Hernia: A Common Problem for Men with Age

Readers know we try to address problems of aging and our health that are for the most part applicable to both genders, but inevitably there are specific consequences that affect one gender more than another. So, with all apologies to our many female readers this month we address a problem most common in men = inguinal hernia.

Hernias occur when abdominal tissues leave the abdomen and migrate into areas of the anatomy where they do not belong. The kind of tissue is usually fat or intestines. The intestines all belong in the abdomen, but can protrude into other areas. When they do it is called a hernia.

There are a large number of hernias which are generally referred to by the anatomic place that they occur or by what caused them. The more common hernias are inguinal, femoral, incisional, umbilical, epigastric or ventral hernias. Some are caused by congenital openings in the abdominal wall or acquired after age has weakened the abdominal muscles and tissues that keep the integrity of the abdominal wall from being penetrated by tissues in the abdomen.

Figure 1 is the author's attempt to show what happens when a gap in the intestinal wall allows the small intestine to escape the abdomen and protrude below the skin in the groin area and form a bulge. This is usually above the pubic bone and on either side of the groin. The hernias may be labelled reducible, meaning that the bulge or intestines can be gently replaced into the abdomen when lying on one's back. A non-reducible hernia means that the intestine is trapped outside the abdomen. Both ideally should be repaired, but the non-reducible should be repaired to prevent the complication of strangulation.

Incidence and Risk Factors

Inguinal hernias are the most common hernias and present as bulges in the groin area. It is estimated that 27% or more of men will experience an inguinal hernia in their lifetime, and as one ages the chances increase. Of the approximate 1 million hernias surgically repaired each year, 800,000 are inguinal and most are in men (97%.) The risk factors for inguinal hernias are: male gender, age, obesity, heavy lifting, smoking, chronic coughing, straining with urination or defecation, chronic obstructive lung disease, history of lower abdominal surgery, and a family history of hernias.

Symptoms

Symptoms of a hernia are bulge in the groin area when standing, pain in the groin area that may radiate into the testicle, burning sensation and or fullness in the groin and sometimes a swollen scrotum. The bulge often increases in size with coughing or straining. If the pain becomes severe and is associated with nausea and vomiting it can mean that the hernia has become strangulated and requires immediate medical attention. The presence of any of the symptoms requires a visit to your physician for diagnosis.

Diagnosis

The diagnosis of a hernia is based upon a history of the symptoms and a physical exam that allows the physician to feel the hernia with a gloved hand. You will be asked to cough and or strain during the exam. Laboratory tests are generally performed including a urinalysis and complete blood count (CBC.) Other blood tests may be done to rule out kidney or kidney diseases. Radiologic exams can be done to confirm the diagnosis, commonly either an x-ray of the abdomen or a PET scan. The diagnosis is relatively straightforward; often the patient makes it!

Treatment

While the presence of a hernia is common and generally a benign process, hernias can become entrapped (incarcerated) and blood supply cut off (strangulated) and this becomes life-threatening. Thus, to prevent strangulation and or to treat the symptoms, most physicians will advise hernia patients to have a surgical repair.

We have before said that there is no such thing as a minor operation, but as reported above the surgical repair of hernias is performed in over a million people a year with minimal complications. There are three surgical approaches.

Open hernia repair is performed by the surgeon under either local, spinal or general anesthesia with one large incision. This approach is done under direct vision and with the surgeon completing the repair usually on the outside of the abdomen. A mesh patch is usually placed over the defect. There is a higher risk of infection with this technique.

Laparoscopic repair is performed by the surgeon making 3 or 4 small incisions and inserting instruments through the small incision including a camera that is used to "see" the repair. The surgeon looks at the camera screen, but manipulates the instruments with his hands to dissect the tissue and suture in mesh to cover the defect. This is done in the abdomen and requires general anesthesia as well as insufflation of an absorbable gas to extend the abdomen and allow space to see and operate. This technique has less pain and infection than the open approach.

 

Robotic Laparoscopic repair has gained popularity among some surgeons and hospitals that have invested in the robotic surgical apparatus. The major difference between robotic and non-robotic surgery is that the surgeon operates robotic arms from a console distant from the patient, and with a better picture and more versatile instruments for the repair. (See figure 2.) Learning to use the robot requires practice (experience) and surgeons who are experienced with it tend to prefer it. The advantages of robotic over laparoscopic alone is that there is generally less tissue disturbance and patients seem to have less pain postoperatively, often not requiring opiates.

With all surgical approaches, patients will be instructed not to lift more than 10 pounds or participate in strenuous exercise for about 6 - 8 weeks. For those working, return to work is advised between 1 and 2 weeks after surgery. The laparoscopic approaches tend to have faster recovery.

Surgical Complications

All three surgical approaches have complications, but in aggregate (counting all complications) the rate is less than 10%, and the major complications such as heart attack, blood clots, and stroke are each well under 1%. The more common complications are wound infection, urinary retention, urinary tract infection, fluid collection, numbness at the surgical site, and hematoma with each occurrence tending to be under 10% and even less frequent with either of the laparoscopic approaches. Anesthetic complications may include, nausea, vomiting, sore throat and general tiredness for a few days. Late complications can be long term pain in about 10% of patients and recurrence of the hernia in 5-10% of patients. Recurrence is less common with open than laparoscopic.

The Bottom Line

Hernias are common in older men. When symptoms occur, see your physician and if surgery is indicated - get it. The choice of surgical approach will be made by you and your surgeon in consultation.