Direct inguinal hernia

A direct inguinal hernia is a pathology characterized by a reversible ablation of the abdominal cavity organs. Consider the causes of the disease, the methods of diagnosis, treatment and prevention.

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

The elderly men are most affected by pathology, they are 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, fall 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 of the site 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 of the digestive system.

Let's consider more detailed a code on mb 10:

• K40-K46 Hernia

K40 Inguinal hernia:

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

• K40.0 Double-sided inguinal hernia with obstruction without gangrene
• K40.1 Double-sided inguinal hernia with gangrene
• K40.2 Double-sided inguinal hernia without obstruction or gangrene
• K40.3 Unilateral or unspecified inguinal hernia with obstruction without gangrene:
  • obstructive
  • stricken
  • irreversible
  • without gangrene
  • strangulation
• K40.4 Unilateral or unspecified inguinal hernia with gangrene:
  • NOS with gangrene
• K40.9 Unilateral or unspecified inguinal hernia without obstruction or gangrene

If this disorder appears as a result of a primary lesion, then an auxiliary encoding is used.

Causes of a direct inguinal hernia

The protrusion of the abdominal organs is a pathology that can be both congenital and acquired. The causes of a direct inguinal hernia indicate that the disorder appears as a result of weakness of the back 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 are torn, significantly reducing the strength of the inguinal space.

Most often, such a disorder is diagnosed in men over 40 years of age. This is due to the fact that the inner inguinal ring, which forms the posterior wall of the same channel, is most susceptible to hernia lesions. Women through a similar ring passes a ligament of the uterus, which has strong muscles, and in men, deprived muscles and tendons - the seed canal.

Causes of protrusion in the groin:

• Underdeveloped walls of peritoneum
• Elevated and frequent physical activity and trauma associated with them
• Obesity (overweight increases the burden on the abdominal wall)
• Pregnancy (provokes stretching of the peritoneum)
• Complications from surgical operations on the peritoneum
• Chronical bronchitis
• Problems with the intestines (constipation, irregular stools)
• Prolonged smoking accompanied by cough
• Age deterioration of tissues

Allocate a risk group for the development of the disease, which includes: heavy smokers, elderly people, pregnant women, children, athletes, people with obesity.

[1], [2], [3]

Pathogenesis

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

There are several stages of formation of tumor formation, consider them:

• The formation of a small protrusion on the back wall of the canal.
• The formation of a hernial sac, which is located in the inguinal canal under the aponeurosis of the external oblique muscle.
• Lowering hernia.

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 bladder, which is covered by the peritoneum. Also, it is extremely rare to bulge the extraperitoneal part of the bladder.

• If the disease is in the correct form, then the tumor formation can be probed in an atypical location. The protrusion appears with tension and disappears when pressing on it and in a prone position.
• The unrecoverable form has a localization typical for the ailment and can increase with straining. When palpation of the inguinal canal, enlarged hernial gaps are probed, which have a triangular or oval shape. This species requires differential diagnostics with tumor diseases, insipidus, widening of the veins of the spermatic cord and dropsy in men.

Symptoms of a direct inguinal hernia

Painful signs of the disease rarely make themselves felt from the first days of the lesion because of the anatomical features of the structure of the hernia. Symptoms of a direct inguinal hernia practically do not differ 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 pathology.

1. Bulging does not occur when straining, coughing, sneezing, does not go beyond the border of the hernial ring. Fits when the body is horizontal. Patients do not complain about painful symptoms.
2. The hernia has a spherical or oval shape, is seen above the inguinal ligament on the surface of the body. There is a feeling of discomfort and burning sensation in the groin. With walking and physical exertion, there are pains of a pulling, aching character.

If protrusion exists long ago, but has not been diagnosed, then most often it manifests itself after intense physical exertion or when an acute pathological form is achieved. Consider the signs that may indicate a disorder:

• Problems with urination (due to a hernial sac in the bladder)
• Constipation (due to compression of the intestine)
• Digestive disorders
• Flatulence
• The development of appendicitis (acute form) is due to the ingestion of organs into the sac of the cecum
• Increased body temperature
• Vomiting
• Pain in the abdomen
• Disorders of general well-being

First signs

The acquired form of organ outlet into the inguinal region is characterized by a lubricated symptomatology and a sluggish course. The first signs can make themselves felt unexpectedly. While the pathology is small, it does not deliver 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 region of the sacrum and waist.

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

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

[4], [5]

Direct inguinal hernia in men

The passage of internal organs into the cavity of the inguinal canal occurs in patients of any age and sex. But most often a straight 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 characteristics of the structure of the male body. In the groin are weak tissues, and the inguinal canal is quite wide. Most often fall out such organs as: part of the intestine, a large omentum or bladder.

Pathology extends beyond the seminal cord and has a spherical shape. In the early days it does not give any symptoms, but it looks like a small tumor. Over time, the bag increases, and there are signs such as:

• Burning and pain in the groin of a protracted character.
• Inflammation of the peritoneum and the groin area, which vary depending on the position of the body.
• Discomfort during walking and urination.

The main cause of this disorder in men is the constitutional factor. Many doctors claim that there is a hereditary predisposition. But besides this there must be an influence of the second factor. When lifting weights, severe coughing or constipation, the intraperitoneal pressure rises, because of which the least durable place of the inner wall of the peritoneum passes the organ under the skin.

At the first suspicions on illness, it is necessary to address to the attending physician and pass or take place diagnostics. If you delay the visit to the hospital, the risk of complications will increase. For the treatment, a surgical operation is used, since conservative methods do not eliminate the ailment. The main goal of the hernioplasty is to return the fallen organs to their original place and the subsequent plastic of the hernia gates. The rehabilitation period takes from 3-4 months, subject to moderate physical exertion and dietary nutrition.

[6]

Direct inguinal hernia in women

Pathological abdominal prolapse with internal organs in the lumen of the inguinal canal is an acquired pathology. Direct inguinal hernia in women, most often occurs after 40-50 years. At the junction of the tissues surrounding the vaginal opening and the uterus, a hernia forms. The main causes of the disease:

• Congenital anatomical pathologies.
• Muscle weakness (due to increased pressure in the abdominal cavity organs are not retained).
• Increased physical activity (chronic constipation, weight lifting, childbirth).
• Injury of the inguinal region (weaken the ligamentous apparatus).
• Obesity.

Symptoms of malaise:

• Tumor protrusion increases in the vertical position of the body, as well as with physical exertion, coughing, sneezing.
• The pain has a different intensity, gives in the sacrum, lower back, lower abdomen.
• Constipation, flatulence, frequent urination.
• Algodismenorea - severe pain when urinating due to getting into the hernial sac of the ovary and the fallopian tube.

As a rule, the process of diagnosis is not difficult. Women can not put a finger into the inguinal canal, so the doctor collects an anamnesis, conducts a visual examination, palpation. The shape and size of the bag in the vertical and horizontal positions is estimated. The patient is given an ultrasound examination of the pelvic organs and abdominal cavity, irrigoscopy and herniography.

Treatment is a hernia and laparoscopy. If there are contraindications to the operation, the patient is shown wearing a special bandage. This method of therapy does not remove pathology, but only facilitates the painful symptoms, preventing its increase and infringement.

Effects

Herniated lesions of the inguinal region without proper treatment can lead to serious problems. The consequences of the disease are possible in the event that no measures are taken to eliminate it. Lack of medical care will lead to infringement, pathological increase in hernia, various kinds of inflammation and infections, which can lead to death.

Particular attention is paid to the operation to restore organs. Since without surgery, relapses are possible. 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 exertion.

It is very important to realize that conservative treatment and alternative methods will not improve the patient's condition. Therefore, in order to avoid serious complications, at the first signs of a malaise it is worthwhile to see a doctor.

[7]

Complications

Any disease that is 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 hernial diseases is infringement. This pathology requires urgent surgical treatment. Consider the main symptoms of this complication:

• Nausea, vomiting, flatulence
• Absence of gases, prolonged constipation
• Education in the groin is not amenable to correction
• The presence of blood in the feces
• Cardiopalmus
• General weakness

In addition to infringement, there may be complications such as stasis of fecal masses in the large intestine (coprostasia), inflammation of the testicle (ischemic orchitis), inflammation of the hernia. Disease can cause necrosis of organs in the bag. In some cases, acute appendicitis develops due to constriction of the vessels. Another serious complication is peritonitis, that is, inflammation of the entire abdominal cavity.

[8]

Diagnosis of the inguinal hernia

Timely identified disease, significantly facilitates the treatment process and minimizes the risk of complications and severe consequences. Diagnosis of a direct inguinal hernia, as a rule, does not present difficulties, since protrusion is easily detected during 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. Education is located above the inguinal ligament.

When collecting anamnesis takes into account the prescription of protrusion, the presence of constipation, coughing, lifting weights, that is, factors that provoked the disease. The doctor checks how easy the education is to be injected and whether there is an infringement. After a visual examination, a hernia is palpated, its consistence, mobility and content are evaluated. Particular attention is drawn to the presence of soreness with palpation and the color of the skin of the hernial sac.

After this, the patient is sent for ultrasound examination of pelvic organs and education. This diagnostic method allows to evaluate the structure of pathological contents. Most of all, the following are affected: a large omentum, gut, ovary. Ultrasound can differentiate the ailment from dropsy of the spermatic cord in men and a number of other pathologies with similar symptoms.

[9], [10]

Analyzes

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

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

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

Instrumental diagnostics

A variety of methods and procedures are used to identify the hernia. Instrumental diagnosis is used to examine male patients. The study is a diaphanoscopy, that is, scrotal scans. If there is a liquid in it, the light rays pass without difficulty, with dense structures - the light is uneven. This allows you to differentiate the hernia from dropsy.

Particular attention is paid to physical methods of diagnosis. The doctor probes the organ exit, checks whether it can be inserted into the cavity. In addition, the state of natural holes and channels is estimated.

Differential diagnostics

In terms of its symptoms, the hernia is similar to other lesions of the inguinal region. Differential diagnostics makes it possible to recognize various diseases. As a rule, the ailment is differentiated with such disorders:

• Lipoma of spermatic cord
• Femoral hernia
• Dropsy of testis
• Cyst of round ligament of uterus
• Cryptorchidism
• Lymphadenopathy

A characteristic complex of clinical signs is used for recognition. Differential diagnosis of certain types of pathology presents certain difficulties, since all of them provide for surgical treatment. The final diagnosis is established only after an audit of the inguinal canal.

[16], [17]

Difference oblique and straight inguinal hernia

When drawing up a treatment plan, special attention is given to differentiation with other disorders. This is due to the fact that the emergence of the organs of the inguinal region most often occurs oblique and straight.

Consider the difference between an oblique and a straight inguinal hernia:

• The straight leaves the abdominal cavity through the middle cavity in the groin. It lies medial to the spermatic cord, isolated from the sac. The main anatomical layers are: skin, subcutaneous tissue, abdominal muscles, oblique muscle aponeurosis, transverse fascia. The hernial sac consists of two layers - the transverse fascia and peritoneum.
• Anatomic layers oblique form, are: skin, subcutaneous tissue, internal seminal fascia, superficial fascia, aponeurosis of the external oblique abdominal muscle. Hernial sac may have different thicknesses. If the pathology has existed for a long time and the wearing of the bandage was used to alleviate its symptoms, the bag can be tightly welded to the abdominal organs and the spermatic cord. Its contents can be all organs, except the liver.

The oblique and direct inguinal hernia differ in clinical signs. The straight line has a spherical shape, and the oblique elongated form, at later stages it becomes inguinal and scrotal. The slanting can be congenital, and the straight can only be acquired.

[18]

Treatment of a direct inguinal hernia

To eliminate the exit of the abdominal cavity organs, only radical methods are used. Treatment of a direct inguinal hernia involves surgical intervention. Its main goal is to cover the hernial gates and strengthen the back wall of the inguinal canal.

But if there are such contraindications as: pregnancy, weakened general condition of the body or inflammatory processes, then I apply conservative therapy. Its essence lies in wearing a special bandage, limiting physical exertion, adherence to a special diet and eliminating hernia-aggravating diseases.

Alternative medicine methods are used as maintenance therapy. Such treatment can reduce painful symptoms and minimize inflammatory processes in the body. But such methods, as well as drug therapy, will not help to increase the protrusion of organs.

Medications

Several methods are used to treat hernial disease, the main one of which is surgical. Medications are prescribed before surgery and during the postoperative period to prevent complications. But medication alone does not help to eliminate pathology. The intake of vitamins and drugs that accelerate the development of connective tissue collagen can not prevent the organ prolapse. But the increased intake of vitamins in the postoperative period is very useful, as it improves the quality of scar tissue and acts as a prevention of relapses.

Despite the fact that physical activity can cause the development of the disease, special exercises are an excellent medicine and prevention of hernial prolapse. Swimming is one of the most effective and permitted by the doctors training. During such exercises, the muscles of the abdominal muscles are strengthened, creating a positive effect. In addition to swimming, you can use moderate aerobics, athletic walking, cycling.

Alternative treatment

Along with conservative methods of therapy, non-traditional medicine is popular. Alternative treatment 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 flowers of cornflower narrow-scaly and fill them with 500 ml of water. Take 2 cups a day.
• 2 spoons of oak bark fill with boiling water and let it brew for 20-30 minutes. Blot in the infusion of a cotton-gauze bandage and apply a compress for 30 minutes to a sore spot.
• Take pickle brine brine and prepare a compress from a bandage folded in several layers. The remedy is applied to the diseased area.
• Another common remedy for inguinal hernia is ointment from pork fat. Take 500 g of fat and melt it in a water bath. Heat the glass jar and pour the grease into it. In one more jar, pour the vinegar essence and one egg. Mix the contents of the cans and put them in a dark, cool place for 7-10 days. Preheat the jar in a water bath, add 2 quail eggs and a spoonful of badger fat. Ointment should be well mixed, put on a napkin, put on a sick area of the body and fixed with a bandage. The compress is held for 2-3 hours, and the ointment is stored in the refrigerator.

[19], [20]

Herbal Treatment

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

• One spoonful of dry clover leaves pour boiling water and let it brew for an hour. The infusion should be filtered and taken 1/3 cup before each meal.
• Ginger tea, drunk on an empty stomach, facilitates painful symptoms. Take fresh ginger root, grind it with a grater or cut into small pieces. Pour the root with boiling water and let it brew for 10-20 minutes. In the infusion you can add a spoon of honey, cinnamon and lemon.
• Mint is anti-inflammatory and analgesic. It is recommended to add fresh or dried mint to teas and any dishes. But if the patient has a disorder caused by the presence of blood clots, then before using this tool it is worth consulting with a doctor.

Homeopathy

One of the alternative options for treating a hernial lesion of the inguinal region is homeopathy. Let's consider the basic preparations appointed or nominated for treatment of an illness.

• Alumina - helps to get rid of constipation caused by abnormalities in the intestine. Effective with colic in the abdomen, weakness of the peritoneal muscles and dyspeptic disorders.
• Calcarea carbonica - is used for hernia caused by obesity. In this case, the symptoms of the disorder may be an increase in the lymph nodes in the pelvic region.
• Lycopodium - helps in the treatment of right-sided inguinal hernia.
• Nux vomica - eliminates chronic constipation and any other disorders of the stool. The drug is prescribed for digestive disorders, pressing pains in the stomach during or after a meal, eructation with bitterness.
• Phosphorus - is used for organ failure caused by severe cough due to chronic inflammatory diseases of the bronchi or larynx.

In order for homeopathic treatment to be effective and safe, medications should be prescribed by a homeopathic doctor.

Operative treatment

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

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

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

Prevention

The rehabilitation period after treatment of an inguinal hernia of a direct form is a long process. Prophylaxis is aimed at strengthening the muscular corset and eliminating the factors that cause an increase in intraperitoneal pressure. The patient is prescribed therapeutic gymnastics, a balanced diet and wearing a bandage.

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

• When the first symptoms of the disease appear, it is recommended to wear an inguinal bandage.
• Timely elimination of constipation, chronic cough and diseases of internal organs.
• Full nutrition, the use of vitamin preparations.
• Restriction of physical activity and lifting weights.

The combination of all the factors described above makes it possible to accelerate the process of recovery of the organism, prevents complications and relapses.

Forecast

The risk of complications and the prognosis of the disease depends on many factors. First of all, this is a timely request for medical help and the correct diagnosis of the disease. As a rule, the forecast is favorable. But when using tensile hernioplasty, there is a risk of relapse. In addition, in the treatment of unrecoverable hernia there is a danger of development of infringement, which significantly worsens the prognosis.

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