Hernias, Pelvic
Kathy R. Reese and Cheryl A. Glass
Definition
A hernia is the protrusion of a peritoneum-lined sac through some defect from one anatomical space to another. As shown in Figure 14.3, there are three types of pelvic (inguinal) hernias distinguished by presentation:
A.Indirect: Protrudes through internal inguinal ring; can remain in canal, exit external ring, or pass into scrotum; unilateral or bilateral.
B.Direct: Protrudes through external inguinal ring; located in region of Hesselbach’s triangle; rarely enters scrotum.
C.Femoral: Protrudes through femoral ring, femoral canal, and fossa ovalis.
Incidence
A.The lifetime risk of development of a groin hernia is estimated at 27% for men and 3% for women.
B.Indirect inguinal hernias are the most common type of hernia. They affect both sexes. Indirect hernias occur at the extreme of ages, from 0.25% at 18 years of age to 4.2% at 75 to 80 years of age.
C.Direct inguinal hernias are less common than indirect inguinal hernias. They occur more often in males and are more common in those older than age 40. Primary inguinal hernias occur in 1% to 5% of infants and in 9% to 10% of those born prematurely.
D.Femoral hernias are the least common type of hernia (<5% of groin hernias):
1.35% to 40% of femoral hernias are not diagnosed until the patient presents with strangulation or bowel obstruction.
2.They occur more often in females.
3.The incidence steadily increases with age and is higher among patients with recurrent hernias.
4.Right-side presentation is more common than left.
E.Among inguinal hernias, a sliding component is found in 3%; they are overwhelmingly on the left side (left-to-right ratio, 4.5:1). Sliding hernias are much more common in men than in women, and the predominance increases with age.
F.Primary perineal hernias occur most often in elderly multiparous women.
Pathogenesis
Pelvic hernias occur because there is a potential space for protrusion—commonly of the bowel but occasionally of the omentum.
A.Indirect and direct hernias arise along the course that the testicle travels as it exits the abdomen and enters the scrotum during intrauterine life. Indirect hernias may be due to a congenital defect in which the processus vaginalis remains patent.
B.Femoral hernias occur at the fossa ovalis, where the femoral artery exits the abdomen.
Predisposing Factors
A.Pregnancy.
B.Straining.
C.Age.
D.Obesity.
E.Gender.
F.Repetitive stress/hard physical labor.
G.Congenital defect.
H.Premature birth.
I.Chronic cough/chronic obstructive pulmonary disease (COPD).
J.Chronic constipation.
K.Family history of hernia.
L.History of an abdominal aortic aneurysm (AAA).
M.Straining to urinate.
N.Previous inguinal hernia or hernia repair.
O.Collagen vascular disease.
P.Peritoneal dialysis.
Common Complaints
A.Bulging or swelling localized in the groin or scrotum.
B.Dull ache in lower abdomen or groin.
C.Swelling of labia majora in women.
D.Bowel obstruction symptoms may be present with an incarcerated hernia.
Other Signs and Symptoms
A.Ability to reduce hernia.
B.Exacerbation on standing, straining, or coughing.
C.Strangulation.
Systemic toxicity secondary to ischemic bowel is possible. Signs of sepsis include fever, tachycardia, hypotention, vomiting, and confusion.
FIGURE 14.3Pelvic hernias. (A) Indirect hernia comes down canal and touches the fingertip on exam. (B) Direct hernia bulges anteriorly and pushes against the side of the finger on exam. (C) Femoral hernia protrudes through femoral ring, femoral canal, and fossa ovalis, so the inguinal canal is empty on exam.
1.Colicky abdominal pain.
2.Extreme tender groin mass.
3.Hyperperistalsis.
4.Edema.
5.Discoloration.
Subjective Data
A.Review time of onset, duration, course of hernia, and swelling.
B.Review any symptoms and quality of pain. Blatant pain with hernias is unusual, and its presence should raise the possibility of incarceration or strangulation.
C.Ask the patient about history of straining, trauma, physical labor, and pregnancy.
D.Inquire about symptoms of obstruction or strangulation of entrapped bowel: pain, nausea, and vomiting. Groin pain and tenderness are generally absent in strangulated femoral hernias.
E.Determine if the patient can reduce the hernia.
F.Review irritating (e.g., exercise, straining, cough) and alleviating factors.
G.Review bowel habits, particularly constipation.
H.Evaluate history of COPD and cough.
Physical Examination
Physical examination is the same for all types of hernias and is directed at determining the type of hernia and whether it is reducible, incarcerated, or strangulated. Perform the exam while the patient is standing and supine. Palpation is best done with the patient standing:
A.Check temperature (if indicated), pulse, respirations, and blood pressure (BP).
B.Inspect:
1.Inspect for discoloration and edema of the herniated area.
2.Inspect for visible hernia. Instruct the patient to perform Valsalva’s maneuver to increase intra-abdominal pressure.
3.Preform transillumination of the scrotum to evaluate any bowel contents.
4.Inspect for the presence of ascites.
C.Auscultate abdomen for bowel sounds.
D.Palpate:
1.Palpate the groin for lymphadenopathy, masses, and tenderness. The right side is more commonly affected in both genders:
a.Males: Using the second or third finger, invaginate the scrotal skin, with and without cough and strain. There will be some degree of pressure with this maneuver, but a true hernia can typically be felt as a silky
impulse tapping against the finger. Palpate the scrotum: scrotal lump is either soft or unusually firm.
b.Females: Visually examine for a bulge, and then place two or three fingers across the inguinal canal and ask the patient to bear down or cough to elicit the characteristic bulge or impulse. Palpate the labia for swelling: either soft or unusually firm.
Diagnostic Tests
A.History and physical examination remain the best means of diagnosing hernias.
B.Perform ultrasonography for abdominal masses and strangulation.
C.MRI appears to be able to differentiate inguinal and femoral hernias with a high sensitivity.
D.Sigmoidoscopy is not recommended as a screening test.
E.Plain abdominal x-rays are of limited value in evaluating an incarcerated hernia.
F.Karyotyping should be considered when a testicle is palpable in the inguinal canal or found at herniorrhaphy in phenotypic females.
G.Routine laboratory work is not recommended.
Differential Diagnoses
A.Inguinal or pelvic hernia.
B.Acute conditions:
1.Testicular torsion causes sudden, excruciating pain in or around the testicle, which may spread to the lower abdomen; the pain may get worse with standing. Other signs and symptoms include swelling, rising of the affected testicle, nausea, vomiting, fever, and fainting or lightheadedness.
2.Epididymitis.
C.Nonacute conditions:
1.Testicular tumor.
2.Muscle strain.
3.Hip arthritis.
4.Undescended testicle.
5.Hydrocele.
6.Varicocele.
7.Spermatocele.
8.Lymphadenopathy.
D.Bowel obstruction.
Plan
A.Patient teaching:
1.Instruct the patient to call the office right away if he finds a lump or swelling in the scrotum, even if it is small or painless. Testicular tumors are usually painless.
2.Discuss condition and treatment options with the patient:
a.Surgery is the only effective treatment.
b.Watchful waiting rather than surgical repair is an option if the patient is asymptomatic as long as he is aware of the risk and understands the need for prompt attention should symptoms of complication occur.
c.Watchful waiting is not recommended in women, given their higher prevalence of femoral hernias, which are associated with a high risk of strangulation.
d.Nonsurgical therapy for groin hernias is the use of a truss. There is insufficient data to determine the efficacy of trusses in controlling symptoms. A truss has the potential risk of bowel constriction; prolonged use of a truss can lead to atrophy of the spermatic cord or fusion to the hernial sac.
3.Instruct the patient on signs of strangulation.
4.Instruct the patient to avoid heavy lifting and straining to have bowel movements (BMs) because they increase intra-abdominal pressure.
B.Medical and surgical management: Gently reduce a groin hernia while the patient lies supine with hips slightly flexed to relax the abdominal muscles. See Section II: Procedures for Hernia Reduction (Inguinal/Groin).
Follow-Up
A.Preoperative:
1.Excessive waiting time for elective repair increases the risk of strangulation, bowel resection, and mortality, especially with older patients.
B.Postoperative evaluation for hernia recurrences as needed:
1.Immediately from repair.
2.Greater than 6 months and up to 5 years from repair.
3.Late recurrences beyond 5 years from the repair.
Emergent Issues/Instructions
A.Strangulated hernias are nonreducible, and blood supply to protruded tissue is compromised. Refer patients for immediate surgical intervention.
B.Instruct the patient to return to the office if fever, severe pain, or strangulation occurs.
Consultation/Referral
A.Refer patients with femoral hernias to a physician. These hernias need to be repaired as soon as possible because of increased risk of incarceration and strangulation.
Individual Considerations
A.Pregnancy: Preexisting groin hernias may become more symptomatic during the first trimester of pregnancy. The symptoms must be differentiated from round ligament pain.
B.Geriatrics:
1.Groin hernias are one of the most frequently encountered pathologies occurring in old age, secondary to the presence of constipation, coughing, abdominal fat deposit, and loss of strength of the abdominal wall.