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An indirect hernia is a protrusion of an organ through the "wall" located near the groin or abdomen. The bulge is painless but when strangulated, can cause symptoms.
What is an indirect hernia?
Hernias occur when an organ protrudes through part of the abdominal / pelvic wall that normally contains it. Indirect hernias are located near the groin and occur when abdominal contents, such as the intestines, pass through an opening into a channel called the inguinal canal.
Symptoms include a bulge in the groin that may become more prominent when coughing or standing. It is usually located near the scrotum in men but may be more difficult to pinpoint in women. The bulge itself is usually painless; however, there may also be a heaviness or discomfort in the groin, as well as abdominal pain, fever, nausea, and vomiting if the hernia becomes strangulated.
Treatment may first involve clinical observation for a period of time followed by surgery in order to fully resolve the hernia.
A physician is needed to determine the course of treatment. A hernia reduction will be attempted, meaning that the bulging loop of intestine will be carefully pushed back, if possible. Then, your doctor will recommend surgery in some cases. Often, watchful waiting is the preferred route in minimally symptomatic hernias.
Symptoms of an indirect hernia
There are a few main symptoms of indirect hernias as well as other symptoms that are possible.
The main symptoms experienced in indirect hernias include:
- A bulge in the groin: The bulge is usually located above the groin crease separating the abdomen from the thigh. It may be located near the scrotum in males. It is usually harder to see or feel in females. The bulge may become more prominent with coughing, bearing down, or standing up. The bulge is usually painless but may become painful if parts of the bowel become trapped in the hernia and start to lose their blood supply.
- Heaviness or discomfort in the groin: Similar to the appearance of the bulge, the feeling of heaviness or discomfort may get worse with coughing, bearing down, or prolonged standing or straining, and may improve with rest or lying down.The discomfort may be worse at the end of the day.
This following be experienced in less common cases when parts of the bowel that have passed through the hernia become trapped or strangulated, causing them to lose their blood supply. This is considered a medical emergency.
- Significant abdominal or groin pain and bloating: If this occurs, pushing on the bulge may worsen the pain. The skin overlying the hernia may appear red.
- Fever, nausea, and vomiting: These are also concerning symptoms that need to be treated urgently.
Causes of an indirect hernia
There are two inguinal canals — one on each side of the groin. In men, the inguinal canals lead from the inside of the abdomen to the inside of the scrotum where the testes are located. In women, the inguinal canals lead to a region near the opening of the vagina in females.
Specific factors below can contribute to the development of indirect hernias due to their weakening effects on the wall of the abdomen, making it easier for abdominal contents to go through the opening into the inguinal canal, such as:
- Abnormal development: In normal development, the opening to the inguinal canal near the inside of the abdomen closes off, preventing abdominal contents from entering the inguinal canal. But in some people, this internal opening to the inguinal canal fails to close, allowing abdominal structures, such as intestines, to enter the inguinal canal.
- Chronic coughing or constipation: This can cause an indirect hernia due to increasing the pressure within the abdomen.
- Injury to the abdomen
Who is most likely to be affected
People who have the following characteristics are more likely to experience an indirect hernia, including:
- Those with a family history
Treatment options and prevention for indirect hernia
Indirect hernias are definitively treated with surgical repair. However, if you have an indirect hernia that is not causing substantial symptoms, you can choose to clinically monitor the hernia and wait to have surgery when symptoms develop.
Clinical observation — watchful waiting or monitoring — is an option if you have an indirect hernia that is not causing symptoms or causing only minimal symptoms. Approximately 25% of people with asymptomatic indirect hernias who choose clinical observation experience a change in symptoms that require surgery in four to five years.
Surgery is the definitive way to treat an indirect hernia. People with indirect hernias can choose to have elective surgery to have it repaired, even if it is not causing the symptoms, in order to prevent future complications. People with indirect hernias that become strangulated need to undergo emergency surgery within four to six hours to prevent permanent damage to the bowel (bowel infarction) that is trapped within the hernia. There are a number of surgical options for treating indirect hernias:
- Laparoscopic surgery: This involves small incisions in the abdomen or groin area. A small camera, as well as surgical instruments, are passed through the incisions to repair the hernia. The surgeon may place a piece of mesh over the opening of the hernia to prevent it from reforming.
- Open surgery: This involves making a larger incision in the abdomen or groin area and directly repairing the hernia. The surgeon may place a piece of mesh over the opening of the hernia to prevent it from reforming after the surgery.
When to seek further consultation for an indirect hernia
If you develop any symptoms of an indirect hernia, such as groin discomfort or a bulge in the groin, you should see your physician, who can perform an exam and possibly order imaging tests to determine if you have an indirect hernia.
If you develop any symptoms of a strangulated indirect hernia
You should go to the emergency room or call an ambulance right away if you experience severe abdominal or groin pain, fever, nausea, or vomiting. Surgery needs to be performed within four to six hours, if necessary.
Dr. Liu received his medical degree from the University of Pennsylvania Perelman School of Medicine and is pursuing a career in ophthalmology. He graduated Phi Beta Kappa from Swarthmore College with a BA in biology. He has published research in multiple ophthalmology and healthcare journals and has received awards from Research to Prevent Blindness. In his free time, he enjoys running, biking, and spending time with his friends and family.
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