Hernia: symptoms, treatment

Hernias are a common problem, especially as we become older. The good news is that they are usually not very serious, and can, generally, be repaired with a fairly straightforward operation.

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What causes hernias?

Hernias happen when the tissue or muscle wall that normally surrounds that part of your body, develops a weakness or gap. When that happens part of your internal organs – part of your intestines for example – can bulge through this opening. This may be so slight, that you don’t know that it has happened, or the bulge may be large enough to be quite noticeable, causing stomach bloating, for example.

The bump caused by the internal organ pushing through the hernia may disappear when you change position – for instance, your hernia might disappear when you lie down. Or you may be able to push the lump back in. Hernias may reappear if you cough, or may always be noticeable.

A hernia happens when a part of your internal organs bulges through a weak area in the muscle or tissue that surrounds it. The result is that the bulge appears in that part of your body as a soft lump.

There are a number of triggers that can cause a hernia, including:

• straining to go to the toilet
• constipation
• lifting something heavy
• being overweight
• smoking
• over-exerting yourself

Types of hernia

Inguinal Hernia

Inguinal hernias are the most common type of hernia. Men are more prone to inguinal hernias than women. This is because they are born with a small tunnel or tube in their groin area – this lets their testicles descend from their abdomen into their scrotum. Inguinal hernias can happen if part of the intestine comes through this opening.

This type of hernia can also happen if part of your bowel or fatty tissue comes through a space in the muscle tissue in your groin. These hernias are located at the top of your inner thigh.

Treatment for an inguinal hernia

YYou will need to have an operation to repair the problem. You may be able to have your hernia operation under local anaesthetic, which means that you will be awake while it happens. You won’t feel pain during this procedure, as you will have a local (or regional) anaesthetic. However, if this isn’t suitable in your case, you’ll have a general anaesthetic, which means that you will be asleep while the operation is carried out (as with a local anaesthetic, you won’t feel any pain).

Femoral hernia

These hernias are much less common than inguinal hernias, and tend to be more common in women, especially older women, than men. Around 1 out of every 20 groin hernias is found to be femoral. This means that they have developed in the femoral canal. You are more likely to have a femoral hernia if you have developed a smoker’s cough, and suffer from constipation.

Femoral hernias are most likely to happen in the upper thigh area, and are usually smaller than inguinal hernias. Femoral hernias also usually happen rather lower down in your groin than inguinal hernias. If you develop a femoral hernia you’ll probably notice a lump about the size of a grape in your groin.

Femoral hernias are similar to inguinal hernias as they also involve body tissue or part of your bowel, coming through a weak area in the groin. Common causes include straining to have a bowel movement on the toilet, or trying to carry something heavy.

Treatment for a femoral hernia

If you have a femoral hernia your doctor will probably suggest that you have it surgically repaired straight away. This is because these hernias are more likely to develop complications than some other types of hernia.

The complications can include developing an obstruction and becoming strangulated. When this happens part of your bowel can be trapped in your femoral canal. This can make you feel nauseous, make you throw up, and cause a painful lump in your groin area. It can also be quite dangerous – see strangulated hernias below.

Hiatus hernia

This type of hernia is located in the upper part of your body and happens when your stomach pushes upwards, through your diaphragm - the muscle that divides your chest and your abdomen. Because your body needs to be able to pass food from your mouth down your oesophagus and into your stomach, you have a hiatus – a small space – in your diaphragm, through which food passes to reach your stomach. If the top part of your stomach goes through the hiatus, you have a hiatus hernia.

Treatment for a hiatus hernia

You may not need surgery with this type of hernia, it depends on whether other treatments have had any effect, and how bad your symptoms are. If none of the suggestion above help, talk to your GP about whether you need an operation.

A hiatus hernia may cause the symptoms of gastro-intestinal reflux disease (GORD). These can include;

• bad breath
• feeling bloated and burping more than normal
• heartburn – a burning feeling in your chest (especially after eating)
• problems and/or pain when you swallow
• being sick, or feeling as though you might throw up.

Easing the symptoms of a hiatus hernia

Change your eating habits – by having smaller meals, but more often, and asking your pharmacist which medicines might help ease your symptoms. If you smoke, try to give up, as smoking can exacerbate your symptoms.

If these suggestions don’t help your doctor may be able to prescribe medicines to help with the discomfort. They can also arrange for you to have tests to find out what is causing your discomfort.

If you do need treatment for a hiatus hernia, it’s usually carried out as keyhole surgery, under general anaesthetic. Recovery time is likely to be up to 3 days in hospital before you can go home, and six weeks before you can eat as you please. You’re likely to still have side effects such as passing wind, bloating and trouble swallowing, for a few months.

You should see your GP as soon as possible if:

• you keep being sick
• there’s blood in your vomit
• your upper stomach area is painful
• you have lost weight without being on a diet

In these cases, you may have to have another operation.

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Umbilical hernia

This type of hernia happens when a section of your bowel, or some fatty tissue manages to pass through a space in your diaphragm. This usually happens in or near your belly button, which is why it is called an umbilical hernia.

This can happen from birth, but it can also happen during adulthood, particularly in people who are overweight or obese. Having a bad cough that won’t go away, and putting pressure on that part of your body while lifting heavy objects can also cause an umbilical hernia.

If you still have an umbilical hernia as an older adult, talk to your doctor about having it repaired. By this stage a hernia probably won’t get better on its own, and your chances of having complications as a result of your hernia increase.

These complications can include part of your bowel being trapped outside your abdomen. The symptoms to watch out for are pain, feeling sick, and throwing up.

Treatment for an umbilical hernia

If your doctor and surgeon feel that you need to have an operation to repair an umbilical hernia, this will probably be carried out while you are under a general anaesthetic. In adults, the operation may involve having a patch of special surgical mesh inside the affected area. This is used to help strengthen the affected area.

Surgical mesh is used in other operations, as well as hernia repair. While it is accepted practice, there are some issues with its continued use. See section on surgical mesh below.

Incisional Hernia

This happens when tissue from your abdominal area pushes through a wound in your abdomen caused by a previous operation. This is more likely to happen if the scar hasn’t fully healed. Because of the link with operations, this type of hernia is likely to happen with a couple of years of having surgery carried out.

Strangulated hernia

This starts off as a normal hernia, so some of your bowel or intestine, for instance, pushes through a weakness in the wall of your abdomen, creating a soft lump or bulge.

If too much of your bowel (or intestine) comes through an opening in this area of strong muscle, and the opening squeezes it, this can cut off the blood supply to that part of your bowel or intestine. (This is more likely to happen with a femoral, rather than an inguinal hernia.)

This can cause a great deal of pain, and possibly vomiting and blood in your poo. It may well damage the section of your intestines trapped in the hernia.

If you or anyone you’re with experiences this, you will need to have emergency surgery to release the part of your bowel that has become trapped, and place it back within your abdominal walls. Call 999 immediately and explain the situation. You will need to have an operation as soon as possible to reduce the risk of long-term damage.

To avoid any possibility of this situation happening, it is best to have your hernia operated on as soon as your doctor or surgeon says it needs doing. This should mean help avoid any risk of a strangulated hernia.

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Do hernias hurt?

In most cases, hernias don’t actually cause any pain. And if any do cause pain they’re more likely to be the smaller hernias. This is because you have a large area of tendons and muscles that surrounds and protects the vital organs from your ribs to the tops of your legs.

If a small hole develops in this protective sheath (known as the abdominal wall), the section of intestine that slips through the opening, may be squashed or squeezed, causing pain. However, if the opening is larger, the part of your intestine that pops through the hole is less likely to be squashed, and less likely to be painful.

Hernias and pain

If you have a hernia that is causing you pain, don’t wait, see your GP or call 911 or 999 straight away. A painful hernia may be a strangulated hernia, (see above) which could be very dangerous.

Hernia mesh repairs

The standard treatment for hernia repairs (and some other operations, including incontinence and prolapse), includes the use of mesh implants. Of the 665,759 inguinal hernia operations carried out in 2012/2013, mesh was used in 93%.

However there is some controversy over this type of treatment, with some patients finding that they experienced far greater pain after the operation.

If you have any concerns about an existing mesh repair for a hernia or any other condition, talk to your GP, and if necessary, to the surgeon who carried out the operation. If you are going to have a hernia operation, it would be a good idea to talk to your surgeon before the operation, and ask whether they intend to use mesh.

Can you leave a hernia untreated?

In April 2019 a reader wrote to Saga Magazine's Dr Mark Porter with this question:

Q: Is it OK to leave a hernia? I have recently developed one in my groin, but my GP seems reluctant to refer me for surgery to have it repaired. To be honest, it doesn’t bother me at the moment, but I worry about it getting bigger or twisting if I don’t have the operation.

Dr Mark Porter's reply: It depends on a number of factors. In an otherwise fit and active older person I tend to have a low threshold for seeking a specialist opinion, as new hernias have a higher chance of strangulating (the ‘twisting’ you mention), requiring urgent surgery. And in these cases, planned repair – which can now be done under local anaesthetic – has much better outcomes than emergency surgery. Clues that a groin hernia may be more likely to strangulate include groin and abdominal discomfort, and a lump that you can’t push back in (reduce) when relaxed and lying flat.

However, if the hernia is easily reducible and not bothering you – or if you have other medical conditions that might complicate surgery or recovery – then watchful waiting is a perfectly acceptable option. I have patients who have lived with huge groin hernias for decades, and the risk of strangulation is quite low – roughly 1 in 100 per year for the typical person. Just make sure you report any changes to your doctor, and if you develop signs of strangulation – a painful (and often red) swelling that won’t reduce and/or a distended painful abdomen – then seek help urgently.

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