Direct inguinal hernia

Direct inguinal hernia is a pathology characterized by reversible protrusion of abdominal organs. Let's consider the causes of the disease, diagnostic methods, treatment and prevention.

This disease is acquired and is one of the most common among hernial formations, accounting for 70-80%. Most often, the disease appears due to excessive physical exertion, obesity, prolonged constipation, cachexia, chronic cough.

Elderly men are most susceptible to the pathology; it is rare in children and women. As a rule, the hernial protrusion has a rounded shape and is localized in the medial part of the inguinal ligament. The hernia can be bilateral, descend into the scrotum or be located near the spermatic cord in men.

ICD-10 code

There are several types of hernias, which are classified depending on the location and a number of other features. According to the International Classification of Diseases of the 10th revision, this disorder belongs to the category K00-K93 diseases of the digestive system.

Let's take a closer look at the ICD 10 code:

• K40-K46 Hernias

K40 Inguinal hernia:

(Bubonocele, NCD, direct, bilateral, indirect, oblique, scrotal hernia)

• K40.0 Bilateral inguinal hernia with obstruction without gangrene
• K40.1 Bilateral inguinal hernia with gangrene
• K40.2 Bilateral inguinal hernia without obstruction or gangrene
• K40.3 Unilateral or unspecified inguinal hernia with obstruction, without gangrene:
  • causing obstruction
  • disadvantaged
  • irreparable
  • without gangrene
  • strangulation
• K40.4 Unilateral or unspecified inguinal hernia with gangrene:
  • BDU with gangrene
• K40.9 Unilateral or unspecified inguinal hernia without obstruction or gangrene

If this disorder appeared as a result of a primary lesion, then auxiliary coding is used.

Causes of Direct Inguinal Hernia

Protrusion of abdominal organs is a pathology that can be both congenital and acquired. The causes of direct inguinal hernia indicate that the disorder occurs as a result of weakness of the posterior wall of the inguinal canal. The transverse fascia, which forms the posterior wall of the inguinal canal, gradually stretches and atrophies. As a result, the tissues rupture, significantly reducing the strength of the inguinal space.

Most often, such a disorder is diagnosed in men over 40 years old. This is due to the fact that the internal inguinal ring, which forms the back wall of the canal of the same name, is most susceptible to hernia lesions. In women, the uterine ligament passes through such a ring, which has strong muscles, and in men, the spermatic canal is devoid of muscles and tendons.

Causes of bulge in the groin:

• Poorly developed peritoneal walls
• Increased and frequent physical activity and associated injuries
• Obesity (excess weight increases the load on the abdominal wall)
• Pregnancy (causes stretching of the peritoneum)
• Complications from abdominal surgery
• Chronic bronchitis
• Bowel problems (constipation, irregular bowel movements)
• Long-term smoking accompanied by coughing
• Age-related wear and tear of tissues

There is a risk group for developing the disease, which includes: heavy smokers, elderly people, pregnant women, children, athletes, and obese people.

[ 1 ], [ 2 ], [ 3 ]

Pathogenesis

The mechanism of development of hernial protrusion is characterized by the fact that the entire process passes through the walls of the peritoneum, but does not affect the inguinal canal. Pathogenesis is associated with increased physical activity, injuries, diseases and other factors.

There are several stages of tumor formation, let's consider them:

• Formation of a small protrusion on the back wall of the canal.
• Formation of a hernial sac, which is located in the inguinal canal under the aponeurosis of the external oblique muscle.
• Hernia prolapse.

The direct form of protrusion of organs from the abdominal cavity passes through the medial fossa, gradually stretching the transverse fascia. Thus, the hernia leaves the inguinal canal. In rare cases, the hernial sac gets into the area of the urinary bladder, which is covered by the peritoneum. Also, protrusion of the extraperitoneal part of the urinary bladder is extremely rare.

• If the disease has a reducible form, then the tumor formation can be palpated in an atypical place. The protrusion appears with tension and disappears when pressing on it and in a lying position.
• The irreducible form has a typical localization for the disease and can increase with straining. When palpating the inguinal canal, dilated hernial orifices are felt, which have a triangular or oval shape. This type requires differential diagnostics with tumor diseases, abscesses, dilation of the veins of the spermatic cord and hydrocele in men.

Symptoms of a Direct Inguinal Hernia

Painful signs of the disease rarely make themselves known from the first days of the lesion due to the anatomical features of the hernia structure. Symptoms of a direct inguinal hernia are practically no different from other types of protrusion, but have a sluggish picture. All symptoms can be divided into two groups, which depend on the degree of development of the pathology.

1. The protrusion does not occur during straining, coughing, sneezing, and does not extend beyond the hernial ring. It is reduced when the body is in a horizontal position. Patients do not complain of painful symptoms.
2. The hernia has a spherical or oval shape, visible above the inguinal ligament on the surface of the body. There is a feeling of discomfort and burning in the groin. When walking and physical activity, pains of a pulling, aching nature occur.

If the protrusion has existed for a long time but has not been diagnosed, then most often it appears after intense physical activity or upon reaching an acute pathological form. Let's consider the signs that may indicate the presence of a disorder:

• Problems with urination (due to the hernial sac entering part of the bladder)
• Constipation (due to compression of the intestines)
• Digestive disorders
• Flatulence
• Development of appendicitis (acute form) – caused by organs getting into the cecum
• Increased body temperature
• Vomit
• Abdominal pain
• Violation of general well-being

First signs

The acquired form of protrusion of organs into the groin area is characterized by vague symptoms and a sluggish course. The first signs may make themselves known unexpectedly. While the pathology is small in size, it does not cause painful sensations. If it exists for a long period of time, the patient complains of discomfort. Pain also occurs when its size increases. In this case, the patient complains of constant pain in the lower abdomen and groin. Unpleasant sensations can be localized in the sacrum and lumbar region.

At first, a direct hernia is a small, elongated, dense protrusion in the groin area. It appears during physical activity and disappears on its own. As soon as the disease takes a permanent form, the protrusion is visible in any position of the body. Over time, adhesions appear in the hernial sac, which are accompanied by pain.

If the bladder, uterus or ovaries get into the bag, this leads to urination disorders, menstrual cycle and painful sensations. In some cases, the inguinal ring compresses blood vessels, causing acute pain associated with circulatory disorders. In this case, the pathology takes a strangulated form. Its danger is that tissue necrosis and the spread of infection to the entire abdominal cavity can begin.

[ 4 ], [ 5 ]

Direct inguinal hernia in men

The protrusion of internal organs into the inguinal canal cavity occurs in patients of any age and gender. But most often, a direct inguinal hernia occurs in men. According to medical statistics, about 90% of all inguinal pathologies occur in male patients. This is due to the physiological features of the male body structure. There are weak tissues in the groin, and the inguinal canal is quite wide. Most often, such organs as part of the intestine, the greater omentum or the urinary bladder fall out.

The pathology extends beyond the spermatic cord and has a spherical shape. In the early stages, it does not give any symptoms, but looks like a small tumor. Over time, the sac increases in size, and signs such as:

• Burning and pain in the groin of a prolonged nature.
• Swelling of the peritoneum and groin area, which changes depending on the position of the body.
• Discomfort when walking and urinating.

The main cause of this disorder in men is a constitutional factor. Many doctors claim that there is a hereditary predisposition. But in addition to this, there must be an influence of a second factor. When lifting weights, a strong cough or constipation, the intra-abdominal pressure increases, due to which the weakest place of the inner wall of the peritoneum allows the organ to pass under the skin.

At the first suspicion of the disease, it is worth contacting the attending physician and undergoing diagnostics. If you delay a visit to the hospital, the risk of complications will increase. Surgical operation is used for treatment, since conservative methods will not eliminate the disease. The main goal of hernioplasty is to return the prolapsed organs to their original place and subsequent plastic surgery of the hernial orifice. The rehabilitation period takes 3-4 months, subject to moderate physical activity and dietary nutrition.

[ 6 ]

Direct inguinal hernia in women

Pathological prolapse of the peritoneum with internal organs into the lumen of the inguinal canal is an acquired pathology. Direct inguinal hernia in women most often appears after 40-50 years. A hernia is formed at the junction of the tissues surrounding the vaginal opening and the uterus. The main causes of the disease:

• Congenital anatomical pathologies.
• Muscle weakness (due to increased pressure in the abdominal cavity, the organs cannot be held in place).
• Increased physical activity (chronic constipation, lifting weights, childbirth).
• Injuries to the groin area (weaken the ligamentous apparatus).
• Obesity.

Symptoms of malaise:

• The tumor protrusion increases in a vertical position of the body, as well as with physical exertion, coughing, and sneezing.
• The pain varies in intensity and radiates to the sacrum, lower back, and lower abdomen.
• Constipation, flatulence, frequent urination.
• Algomenorrhea is severe pain when urinating due to the ovary and fallopian tube getting into the hernial sac.

As a rule, the diagnostic process is not difficult. In women, it is impossible to insert a finger into the inguinal canal, so the doctor collects anamnesis, conducts a visual examination, palpation. The shape and size of the sac are assessed in vertical and horizontal positions. The patient undergoes an ultrasound examination of the pelvic organs and abdominal cavity, irrigoscopy and herniography.

Treatment involves herniotomy and laparoscopy. If there are contraindications to surgery, the patient is prescribed to wear a special bandage. This method of therapy does not remove the pathology, but only alleviates painful symptoms, preventing its increase and infringement.

Consequences

Hernial lesion of the inguinal region without proper treatment can lead to serious problems. Consequences of the disease are possible if no measures are taken to eliminate it. Lack of medical care will lead to strangulation, pathological enlargement of the hernia, various types of inflammation and infections, which can cause death.

Special attention is paid to the operation to correct the organs. Since relapses are possible without surgical intervention. To avoid serious consequences, it is necessary to follow all the recommendations of doctors in the postoperative period. The patient is prescribed a special diet that will relieve constipation and flatulence, as well as minimal physical activity.

It is very important to realize that conservative treatment and folk methods will not improve the patient's condition. Therefore, to avoid serious complications, at the first signs of illness, you should consult a doctor.

[ 7 ]

Complications

Any disease left without proper medical treatment entails a number of negative consequences. Complications affect the functioning of all organs and systems. The most common problem faced by patients with hernia diseases is strangulation. Such pathology requires urgent surgical treatment. Let's consider the main symptoms of this complication:

• Nausea, vomiting, flatulence
• No gases, prolonged constipation
• The formation in the groin cannot be reduced
• Presence of blood in stool
• Rapid heartbeat
• General weakness

In addition to strangulation, there may be complications such as: stagnation of fecal matter in the large intestine (coprostasis), inflammation of the testicle (ischemic orchitis), inflammation of the hernia. The disease can cause necrosis of the organs located in the sac. In some cases, acute appendicitis develops due to compression of the vessels. Another serious complication is peritonitis, that is, inflammation of the entire abdominal cavity.

[ 8 ]

Diagnosis of direct inguinal hernia

Early detection of the disease significantly simplifies the treatment process and minimizes the risk of complications and serious consequences. Diagnosis of a direct inguinal hernia is usually not difficult, since the protrusion is easily detected during a physical examination.

• Thus, in men, the affected half of the scrotum is enlarged in volume, the skin is stretched, and the genital organ is directed to the contralateral side.
• When examining female patients, it is noted that it is impossible to insert a finger into the external opening of the inguinal canal. The formation is located above the inguinal ligament.

When collecting anamnesis, the duration of the protrusion, the presence of constipation, cough, lifting weights, i.e. the factors that provoked the disease, are taken into account. The doctor checks how easily the formation is repositioned and whether there is strangulation. After a visual examination, the hernia is palpated, its consistency, mobility and content are assessed. Particular attention is paid to the presence of pain when palpating and the color of the skin of the hernial sac.

After this, the patient is sent for an ultrasound examination of the pelvic organs and formations. This diagnostic method allows you to assess the structure of the pathological contents. The following are most susceptible to discharge: the greater omentum, intestine, ovary. Ultrasound allows you to differentiate the disease from hydrocele of the spermatic cord in men and a number of other pathologies with similar symptoms.

[ 9 ], [ 10 ]

Tests

To clarify the diagnosis and choose a treatment plan, the patient must undergo a series of tests. General clinical studies include blood and urine tests, as well as methods to exclude diseases that may be a contraindication for surgical intervention. In addition, the patient must undergo an ECG, ultrasound, and a blood clotting test.

Ultrasound examination allows to determine what is inside the hernial sac. Since in some cases the signs of hernial lesion are symptoms of a completely different disease.

[ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ]

Instrumental diagnostics

Many methods and procedures are used to detect hernia. Instrumental diagnostics is used to examine male patients. The study is a diaphanoscopy, that is, transillumination of the scrotum. If there is fluid in it, the light rays pass without difficulty, with dense structures - the light is uneven. This allows you to differentiate hernia from dropsy.

Particular attention is paid to physical diagnostic methods. The doctor palpates the protrusion of organs, checks whether it can be returned to the cavity. In addition, the condition of natural openings and channels is assessed.

Differential diagnostics

In its symptoms, a hernia is similar to other lesions of the inguinal region. Differential diagnostics allows you to recognize various diseases. As a rule, the disease is differentiated from the following disorders:

• Lipoma of the spermatic cord
• Femoral hernia
• Hydrocele of the testicle
• Round ligament cyst of the uterus
• Cryptorchidism
• Lymphadenopathy

A characteristic set of clinical signs is used for recognition. Differential diagnostics of individual types of pathology presents certain difficulties, since all of them require surgical treatment. The final diagnosis is established only after revision of the inguinal canal.

[ 16 ], [ 17 ]

The difference between oblique and direct inguinal hernias

When making a treatment plan, special attention is paid to differentiation from other disorders. This is due to the fact that the protrusion of the organs of the inguinal region is most often oblique and direct.

Let's consider the difference between oblique and direct inguinal hernias:

• The rectum exits the abdominal cavity through the median depression in the groin. It lies medial to the spermatic cord, isolated from the sac. The main anatomical layers are: skin, subcutaneous tissue, abdominal muscles, aponeurosis of the oblique muscle, transverse fascia. The hernial sac consists of two layers - transverse fascia and peritoneum.
• The anatomical layers of the oblique form are: skin, subcutaneous tissue, internal spermatic fascia, superficial fascia, aponeurosis of the external oblique abdominal muscle. The hernial sac may have different thicknesses. If the pathology has existed for a long time and wearing a bandage was used to relieve its symptoms, then the sac may be tightly fused with the abdominal organs and spermatic cord. Its contents may be all organs except the liver.

Oblique and direct inguinal hernias differ in clinical signs. Direct has a spherical shape, and oblique is elongated, in the later stages it becomes inguinoscrotal. Oblique can be congenital, and direct only acquired.

[ 18 ]

Treatment of direct inguinal hernia

Only radical methods are used to eliminate the protrusion of abdominal organs. Treatment of direct inguinal hernia involves surgical intervention. Its main goal is to suture the hernial orifice and strengthen the posterior wall of the inguinal canal.

But if there are such contraindications as pregnancy, weakened general condition of the body or inflammatory processes, then I use conservative therapy. Its essence lies in wearing a special bandage, limiting physical activity, following a special diet and eliminating diseases that aggravate the hernia.

Traditional medicine methods are used as supportive therapy. Such treatment allows to reduce painful symptoms and minimize inflammatory processes in the body. But such methods, as well as drug therapy, will not help to correct the protrusion of organs.

Medicines

Several methods are used to treat hernia disease, the main one being surgical. Medicines are prescribed before surgery and in the postoperative period to prevent complications. But drug therapy alone will not help eliminate the pathology. Taking vitamins and drugs that accelerate the development of connective tissue collagen cannot prevent the organs from protruding. But increased intake of vitamins in the postoperative period is very useful, as it improves the quality of scar tissue and acts as a preventive measure against relapses.

Despite the fact that physical activity can cause the development of the disease, special exercises are an excellent cure and prevention of hernia. Swimming is one of the most effective and doctor-approved exercises. During such exercises, the abdominal muscles are strengthened, creating a positive effect. In addition to swimming, you can use moderate aerobics, race walking, cycling.

Folk remedies

Along with conservative methods of therapy, alternative medicine is popular. Traditional medicine helps to minimize painful symptoms and improves the effectiveness of the main treatment.

• To eliminate painful sensations, wash the sore spot with cold water and vinegar. If there are bouts of nausea, it is recommended to swallow a piece of ice, ice can be applied to the hernia.
• Take a couple of spoons of cornflower flowers and pour 500 ml of water over them. Take 2 cups of the remedy per day.
• Pour boiling water over 2 tablespoons of oak bark and let it brew for 20-30 minutes. Soak a cotton-gauze bandage in the infusion and apply a compress to the sore spot for 30 minutes.
• Take the sauerkraut brine and make a compress from a bandage folded in several layers. Apply the remedy to the sore area.
• Another common remedy for treating inguinal hernia is an ointment made from pork fat. Take 500 g of fat and melt it in a water bath. Heat a glass jar and pour the fat into it. Pour vinegar essence and one egg into another jar. Mix the contents of the jars and put them in a dark, cool place for 7-10 days. Heat the jar in a water bath, add 2 quail eggs and a spoonful of badger fat. Mix the ointment well, apply it to a napkin, put it on the sore area of the body and fix it with a bandage. Keep the compress for 2-3 hours, and store the ointment in the refrigerator.

[ 19 ], [ 20 ]

Herbal treatment

Various methods of treating direct inguinal hernia can effectively eliminate pain and reduce discomfort. Herbal treatment is especially popular. Decoctions and infusions are easy to prepare, and their therapeutic effect is immediately apparent after use.

• Pour boiling water over one spoon of dried clover leaves and let it brew for an hour. Strain the infusion and take 1/3 cup before each meal.
• Ginger tea, drunk on an empty stomach, alleviates painful symptoms. Take fresh ginger root, grind it with a grater or cut it into small pieces. Pour boiling water over the root and let it brew for 10-20 minutes. You can add a spoonful of honey, cinnamon and lemon to the resulting infusion.
• Mint has anti-inflammatory and analgesic properties. It is recommended to add fresh or dried mint to teas and any dishes. But if the patient has disorders caused by the presence of blood clots, then before using this remedy, it is worth consulting a doctor.

Homeopathy

One of the alternative treatment options for hernial lesions of the inguinal region is homeopathy. Let's consider the main drugs prescribed for the treatment of the disease.

• Alumina – helps to get rid of constipation caused by intestinal disorders. Effective for abdominal colic, weakness of the abdominal muscles and dyspeptic disorders.
• Calcarea carbonica – used for hernia caused by obesity. In this case, the symptoms of the disorder may be enlarged lymph nodes in the pelvic area.
• Lycopodium – helps in the treatment of right-sided inguinal hernia.
• Nux vomica – eliminates chronic constipation and any other stool disorders. The remedy is prescribed for digestive disorders, pressing pain in the stomach during or after meals, belching with bitterness.
• Phosphorus - used for organ discharge caused by severe cough due to chronic inflammatory diseases of the bronchi or larynx.

For homeopathic treatment to be effective and safe, the drugs must be prescribed by a homeopathic physician.

Surgical treatment

The main method of eliminating prolapse of internal organs is surgical intervention. Surgical treatment involves plastic surgery of the inguinal canal and restoration of the normal arrangement of organs. For this, herniotomy, laparoscopy or endoscopic method can be used. Let's consider the main stages of the operation:

• At the first stage, access to the hernia is formed. An incision is made in the groin area and the aponeurosis of the external oblique abdominal muscle is dissected. The upper flap of tissue is separated from the internal transverse and oblique muscles, exposing the groove of the inguinal ligament.
• At the second stage, the hernial sac is isolated and completely removed.
• The inguinal ring is sutured to normal dimensions of 0.6-0.8 cm.
• Plastic surgery of the inguinal canal is performed.

Laparoscopic surgery is performed under general anesthesia. Small incisions are made in the abdominal area, into which special surgical manipulators are inserted. To visualize the procedure, a special gas is introduced into the abdominal cavity, which is pumped out at the end. When removing the hernia, the doctor releases the sac from its contents and strengthens the walls with a special mesh. This prevents the development of pathology and spread to the inguinal canal. The mesh is made of a hypoallergenic substance that does not cause inflammatory reactions. After the operation, muscle tissue defects are sutured, and surgical instruments are removed. Skin incisions are closed with single sutures and a plaster. This type of surgery minimizes damage, since there is no reason to use a wide cavity incision that increases the wound surface.

Prevention

The rehabilitation period after treatment of a direct inguinal hernia is a long process. Prevention is aimed at strengthening the muscular corset and eliminating factors that cause increased intra-abdominal pressure. The patient is prescribed therapeutic exercises, a balanced diet, and wearing a bandage.

There are a number of preventive measures that prevent relapses of the pathology:

• When the first symptoms of the disease appear, it is recommended to wear a groin support.
• Timely elimination of constipation, chronic cough and diseases of internal organs.
• Good nutrition, use of vitamin supplements.
• Limit physical activity and heavy lifting.

The combination of all the above factors allows you to speed up the process of recovery of the body, prevents complications and relapses.

Forecast

The risk of complications and the prognosis of the disease depend on many factors. First of all, it is timely seeking medical help and correct diagnosis of the disease. As a rule, the prognosis is favorable. But when using tension hernioplasty, there is a risk of relapse. In addition, when treating an irreducible hernia, there is a risk of strangulation, which significantly worsens the prognosis.

Direct inguinal hernia is an acquired pathology, the effectiveness of which largely depends on early diagnosis and properly formulated treatment. The outcome of treatment, that is, the prognosis, is influenced by the patient's age, the presence of concomitant diseases, complications and individual characteristics of the patient's body.