Risk factors for inguinal hernias include a family history of the condition, male sex, older age, low body mass index, systemic connective tissue disease, and history of radical prostatectomy or radiation therapy.^[4] In women, inguinal hernias have also been associated with taller height, chronic cough, umbilical hernia, and rural residence.^[4]

Other factors that increase your risk:^[8]

• Pregnancy: Your abdominal muscles get weaker and there is more pressure in the abdomen during pregnancy
• Family history: If someone in your close family has had a hernia, you are more likely to have one too
• Chronic cough: This creates pressure in the abdomen
• Chronic constipation: Straining while going to the bathroom increases pressure in the abdomen
• Frequent strenuous activities: A lot of walking, standing, lifting heavy objects, or intense exercise creates pressure in the abdomen
• Low birth weight and premature birth: Babies born early or with a low birth weight are more likely to have inguinal hernias
• Past inguinal hernia: If you’ve already had an inguinal hernia, your risk of having another one is higher

Some factors place children at higher risk for inguinal hernias, such as premature birth, undescended testicles, family history of hernias, cystic fibrosis, developmental hip dysplasia, and urethral abnormalities.^[7]

No association has been found between smoking or alcohol use and hernias.^[4] However, people who smoke get hernias at higher rates than nonsmokers. This occurs because long-term smokers often experience a chronic cough, and smoking also interferes with collagen formation in the body, decreasing tissue strength, especially in the abdominal wall. People who smoke are four times more likely to have recurring hernias.^[17]

How is it diagnosed?

A physical exam is usually all that’s needed to diagnose an inguinal hernia. A doctor can usually tell if you have an inguinal hernia based on your symptoms and a physical exam. The bulge of a hernia is usually easy to feel.^[6] A healthcare professional will check for a bulge in the groin area. Because standing and coughing can make a hernia more prominent, you’ll likely be asked to stand and cough or strain.^[9]

Although groin hernias are easily diagnosed on physical examination in men, ultrasonography (an imaging test that uses sound waves to create pictures of the inside of the body) is often needed in women.^[4] Ultrasonography is also helpful when a recurrent hernia, surgical complication after repair, or other cause of groin pain (such as groin mass or hydrocele) is suspected.^[4]

If the inguinal hernia isn’t readily seen, a healthcare professional might order an imaging test, such as an abdominal ultrasound, CT scan (a test that uses X-rays and a computer to create detailed images of the inside of the body) or MRI (a test that uses magnets and radio waves to create detailed images of the body).^[9] Magnetic resonance imaging has higher sensitivity and specificity than ultrasonography and is useful for diagnosing occult hernias (hernias that are not visible or easily felt) if clinical suspicion is high despite negative ultrasound findings.^[4]

Treatment options

Only surgery can repair an inguinal hernia. But if your hernia does not bother you and it causes no other problems, you may not need treatment right now.^[6] If the hernia is small and isn’t causing problems, a healthcare professional might recommend watchful waiting. Sometimes, wearing a supportive truss may help relieve symptoms. A health professional can help make sure the truss fits properly and is being used appropriately.^[9]

Watchful waiting is a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias. Watchful waiting is not recommended in patients with symptomatic hernias or in nonpregnant women.^[4] Watchful waiting may be a safe option for adults who are not uncomfortable. Most men with an inguinal hernia need surgery due to increased pain with exercise, chronic constipation or urinary symptoms. 23% crossed over to surgery after 2 years and 50% after 5 years.^[11]

Hernias in babies and young children can be more dangerous and generally need to be repaired with surgery right away.^[6] In children, a healthcare professional might try applying manual pressure to reduce the bulge before considering surgery.^[9]

A healthcare professional is likely to recommend surgery to fix an inguinal hernia that’s painful or getting bigger. Inguinal hernia repair is a common surgical procedure.^[1] Hernias that are painful or getting bigger usually need surgery to relieve discomfort and prevent serious complications.^[9]

Types of surgery

There are two general types of hernia operations:^[9]

Open hernia repair: In this procedure, the surgeon makes a cut in the groin and pushes the protruding tissue back into the abdomen. The surgeon then sews the weakened area, often reinforcing it with a synthetic mesh. This is called a hernioplasty (surgical repair of a hernia). The opening is then closed with stitches, staples or surgical glue. Open hernia repair might be done with local anesthesia and sedation or general anesthesia.^[9]

Minimally invasive hernia repair: In this procedure requiring general anesthesia, the surgeon operates through several small cuts in the belly. The surgeon may use laparoscopic or robotic instruments to repair the hernia. Gas is used to inflate the abdomen to allow the surgeon to see better.^[9] The hernia is repaired by mesh or sutures inserted through instruments placed into small incisions in the abdomen.^[11]

Laparoscopic hernia repair is associated with shorter recovery, earlier resumption of activities of daily living, and less pain compared with open repair.^[4] Laparoscopic repair is associated with shorter recovery time, earlier resumption of activities of daily living, less pain, and lower recurrence rates than open repair.^[4]

After the surgery, you’ll be encouraged to move about as soon as possible, but it might be several weeks before you’re able to resume regular activities.^[9]

Possible complications

Hernias aren’t always serious, but serious complications can develop. Hernias do tend to worsen over time. As the opening becomes weaker and wider, more tissue can push through it. The more tissue pushes through, the more likely it is to become trapped.^[2] This can be painful, and in extreme cases, can be dangerous. Once trapped, a piece of your intestine could become pinched and blocked, or the tissue could become cut off from your blood supply.^[2]

Over time, hernias tend to increase in size as the abdominal muscle wall becomes weaker and more tissue bulges through. If you can’t push your hernia back into your belly, it is incarcerated (trapped). A hernia gets incarcerated when tissue moves into the sac of the hernia and fills it up. This is not necessarily an emergency. But if a loop of the intestine is trapped very tightly in the hernia, the blood supply to that part of the intestine can be cut off (strangulated), causing tissue to die.^[6] In a man, if tissue is trapped, the testicle and its blood vessels can also be damaged.^[6]

Complications of surgery

As with any operation, complications can happen during or after an inguinal hernia repair. Your doctor will explain the risks to you before the procedure. Complications are uncommon but include:^[15]

• Your wound becoming infected
• A lump or swelling that develops where the hernia was that can last a few weeks or months
• A large painful bruise in the top of your inner thigh (groin) or genitals that can last a few months
• Pain or numbness in your groin that may last longer than 3 months
• The hernia coming back
• Damage to the area around the hernia such as the bowel, blood vessels or bladder
• A blood clot, DVT (deep vein thrombosis) or pulmonary embolism

Possible risks also include return of the hernia; infection; injury to the bladder, blood vessels, intestines or nerves, difficulty passing urine, continued pain, and swelling of the testes or groin area.^[11]

Prevention tips

Most inguinal hernias cannot be prevented, especially in infants and children. Adults may be able to prevent a few hernias or prevent a hernia from recurring by using some common self-care steps:^[6]

• Avoid becoming overweight. Being overweight creates greater abdominal pressure and increases your risk for developing an inguinal hernia. Stay at a healthy weight through diet and exercise
• Avoid rapid weight loss (such as in crash dieting). Rapid weight-loss programs may be lacking in protein and vitamins that are needed for muscle strength, causing weakness in the muscles of the abdomen
• Stop smoking. Chronic coughing from smoking increases the risk for developing a hernia
• Avoid constipation and straining. Constipation and straining during bowel movements and urination causes increased pressure inside the abdomen
• Lift carefully. Use good body mechanics when you lift heavy objects. Lift with your legs, not with your back

Increasing core strength has many benefits in helping to prevent a hernia. Regular core-strengthening exercises will strengthen the muscles surrounding your abdomen and groin and help them stay strong and elastic.^[19] Using proper lifting techniques can minimize risk and decrease fatigue. Always bend from your knees, not your waist. Lift using the muscles of your legs with a straight back and proper support over your ankles. If you feel pain, stop.^[19]

Controlling diabetes is also important in hernia prevention. Studies suggest diabetes increases the risk of complications following the repair of a ventral or umbilical hernia surgery.^[19]

Recovery after surgery

You can usually go home the same day as the operation.^[15] It usually takes up to 4 to 6 weeks to recover from an inguinal hernia repair, but it can take longer.^[15]

After the operation it’s normal to have:^[15]

• Some bleeding from the wound for a couple of days
• Pain around the wound for a few days
• Bruising or swelling around the wound or genitals for a couple of weeks
• Bloating or shoulder pain for a couple of days if you had keyhole surgery (this is caused by the air that was pumped into your tummy)
• Numbness below the wound – usually the feeling slowly comes back, but sometimes a small area of numbness remains

There are some things you can do to help you recover:^[15]

• Take painkillers such as paracetamol or ibuprofen to ease any pain
• Keep moving and do gentle exercise such as walking – slowly increase your activity as you recover
• Stay off work for usually at least 1 to 2 weeks (or up to 6 weeks if your job involves heavy lifting) – you can speak to your surgeon about how long you need off
• Keep the wound covered, clean and dry while it heals
• Place your hand over the wound if you cough or sneeze to help ease any pain

Things to avoid:^[15]

• Do not do any heavy lifting or strenuous activity for at least 4 to 6 weeks
• Do not have a bath or swim until your wound has healed (this usually takes around 2 weeks) – you can usually shower from a few days after your surgery if you have a waterproof dressing
• Do not drive after surgery – check with your healthcare team and insurance provider when you are allowed to drive again

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments.^[16] Use proper lifting techniques, and avoid heavy lifting if you can. To lift things more safely, bend your knees and let your arms and legs do the work. Keep your back straight, and do not bend over at the waist. Keep the load as close to your body as you can. Move your feet instead of turning or twisting your body.^[16]