Inguinal Hernia: Symptoms, Causes & Surgical Treatment

What Is an Inguinal Hernia?

An inguinal hernia is a bulge in the groin or scrotum caused by abdominal contents (usually fatty tissue or intestine) pushing through a weakness in the abdominal wall. The bulge often appears when standing, coughing, or straining and may disappear when lying down.

The abdominal wall is the layered structure that separates the skin from the internal organs of the abdomen. It consists of several components: the peritoneum (inner lining), a layer of fat, one or more muscle layers, and subcutaneous fat beneath the skin. When these muscle layers develop a weakness or opening, the inner contents can push through, creating what we call a hernia.

In an inguinal hernia, the peritoneum and abdominal contents – typically fatty tissue and sometimes a loop of intestine – push through the muscle layer in the groin region. However, they don't push through the skin. Instead, a sac forms beneath the skin called the hernia sac. The contents of this sac may move in and out through the opening in the abdominal wall, which is why hernias often appear and disappear.

Inguinal hernias can develop on either the right or left side of the groin, and some people develop them on both sides simultaneously (bilateral hernias). The groin is one of the most common locations for hernias to occur because of natural weaknesses in the abdominal wall structure, particularly around the inguinal canal – the passage through which blood vessels, nerves, and (in males) the spermatic cord travel.

The term "inguinal hernia" also encompasses hernias that extend into the thigh area (femoral hernias) or into the scrotum in males. While these may be classified differently in medical literature, they share similar mechanisms and treatment approaches.

Types of Inguinal Hernias

There are two main types of inguinal hernias, distinguished by where the weakness occurs in the abdominal wall:

• Indirect inguinal hernia: The most common type, occurring when the hernia sac passes through the inguinal canal – the same passage the testicles use to descend during fetal development. This type can occur at any age and is the type seen in children.
• Direct inguinal hernia: Occurs when the abdominal wall weakens in an area called Hesselbach's triangle, allowing contents to push directly through. This type is almost always acquired and typically affects older adults.

Understanding the type of hernia helps surgeons plan the most appropriate repair technique, though for patients, the symptoms and treatment approach are generally similar.

What Is a Strangulated Hernia?

A strangulated inguinal hernia is a medical emergency that occurs when the contents of the hernia sac become trapped and cannot be pushed back into the abdomen. This is called incarceration. When incarceration persists, the blood supply to the trapped tissue can be cut off, which is strangulation.

Strangulation can compress both the hernia contents and the blood vessels supplying them. Without blood flow, the trapped tissue (often intestine) can die, leading to tissue necrosis, bowel perforation, and potentially life-threatening infection. This is why strangulated hernias require emergency surgery.

Both adults and children can develop strangulated hernias. In some cases, a strangulated hernia can occur without a previously known hernia – it may be the first sign that a hernia exists.

Other Types of Hernias

While inguinal hernias are the focus of this article, other types of abdominal hernias exist:

• Scrotal hernia (scrotal extension): When an inguinal hernia extends down into the scrotum
• Hydrocele: When the hernia sac fills only with fluid rather than tissue
• Umbilical hernia: When the hernia sac pushes through a weakness near the navel
• Incisional hernia: When a hernia develops at the site of a previous surgical incision

What Are the Symptoms of an Inguinal Hernia?

The main symptom of an inguinal hernia is a visible bulge in the groin or scrotum that may appear and disappear. Other symptoms include groin pain or discomfort, especially when bending, coughing, or lifting, and a feeling of heaviness or dragging in the groin area.

Both adults and children can have an inguinal hernia without experiencing any symptoms – it may only be discovered during a routine medical examination or investigation for another condition. However, many people with inguinal hernias do experience noticeable signs that prompt them to seek medical attention.

Common Signs and Symptoms

Inguinal hernias can cause one or more of the following symptoms:

• A visible or palpable bulge: You may see or feel a soft, rounded protrusion under the skin in the groin area or scrotum. This bulge can typically be pushed back into the abdomen (called "reducible").
• Pain in the groin or scrotum: Particularly noticeable during movement or physical activity. The pain may range from a dull, aching sensation to a brief, sharp, stinging pain.
• Heaviness or discomfort: A sensation of pressure, fullness, or dragging at the hernia site.
• Abdominal discomfort: Some people experience generalized abdominal pain.
• Burning sensation: Some describe a burning feeling at or around the bulge.

How the Bulge Changes

It's characteristic for an inguinal hernia to be less noticeable in the morning and become larger as the day progresses. This occurs because gravity and activity throughout the day cause more abdominal contents to push into the hernia sac. Sometimes the hernia may only appear as subtle swelling.

The hernia typically becomes more visible and prominent during activities that increase pressure in the abdomen, such as:

• Lifting heavy objects
• Standing up from a sitting position
• Straining during bowel movements
• Coughing or sneezing

In children, the hernia may be easier to see when the child is crying, coughing, or straining during a bowel movement. Many parents first notice the bulge during diaper changes or bath time.

Symptoms of Strangulated Hernia

A strangulated or incarcerated hernia typically causes more severe and alarming symptoms that are clearly distinguishable from an uncomplicated hernia:

• Severe abdominal, groin, or scrotal pain: Usually sudden onset and intense
• A painful bulge that cannot be pushed back: The hernia feels hard and tender
• Redness or discoloration: The groin or scrotum may turn red, purple, or dark
• Nausea and vomiting: Often accompanying the pain
• Signs of bowel obstruction: Inability to pass gas or have bowel movements

A strangulated hernia can lead to intestinal obstruction. Severe abdominal pain may be the first sign of a strangulated hernia, even if no hernia was previously noticed.

Children with strangulated hernias may also become lethargic, uninterested in their surroundings, and less interactive than usual. They may also vomit.

Not All Groin Lumps Are Hernias

A lump in the groin, especially in children, isn't necessarily a hernia. It could be:

• A swollen lymph node (lymphadenopathy), often related to an infection
• A hydrocele (fluid collection around the testicle)
• An undescended testicle in children
• A lipoma (benign fatty growth)

Only a medical professional can determine the cause of a groin lump through examination and, if needed, imaging studies.

When Should You See a Doctor for an Inguinal Hernia?

Contact a healthcare provider if you notice a bulge in your groin that appears when standing or straining. Seek emergency care immediately if you have sudden severe groin pain, a hernia that won't push back in, nausea and vomiting, or if the skin over the hernia changes color.

Most inguinal hernias don't require emergency treatment, but all suspected hernias should be evaluated by a healthcare provider to confirm the diagnosis, assess the risk of complications, and discuss treatment options.

Schedule a routine appointment with your doctor if:

• You notice a bulge in your groin area that comes and goes
• You experience mild, intermittent groin discomfort
• You suspect your child may have a hernia

For children, you can also consult with a pediatrician or child health clinic if you suspect a hernia.

What Can You Do at Home?

While inguinal hernias cannot be cured without surgery, you can temporarily manage symptoms by gently pushing the hernia back while lying down, using over-the-counter pain relievers, and avoiding activities that increase abdominal pressure like heavy lifting.

There are several things you can do to manage symptoms while awaiting surgery or medical evaluation. However, remember that these measures are temporary – an inguinal hernia will not heal on its own.

Manually Reducing the Hernia

If the hernia is not painful or trapped, you may be able to temporarily push it back into place (reduce it). This is easiest to do while lying on your back with your knees bent and raised. Using gentle, steady pressure, guide the hernia back toward the navel. Do not force it – if it doesn't go back easily, stop and contact a healthcare provider.

Pain Management

Over-the-counter pain medications can help relieve discomfort. Options include:

• Acetaminophen (paracetamol)
• Anti-inflammatory medications (NSAIDs) like ibuprofen

Always follow package directions and consult a pharmacist if unsure which medication is appropriate for you or your child.

Lifestyle Modifications

Certain activities can worsen hernia symptoms by increasing pressure in the abdomen. Consider:

• Avoiding heavy lifting: Especially if it causes discomfort at the hernia site
• Using proper lifting technique: Bend at the knees, not the waist
• Preventing constipation: Straining during bowel movements increases abdominal pressure. Drink plenty of water and eat fiber-rich foods
• Treating chronic cough: Repeated coughing can worsen hernias

How Is an Inguinal Hernia Diagnosed?

Inguinal hernias are usually diagnosed through physical examination, where the doctor looks for a bulge in the groin area that becomes more prominent when you stand or cough. Imaging tests like ultrasound or CT scan may be used if the diagnosis is unclear.

When you visit a healthcare provider for a suspected inguinal hernia, they will first ask about your symptoms – when the bulge appeared, what makes it better or worse, and whether you experience any pain. They will then perform a physical examination.

During the examination, the doctor will look at and feel the groin area to check for swelling or a bulge. It's usually sufficient for the doctor to confirm the diagnosis, even if the hernia isn't visible at the time of the appointment – your description of an intermittent bulge in the area is often enough.

Additional Tests

In most cases, imaging isn't necessary. However, if the diagnosis is uncertain or the doctor needs more information, additional tests may be ordered:

• Ultrasound: A non-invasive imaging technique that can visualize the hernia and its contents
• CT scan (computed tomography): Provides detailed images and is useful for complex or recurrent hernias
• MRI: May be used in specific situations where other imaging is inconclusive
• Herniography: A specialized X-ray where contrast dye is injected into the abdomen to make hernias more visible. You receive local anesthesia before the injection, and images are taken while you bear down.

In some cases, the doctor may recommend diagnostic laparoscopy – a minimally invasive procedure where a small camera is inserted through a tiny incision to directly visualize the hernia. If a hernia is found, it can often be repaired during the same procedure. This is performed under general anesthesia.

How Is an Inguinal Hernia Treated?

The only effective treatment for inguinal hernia is surgical repair. Adults with minimal symptoms may be monitored (watchful waiting), while children always require surgery. Hernia trusses can provide temporary symptom relief but don't treat the underlying problem.

Surgery is the only way to permanently fix an inguinal hernia. Unlike some other medical conditions, hernias will not heal on their own – the weakness in the abdominal wall doesn't repair itself naturally. However, not all hernias require immediate surgery.

Watchful Waiting for Adults

For adults with small hernias that cause few or no symptoms, doctors may recommend a period of "watchful waiting" – monitoring the hernia over time without immediate surgery. This approach is based on evidence that small, minimally symptomatic hernias in adults have a low risk of complications in the short term.

During watchful waiting:

• You'll have regular check-ups to monitor the hernia
• You'll learn to recognize warning signs of complications
• Surgery can be scheduled if symptoms worsen or the hernia enlarges

Most hernias eventually require repair, as they tend to grow larger and more symptomatic over time.

Hernia Truss

A hernia truss (or belt) is a supportive device that applies pressure to keep the hernia in place. It may be used temporarily while waiting for surgery or if surgery isn't possible for medical reasons.

Important limitations of hernia trusses:

• They do not cure the hernia
• They only provide symptom relief
• They don't prevent the hernia from growing
• Long-term use can cause skin problems and may make eventual surgery more difficult

Children Always Need Surgery

In children, inguinal hernias are almost always repaired surgically, regardless of whether they cause symptoms. This is because pediatric hernias have a higher risk of becoming incarcerated or strangulated as the child grows. The timing of surgery depends on the child's age and the severity of symptoms.

Emergency Surgery for Strangulated Hernia

A strangulated or incarcerated hernia almost always requires emergency surgery in both adults and children. In some cases involving children, a doctor may be able to manually push back an incarcerated hernia, which allows the operation to be planned electively rather than performed as an emergency.

What Happens During Hernia Surgery?

Hernia surgery involves pushing the hernia contents back into the abdomen, removing the hernia sac, and strengthening the abdominal wall. This can be done through open surgery or laparoscopic (keyhole) surgery, often using a mesh patch to reinforce the repair.

The surgical procedure is similar whether repairing a standard inguinal hernia or a strangulated one. The key difference is urgency and sometimes the surgical approach.

Anesthesia Options

Children are always given general anesthesia (put to sleep) for hernia surgery. Before anesthesia, an IV line is placed in the arm or hand to deliver fluids and medications.

Adults have several anesthesia options:

• General anesthesia: You're completely asleep
• Spinal anesthesia: You're awake but numb from the waist down
• Local anesthesia with sedation: The surgical area is numbed and you receive medication to keep you relaxed

The choice depends on the surgical technique, your overall health, and your preferences.

Laparoscopic vs. Open Surgery

There are two main surgical approaches:

Laparoscopic (keyhole) surgery is the most common technique today. The surgeon makes several small incisions (typically 3) and uses a tiny camera and specialized instruments to repair the hernia from the inside. Benefits include:

• Smaller incisions and less scarring
• Usually less pain after surgery
• Faster recovery
• Excellent visibility of both sides (useful for bilateral hernias)

Open surgery involves a larger incision directly over the hernia. The surgeon repairs the hernia from outside the abdominal cavity. This approach may be chosen for:

• Strangulated hernias where bowel damage is suspected
• Patients who cannot undergo general anesthesia
• Certain complex or recurrent hernias

Strengthening the Abdominal Wall

During surgery, the surgeon first pushes the hernia contents back into the abdomen and removes the hernia sac. In adults, the weakened area is then reinforced to prevent recurrence. There are several techniques:

• Mesh repair: A synthetic mesh patch is placed over or behind the defect. This is the most common technique, especially in laparoscopic surgery, and has the lowest recurrence rates (1-4%).
• Tissue repair (herniorrhaphy): The surgeon uses your own tissues, suturing them in a specific pattern to reinforce the area. This technique may be used when mesh isn't appropriate.
• Plug repair: A mesh plug is placed in the weakness and expands into a reinforcing patch.

In children, the abdominal wall typically doesn't need reinforcement because the hernia is usually caused by a congenital opening that failed to close rather than tissue weakness. The surgeon simply closes this opening, often with dissolving sutures.

Before Surgery: Important Preparations

To ensure the best surgical outcome and fastest recovery:

You should also avoid alcohol for 4 weeks before and after surgery, as it increases the risk of infection and other complications.

What Is Recovery Like After Hernia Surgery?

Most patients go home the same day as surgery. Pain is usually manageable with over-the-counter medications after the first few days. Light activities can resume within 1-2 weeks, with full recovery in 2-6 weeks depending on the surgical technique.

For planned (elective) surgeries, both children and adults typically go home the same day. If surgery was performed as an emergency, a hospital stay of a few days may be necessary.

Some children experience nausea and vomiting when they wake from anesthesia. The IV line usually remains for a few hours after surgery to provide fluids if needed.

Managing Post-Operative Pain

It's normal to experience pain at the surgical site during the first day or two. Prescription pain medication may be provided initially. After a few days, most people can manage with over-the-counter pain relievers.

Adults may notice a small, tender lump under the incision site – this is normal and will gradually shrink over several weeks. If a mesh was used, the area may feel slightly firm, which is also normal.

Preventing Constipation

Straining during bowel movements can be painful after hernia surgery. To prevent constipation:

• Drink plenty of fluids
• Eat fiber-rich foods
• Consider a stool softener if needed (ask your doctor or pharmacist)

Activity Guidelines

Avoid heavy lifting for the first few days to weeks after surgery – your surgeon will give specific instructions based on your procedure.

Children don't need strict bed rest but should be somewhat less active for a day or two. They may need to stay home from daycare or school for 1-2 days. Physical education and contact sports should be avoided for about a week to prevent bumps to the surgical site. Trampoline jumping should be avoided for several weeks.

Adults may need to take sick leave for a few days to a week or more, depending on their job. Less physical activity is recommended for several weeks, though gentle walking and cycling are usually fine the day after surgery.

Wound Care

The surgical wound will be covered with a dressing. Keep the dressing clean and dry – your surgeon will advise when it can be removed and when showering is permitted. The wound typically heals within 8-10 days.

Follow-Up

Most patients don't require a formal follow-up appointment after uncomplicated hernia surgery. However, contact your healthcare provider if you experience:

• Increasing pain, redness, or swelling at the incision site
• Drainage or pus from the wound
• Fever
• Any concerns about your recovery

Recurrence Risk

It's very rare for hernias to recur in children after repair. In adults, recurrence rates with mesh repair are low (1-4%). However, a new hernia can develop at a different location.

To reduce the risk of developing another hernia:

• Strengthen your abdominal muscles (start gentle exercises about 6 weeks after surgery, with your doctor's approval)
• Maintain a healthy weight
• Use proper lifting techniques
• Avoid smoking
• Treat chronic cough or constipation

What Are Possible Complications After Surgery?

Complications after hernia surgery are uncommon but can include wound infection, bleeding, nerve damage causing numbness or chronic pain, and rarely, testicular inflammation. Most complications are minor and resolve with appropriate treatment.

The following complications apply to both adults and children. Before leaving the hospital, you'll receive information about what to watch for and when to seek care.

Bleeding

Bleeding can occur inside the wound, beneath the skin. The area around the incision may become bluish and very swollen. This usually stops on its own, but occasionally requires a surgeon to open the wound to stop the bleeding.

Wound Infection

Signs of wound infection typically appear 2-4 days after surgery:

• The incision becomes red, swollen, and painful
• The skin around the wound feels warm
• Pus may drain from the wound
• Fever may develop

Infected wounds need to be opened, cleaned, and redressed. Antibiotics may also be prescribed.

Testicular Inflammation

There is a small risk of testicular inflammation after surgery. Initial signs include redness, swelling, and pain in the groin and testicle on the operated side, typically appearing about a day after surgery. This occurs due to disruption of blood flow to the testicle during surgery.

Changes in Sensation

Sometimes sensation around the surgical site is diminished. This can occur if nerves in the surgical area are cut or stretched during the operation. Sensation usually returns within a year, but for some people, it may remain permanently reduced – though this typically isn't problematic.

Chronic Pain

Some people develop persistent pain in the operated area, called post-herniorrhaphy pain or inguinodynia. This can last for months or occasionally longer. Chronic pain is rare in children. Risk factors include younger age (in adults), severe pre-operative pain, and previous groin surgery.

What Causes an Inguinal Hernia?

In children, inguinal hernias are congenital (present from birth) due to incomplete closure of a natural passage. In adults, hernias develop when the abdominal wall weakens over time due to aging, strain, chronic coughing, heavy lifting, or genetic factors.

The causes of inguinal hernias differ between children and adults.

Hernias in Children Are Congenital

In boys, hernias develop during fetal development when the testicles descend from inside the abdomen to the scrotum through the inguinal canal. Normally, a piece of the peritoneum (abdominal lining) follows the testicles down and then closes off. If it fails to close completely, a channel remains between the abdominal cavity and the scrotum, allowing contents to herniate through.

Girls also have an inguinal canal and can develop hernias, though this is less common. In girls, the ovary may sometimes be found within the hernia sac.

Hernias are most common in children under two years old but can also appear later. They're more common in premature babies.

Hernias in Adults Develop from Weakness

In adults, the abdominal wall in the groin region can weaken over time, making hernia formation more likely. Several factors contribute:

• Smoking: Damages connective tissue (including tendons and ligaments), making it weaker
• Heavy lifting: Prolonged heavy lifting over time increases abdominal pressure and stresses the muscles
• Certain medical conditions: Diseases affecting connective tissue or nerve damage in the abdominal wall
• Genetic factors: Some people inherit weaker connective tissue
• Aging: Natural weakening of tissues over time
• Chronic cough: Repeated coughing strains the abdominal muscles
• Chronic constipation: Straining during bowel movements increases abdominal pressure

The anatomy of the groin also plays a role. Natural openings in the abdominal wall – particularly where the spermatic cord passes through in men – create areas of potential weakness where hernias can form.

The exact cause of inguinal hernias isn't always clear. Sometimes they appear without any obvious contributing factors.