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Stephanie Prendergast. This week, our guest writer Dr. Shirin Towfigh will discuss Inguinal Hernia’s and how they may be related to pelvic pain. Shirin Towfigh. I am a Board Certified General Surgeon who specializes exclusively in all things hernia, with specialty in hernias among women and complications related to hernia repair.

Inguinal hernias are a common and under diagnosed cause of pelvic pain. Here, I’ll share my secrets, tips, and tricks on how to accurately diagnose  inguinal hernias.

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Early and accurate diagnosis can lead to reduction in cost and suffering! SIGNS & SYMPTOMS OF AN INGUINAL HERNIAWhat is an inguinal hernia? A hernia is a hole, usually through a muscle or fascia defect. Most hernias occur through natural weaknesses or natural holes. This is true of the inguinal region, where the inguinal canal is a natural tunnel through multiple muscle and fascial layers. In men, this allows for the spermatic cord contents to travel through. In women, it is much smaller and only fits the thin round ligament.

Any hernias in this region are called indirect inguinal hernias. They are the most common among both men and women.

Other hernias in the groin region include direct inguinal hernias (weakness through the transversus abdominis muscle), femoral hernia (medial to the femoral vessels, through the femoral space), and obturator hernia (through the obturator canal). What is an occult inguinal hernia and how can it cause pelvic pain? As the topic of inguinal hernias evolves, my practice has been at the forefront of studying and promoting the entity of occult inguinal hernias. These are hernias that do not present with a palpable bulge, and yet they are quite symptomatic. We see these mostly among women.

In my practice, women comprise of 8. Many believe that a small hernia that can barely even be palpable cannot possibly cause any pain.

Au contraire mon fr. The smaller the hernia, the more the associated pain.

Imaging can help diagnose the majority of these hernias if there is a clinical suspicion. Hernia repair is a cure. In my series, 8. 7% of those with occult hernias are pain- free within weeks of their hernia repair, and 9. How do you get inguinal hernias? Inguinal hernias are common and can occur in a person of any age, with any lifestyle. In fact, we feel that most of the hernias that we treat have an underlying genetic component to them. If you have a relative with a hernia then you are likely slightly more likely to have a hernia.

In my practice, we have noted that specifically having a female relative with a hernia confers an even stronger genetic link to hernia formation. In some cases, patients may report a physical activity, such as lifting or moving a heavy object, associated with their hernia. They may have felt a tear or burning sensation in the groin at the time of this activity. Did that activity actually cause the hernia? We don’t know. Most likely, the patient always had a hernia, though occult or asymptomatic, and the strenuous activity resulted in further opening of the hole, or more content pushed through the hole.

Most inguinal hernias are asymptomatic, that is, there is no pain or discomfort associated with them. There may be a bulge in the area of the groin. Also, most of the time, the bulge is reducible. What are risk factors for hernia formation? Activities that are thought to increase hernia formation include those that increase your abdominal pressure.

These include straining to have a bowel movement, straining to urinate, long or multiple labors, repetitive heavy lifting of objects, chronic cough. This is why treating of constipation, cystocele, rectocele, asthma, bronchitis are important prior to any hernia operation. Obesity has not been validated as a risk for hernia formation, but it has been shown to increase abdominal pressure. It is possible that there is an overall underdiagnosis of hernias among the obese, as they are asymptomatic and a bulge is poorly discernable on examination. Nicotine use has not been associated with development of a primary hernia, however, it confers a higher risk of an incisional hernia or hernia recurrence after hernia surgery.

This is because nicotine directly affects the quality of collagen deposition during the healing process. In my practice, the patient must be nicotine- free (no smoking, gum, or patches) for 6 weeks prior to their hernia repair and is encouraged to be nicotine- free afterward. What activities should be restricted with a hernia? Fortunately, most activities, including almost all exercises, have not been shown to increase abdominal pressure. These include sit- ups, bench press, weight lifting, dead lifts, and other exercises which one may think would “hurt” a hernia. Only two exercises—jumping and leg squats—have been associated with increase in abdominal pressure, and thus may increase the risk of hernia formation.

Patients who exercise regularly are less likely to have hernias. This is especially true among women. I regularly encourage patients to exercise both before and after their hernia operation. Yoga and Pilates are especially great for abdominal core and pelvic floor strengthening. Cycling and most gym exercises are also helpful.

Golfing is safe. I tend to discourage crossfit- type exercises, as they tend to involve a lot of jumping, leg squats, and rapid movements with weights. Anecdotally, I have seen a disproportionate number of patients with groin pain after P9. X and Insanity –type workouts.

Exercise is protective of hernias and in many cases can strengthen the pelvic floor and help reduce symptoms of hernias. Most of us hernia specialists do not recommend restriction of activity once a hernia is diagnosed. What are key questions to ask to diagnose an inguinal hernia?

A detailed history is indispensible. By the time I finish my history taking, I can reliably predict if my patient has a hernia as the cause of his/her pelvic pain. Most men will first complain of a bulge in their groin.

Of course, that will most likely be from a groin hernia. There are very few other causes of bulge in that area, especially if it is a reducible mass.

A physical examination will help confirm this. Women with inguinal hernias more commonly present with groin pain than with a bulge. These are sometimes referred to as “occult” or “hidden” hernias. The pain is felt at or above the level of the groin. Half of the patients will have pain that may radiate up to the hip area, around to the lower back, into the testicle or vagina, to the scrotum or labia, down the front of the leg, and/or to the upper inner thigh region.

Hernia- related pain never extends below the knee and is never at the buttock or down the back of the leg. Symptoms can range from a dull discomfort to a disabling searing pain. The size of the hernia does not correlate with the severity of the pain. In fact, the reverse may be true: the smaller the hernia, the more pain associated with it.

This may be due to increased pressure within the smaller defect. Most patients with inguinal hernias have activity- related symptoms. Any activity that places extra pressure onto the inguinal canal and pelvic floor can theoretically cause pain at the hernia. This includes prolonged standing, prolonged sitting, bending, getting in and out of bed, getting in and out of the car, coughing, laughing. Sexual intercourse and/or orgasm may be painful. I see this more often among my patients with pain. It seems that the nausea and bloating are the patient’s manifestation of groin or pelvic pain.

Contrary to fears, most hernias contain fat only. It is uncommon for inguinal hernias to contain intestine, unless they are large. Even most scrotal hernias contain fat as their primary content.

What are tips to performing an accurate exam for inguinal hernia? The patient should be examined in standing position.

This allows for gravity to accentuate any small hernia. I approach the inguinal hernia exam in a very anatomic way. First, I identify the anterior superior iliac spine (ASIS) and the pubic tubercle.