Can women get hernias

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Technique

A history of pain, swelling, or presence of a mass in the groin area is significant. Specific questions need to be asked: How long have you noticed the discomfort (swelling, mass, pain)? Does standing or activity such as lifting intensify or evoke the pain? Does coughing or sneezing make the lump more prominent? Will lying down relieve the symptoms or allow the swelling to disappear? Can you push the mass back in with your hand? Have you ever had difficulty pushing the mass back into the abdomen? Have you ever had a hernia or operation on the other side? In children, specifically in infants, the parents” observation of a swelling or protusion may be the only positive feature of the evaluation.

Examination of the inguinal region in both men and women is best performed with the patient standing and the physician seated on a stool facing the patient. Observation of the groin area in oblique light with the patient relaxed and then actively coughing may reveal a bulge or an abnormal motion. Scrotal masses may also be noted by inspection and palpation. Carefully observe whether any bulge noted is above (inguinal hernia) or below (femoral hernia) the inguinal ligament crease. The examiner should then stand to the side of the patient with the fingers lightly applied to the groin as shown in Figure 96.1, the left hand on the patient’s left side and the right hand on the patient’s right side. With the fingers placed over the femoral region, the external inguinal ring, and the internal ring, have the patient cough. A palpable bulge or impulse located in any one of these areas may indicate a hernia. The examiner should then return to the sitting position. In the male, the scrotum on each side is inverted with the examining index finger entering the inguinal canal along the course of the cord structures. The size of the external ring can be ascertained by palpating just lateral to the pubic tubercle. Again with the patient coughing, hernia bulges can be felt either against the side of the examining finger (direct hernia) or at the tip of the finger as it approaches the internal ring (indirect hernia). Large, indirect hernias may extend all the way into the scrotum, giving the gross appearance of a hydrocele. Transillumination of the scrotal contents in a darkened room will aid in differentiating a hydrocele from an intrascrotal indirect inguinal hernia.

Figure 96.1

Placement of the hand when examining for a hernia.

Any mass found on groin examination should be gently pressed with the examining fingers in an attempt to reduce the hernia and thereby cause the contents of the sac to return to the peritoneal cavity. Incarcerated hernias may be reduced more easily with the patient recumbent on the examining table. Mild sedation may be necessary to provide sufficient muscle relaxation to allow for reduction. Any hernia mass that is tender to palpation or associated with symptoms of nausea and vomiting should be considered possibly strangulated (compromised vascularity of entrapped bowel), and no attempt should be made to reduce it manually. This condition represents an acute surgical emergency.

Groin Hernias

A hernia occurs when an organ protrudes through the wall of muscle that encircles it. There are a few different types of hernias that can occur in the area of the groin. For more information on inguinal and femoral hernias, and the symptoms and treatment methods associated with these hernias, please see below.

Inguinal Hernias

Inguinal hernias, also known as groin hernias, occur when a bit of tissue protrudes through a weak spot in the muscles between the upper thigh and the lower abdomen.

Inguinal hernias are usually caused by an opening in the muscle wall that should have closed before birth but instead remained open. Because of that abnormality, there is a weak spot in the abdomen.

When tissue pushes through that weak spot, it creates a bulge, or lump, that tends to be painful, though not necessarily dangerous.

Symptoms

The primary symptom of an inguinal hernia is a lump or bulge in the area of the groin. That bulge may appear all of a sudden, after you have been coughing, laughing, lifting heavy weights, or otherwise straining, or it may develop over a longer period of weeks or even months.

You may experience pain or general discomfort in the area of the groin, particularly when straining. Inguinal hernias can cauase significant discomfort, and may also be associated with an aching or burning feeling in the area of the bulge. You may also experience a sensation of dragging, pressure, or weakness in the groin.

Some male patients may experience swelling and pain around the testicles, if the protruding tissue descends into the scrotum.

Causes

Inguinal hernias can be caused by any one of the following, or by a combination of factors:

  • Chronic coughing
  • Chronic sneezing
  • Increase of pressure in the abdomen
  • Pregnancy
  • Straining during bowel movements
  • Strenuous activity
  • Weak spot in the abdominal wall

The cause of an inguinal hernia, however, is not always immediately apparent.

Many people develop inguinal hernias later in life, when their muscles have weakened with age, or when they are more vulnerable following abdominal surgery or an injury. Many others, however, experience a weakening in the abdominal wall during birth, when the peritoneum (abdominal lining) doesn’t close as it should.

In men, that abdominal weak spot usually develops in the inguinal canal, which is where the spermatic cord enters the scrotum. Women, on the other hand, have a ligament in their inguinal canals that helps to hold the uterus in place. Hernias can develop in the place where connective tissue from the uterus is joined to the tissue surrounding the pubic bone.

Risk Factors

Certain populations seem to be at greater risk of developing inguinal hernias than others. Risk factors include the following:

  • Aging: Muscles grow weaker with age.
  • Being male: Men are more likely to develop inguinal hernias than women.
  • Chronic constipation, which usually causes excessive straining during bowel movements.
  • Chronic cough, particularly when caused by smoking.
  • Family history: If you have had a parent or sibling with an inguinal hernia, you may be at greater risk of developing one yourself.
  • Premature birth and low birth rate are both associated with greater incidences of inguinal hernias.
  • Previous inguinal hernia or hernia repair: Those who have already suffered an inguinal hernia are at greater risk of developing another one.

Complications

In some cases, an inguinal hernia can result in additional complications. These may include:

  • Incarcerated hernia: A hernia can grow to obstruct the bowel if its contents become trapped in the weak area of the abdominal wall. An obstructed bowel will result in nausea, vomiting, an inability to pass gas or have a bowel movement, and severe pain.
  • Increased pressure on surrounding tissue: If not treated promptly with surgery, most inguinal hernias will grow larger over time. In men, this means that a hernia may extend into the scrotum, resulting in swelling and pain.
  • Strangulation: An incarcerated hernia may block the flow of blood to part of your intestine. That strangulation can result in the death of the affected bowel tissue. A strangulated hernia requires immediate surgery; it is life threatening.

Femoral Hernias

Femoral hernias occur when a bit of tissue bulges through the lower belly and into the upper thigh, in the area just below the groin crease. Femoral hernias are sometimes mistaken for inguinal hernias because they occur in a nearby location.

Femoral hernias are relatively uncommon. In fact, fewer than 5% of all hernias turn out to be femoral hernias.

Femoral hernias occur more commonly in women than in men.

Femoral hernias may not present any symptoms at all, especially if they are of a small or medium size.

Larger hernias may become visible as a lump or bulge in the area of your upper thigh. That bulge may cause discomfort or pain when you try to stand up, lift a heavy object, or strain in another way. Because femoral hernias are in many cases located in close proximity to the hip bone, they may cause pain in the hip.

As with inguinal hernias, the cause of a femoral hernia is not always clear. While the area of the femoral canal may have weakened over time, you may also have simply been born with a weakened femoral canal.

It does seem clear that straining can cause the muscle walls to weaken, thereby increasing the chances of developing a femoral hernia. Activities that may contribute to straining include:

  • Being overweight
  • Childbirth
  • Chronic coughing
  • Chronic constipation
  • Difficulty urinating caused by an enlarged prostate
  • Heavy lifting

When left untreated, a femoral hernia can result in additional complications, some of them severe. These complications may include:

  • Incarcerated hernia: A hernia can grow to obstruct the bowel if its contents become trapped in the weak area of the abdominal wall. An obstructed bowel will result in nausea, vomiting, an inability to pass gas or have a bowel movement, and severe pain.
  • Strangulation: An incarcerated hernia may block the flow of blood to part of your intestine. That strangulation can result in the death of the affected bowel tissue. A strangulated hernia requires immediate surgery; it is life threatening.

Diagnosis

In most cases, your doctor will be able to determine whether you are in fact suffering from a hernia, whether it is an inguinal or a femoral hernia, simply by looking and by gently palpating the affected area.

If for some reason a diagnosis isn’t immediately apparent, your doctor may decide to order an imaging test, such as an abdominal ultrasound, CT scan, or MRI. These imaging tests can help to show the hole in the muscle wall, along with the tissue protruding from it.

Treatment

Inguinal and femoral hernias that have no symptoms may not require any treatment at all. Your doctor will discuss your options with you regarding surgery or watchful waiting.

Hernias that are causing discomfort or have incarcerated, usually require surgical repair to relieve the discomfortas well as to prevent complications.

There are two types of surgical hernia repair: open and minimally invasive surgery. The type of surgery chosen will depend on the severity and type of hernia you’ve developed, the anticipated recovery time, your medical and surgical history, and your surgeon’s expertise.

Open Surgery

During this procedure, your surgeon will make a small incision into your groin, and then push the protruding tissue back into your abdomen. Your surgeon will then sew up the weakened area. In some cases, your surgeon will use a synthetic mesh to reinforce that weakened area.

Open surgery can be performed either with general anesthesia or with sedation or local anesthesia.

After your surgery, it might be several weeks before you’re able to fully resume your normal activities. However, it’s still important that you begin moving about again as soon as possible for a healthier recovery.

Minimally Invasive Surgery

Minimally invasive surgery is performed under general anesthesia.

During this procedure, your surgeon will make a few small incisions in your abdomen. Your surgeon will then inflate your abdomen, using a special gas, in order to make your internal organs easier to see.

Your surgeon will then insert a small, narrow tube into one of the incisions in your abdomen. This tube has a tiny camera, or laparoscope, at the end of it. That camera serves as a kind of guide for your surgeon, who is then able to insert surgical instruments through the other incisions in your abdomen. Your surgeon will repair the hernia using mesh .

Because minimally invasive surgery allows the surgeon to avoid scar tissue from earlier hernia repairs, it may be an especially good option for people who have had their hernias recur following traditional hernia surgery. It may also be a good option for people with bilateral hernias, or hernias on both sides of the body.

Patients who choose minimally invasive surgery may experience less scarring and discomfort following surgery than those who choose open surgery. Patients may also be able to return more quickly to their normal activities.

Your doctors will speak with you in detail about all of your treatment options and will recommend a course of action best suited to your individual needs.

Make an Appointment

To discuss a potential hernia surgery, contact the Surgery Call Center at (734) 936-5738.

What Is a Hernia?

A hernia occurs when an organ or fatty tissue squeezes through a weak spot in a surrounding muscle or connective tissue called fascia. The most common types of hernia are inguinal (inner groin), incisional (resulting from an incision), femoral (outer groin), umbilical (belly button), and hiatal (upper stomach).

In an inguinal hernia, the intestine or the bladder protrudes through the abdominal wall or into the inguinal canal in the groin. About 96% of all groin hernias are inguinal, and most occur in men because of a natural weakness in this area.

In an incisional hernia, the intestine pushes through the abdominal wall at the site of previous abdominal surgery. This type is most common in elderly or overweight people who are inactive after abdominal surgery.

A femoral hernia occurs when the intestine enters the canal carrying the femoral artery into the upper thigh. Femoral hernias are most common in women, especially those who are pregnant or obese.

In an umbilical hernia, part of the small intestine passes through the abdominal wall near the navel. Common in newborns, it also commonly afflicts obese women or those who have had many children.

A hiatal herniahappens when the upper stomach squeezes through the hiatus, an opening in the diaphragm through which the esophagus passes.

The Differences Between Hernias in Men Versus Women

Hernias are often perceived as a man’s problem, but women get them, too.

“When you talk to people about hernias, they tend to focus on groin hernias, which are the most common — and they are primarily a male problem,” says Stephen Ganshirt, MD, vice chief of surgery at Northwestern Lake Forest Hospital in Illinois. But other types of hernias are actually more common in women, while still others occur at similar rates in men and women.

Hernias occur when an organ or tissue bulges through a weak spot in the wall of muscle that’s holding it in. Inguinal hernias (aka, groin hernias) occur when contents of the abdomen — usually fat or part of the small intestine — bulge through a weak area in the lower abdominal wall into the inguinal canal in the groin region. While inguinal hernias can happen to men and women, they’re much more common in men because men naturally have a small hole in the groin muscles so that blood vessels and the spermatic cord can pass to the testicles, Dr. Ganshirt notes.

By contrast, a femoral hernia occurs when a portion of the intestine pokes through a weakened area in the upper thigh muscle, just under the groin. Femoral hernias are more common in women than in men, Ganshirt says, adding that it probably has to do with the shape of the pelvis, which is shaped differently to accommodate childbearing.

An umbilical hernia occurs when tissue lining the abdomen protrudes into the belly button area. “Women get more umbilical hernias because of pregnancy — it’s that stretching of the abdominal wall — so we see more of those during childbearing years in women,” Ganshirt says. As people get older, however, umbilical hernias tend to be equally common among women and men.

When it comes to hiatal hernias, which occur when the stomach bulges up into the chest cavity through an opening in the diaphragm, women are at slightly higher risk as they get older, especially if they’re obese.

Symptoms and Diagnosis of Hernias in Men and Women

Often a hernia presents with similar symptoms for men and women — a bulge or swelling in the groin or pelvis that’s accompanied by discomfort. The telltale sign for most inguinal hernias is an achiness or dull pain, especially while lifting something, gardening, or getting in and out of a car. By contrast, people with femoral hernias usually have lower and more medial (toward the inside of the leg) groin pain, often radiating down the front of the leg.

“Hernias present the same way — it is the index of suspicion on the part of the practitioner that changes with the sex of the patient,” says David Renton, MD, an associate professor of surgery at The Ohio State University Wexner Medical Center in Columbus. “Hernias are less common in women, so we tend to think of other things that may cause problems for them rather than hernias.”

In fact, a study in a 2016 issue of the Journal of Ultrasound found that hernias (both the inguinal and femoral variety) are a common cause of pelvic pain in women who are sent for pelvic ultrasounds.

Why is the possibility of a hernia sometimes overlooked as a cause of chronic pelvic pain in women? For one thing, “most pelvic pain experts are highly trained gynecologists, who may be more centered upon ovaries and uterine causes for pain,” says study leader Michael Crade, MD, a clinical associate professor in the department of obstetrics and gynecology at the University of California in Irvine. For another, “the right historical questions are not asked,” he adds. “In my experience, femoral hernia patients often answer yes to questions such as: Does the pain go down the front of the leg? Is the pain better if you lie down? Is the pain nagging in the lower abdomen? Do you have pain getting in and out of the car? Or sitting at a computer for a long time? If the patient tells us such things, we are on the hunt for probable hernia.”

If your doctor doesn’t follow that line of thinking, it may be a good idea to ask whether your symptoms could point to a hernia, rather than a gynecological problem, Dr. Crade says. If so, a high-quality ultrasound study may be able to make the correct call.

Gender Differences in Treatment

Since hernias don’t usually improve on their own, surgery is often required to repair them. With open surgery, a surgeon cuts into the body at the hernia’s location, puts the protruding tissue back where it belongs, then stitches the weakened muscle wall back together (often implanting mesh for extra support). “Women are less likely to get mesh — because you can completely close off the hernia opening with sutures in a woman without having to worry about keeping some of the opening there to allow blood flow to the testicles,” Ganshirt says. This is why the rate of hernia recurrence is lower in women, he adds.

With laparoscopic surgery, a surgeon guides the hernia repair using a telescope-like device that’s inserted through small incisions at the belly button. A study in a July 2017 issue of the American Journal of Surgery found that laparoscopic repair of groin hernias dramatically reduced the risk of a recurrence in women (though the opposite was true for men). Even so, “the two biggest risk factors for recurrence are obesity and smoking,” Dr. Renton says. “Unfortunately, these are shared equally between both sexes.”

Femoral Hernia

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Femoral hernias occur in the groin – the small area of the lower abdomen on each side, just above the line separating the abdomen and the legs.

They are relatively uncommon (they account for 2% of all hernias and 6% of all groin hernias, the other 94% are inguinal), more likely to occur in women than in men (70% of femoral hernias occur in women, probably because of their wider pelvis making the femoral canal slightly larger) and are often confused with inguinal hernias by both patients and doctors.

Almost half of all femoral hernias first come to light as emergencies.

What would I see?

A small swelling very low down next to the groin skin crease; sometimes just below the crease so the swelling seems to be at the top of the thigh.

What would I feel?

Often very little, perhaps a bit of an ache. This is why they tend to be so ‘dangerous’ – there are often no symptoms until they strangulate. If strangulation occurs the lump becomes hard and tender.

A femoral hernia that gets stuck or ‘incarcerated’, on the way to strangulation, can cause severe local and abdominal pain, nausea and vomiting. If a loop or knuckle of intestine is within the hernia sac it requires immediate, emergency surgery. The estimated time for bowel viability (survival) is about 8-12 hours.

Why is strangulation common?

The reason so many femoral hernias come to light as emergencies is probably that the femoral canal, through which the hernia appears, is narrow with most of its entrance (the femoral ring) rigid and unyielding.

What should I do?

Femoral hernias should be repaired early and not left until they become a problem. Not all doctors realise how important this is.

What operation?

The goal of surgery is to close off the femoral canal. Before mesh arrived on the scene this was done with stitches, stitching the front and back of the opening together. The problem is that there is not much ‘give’ here, trying to sew two rigid structures to each other. The result can be both painful and not very reliable.

Our preferred method is to place a soft mesh cone plug in the femoral canal. This sits in the femoral canal where it remains, stopping anything going through. This can be done with local anaesthesia through a short cosmetically-placed incision just above the groin crease.

The success rate will depend on who does the operation.
See also: Methods of Repair later in this site

Next: Umbilical and Other Midline Hernias

Intestinal Obstruction due to Bilateral Strangulated Femoral Hernias

4. Conclusion

In conclusion, this case report of a rare phenomenon of bilateral strangulated femoral hernias reinforces the importance of femoral hernias due to their high risk of strangulation. One should be vigilant in patients presenting with gastrointestinal symptoms, especially in case of suggestive of small or large bowel obstruction. Elderly frail patients especially with obstructed femoral hernias may present with atypical symptoms of abdominal pain, nausea, and vomiting. Therefore, meticulous clinical examination including thorough examination of both inguinal areas, complemented by appropriate haematological and radiological investigations, is essential in the diagnosis of these hernias. Any delay or failure to reach this diagnosis would result in a significantly increased risk of morbidity and mortality for the patient.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

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