inguinal hernia in men

A pathology in the form of a localized near the groin rounded bulge under the skin, formed due to the protrusion of part of the abdominal contents beyond the abdominal wall, is diagnosed as inguinal hernia inguinal hernia in men. Moreover, this anomaly occurs quite often and is more typical for men. It is assigned the code according to ICD 10 - K40, class XI (diseases of the digestive system).

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Causes of a male inguinal hernia

The pathogenesis of this disease is anatomical and, to some extent, physiological. And according to the anatomical classification, inguinal hernia in men is an external hernia.

The protrusion of the hernial sac with the intestinal loops and parts of the abdominal omentum trapped in it occurs through the inguinal canal (canalis inguinalis), which is a triangular-shaped slit with an average length of about 50 mm, located in the thickness of the anterior abdominal wall between the internal muscular layers of the abdomen, the oblique and transverse.

The anatomical prerequisites or causes of inguinal hernia in men in adulthood are associated with the peculiarities of embryogenesis of the male genitals, which begin to form in the fetus at the end of the first trimester of pregnancy (as is known, in the first seven weeks the fetus has no differences in gender). The external genitals of the male fetus are already formed by the 20th week, but the testicles from the abdominal cavity descend into the scrotum (scrotum) only by the end of the pregnancy. The descent occurs by protrusion of part of the serous membrane of the vaginal process and downward movement directly through the layers of the abdominal muscles. This is how the inguinal canal is formed, which almost completely closes in boys only in the neonatal period. But for the passage of the spermatic cord, blood vessels and nerves through it, the upper (external) opening and the lower (or internal) opening remain. It is through them that hernial protrusion occurs in most adult men, since during their intrauterine development, weakened zones can arise both in the inguinal canal and in the fibers of the abdominal muscles themselves.

We have provided these anatomical details not only to explain the cause of inguinal hernia in men, but also so that patients understand the essence of the disease and do not hope that medications, herbal folk remedies or homeopathy can help them.

And now about the second component of the cause of inguinal hernia in men - increased internal abdominal pressure. Why does it increase? Doctors explain the reasons for increased internal pressure on the abdominal wall:

• lifting weights;
• jumping from great heights;
• peritoneal injuries (blows to the abdominal area);
• prolonged standing;
• chronic constipation (that is, associated with tension in the abdominal muscles during defecation);
• chronic severe cough;
• overweight and obesity;
• sudden weight loss when losing weight;
• ascites (abdominal dropsy).

Inguinal hernia in older men occurs due to age-related changes in muscle tissue, including the abdominal press. With age, the fascia of the oblique and rectus abdominis muscles becomes shorter and thinner, and muscle tissue is partially replaced by fibrous tissue. This increases the risk of hernia after 60.

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Symptoms of a male inguinal hernia

Many people do not seek medical help when the first signs of this pathology are evident: the appearance of a swelling in the groin area that varies in size, disappears when lying down and increases when changing body position, during physical activity, after coughing or visiting the toilet.

It should be taken into account that the symptoms of inguinal hernia in men either manifest themselves over a long period or can progress rapidly - due to the effect of excessive intra-abdominal pressure (as discussed above). With insignificant hernia sizes, complaints are reduced to a burning sensation in the groin, heaviness in the lower abdomen.

Also, pains with inguinal hernia in men occur periodically - after lifting weights or straining the abdominal press caused by other factors. If the protruding intestine descends into the scrotum, pain and swelling around the external genitalia occur, and problems with urination appear.

A large hernia is associated not only with discomfort when walking, but also with more severe pain, often of a constant nature - in the groin area and lower abdomen, radiating to the sacral or lumbar region.

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Forms

Although the localization of this type of hernia is the same, in surgery it is customary to distinguish between the types of inguinal hernia in men.

Firstly, inguinal hernias can be congenital or acquired. Congenital ones are a consequence of the formation of a hernial sac (in which intestinal loops fall) from the completely unhealed part of the serous membrane of the vaginal process after the descent of the testicles into the scrotum. All other clinical cases represent acquired inguinal hernias.

Secondly, inguinal hernias can be reducible or non-reducible. A reducible inguinal hernia in men is distinguished by the fact that in a supine position, the doctor or the patient himself can carefully return the hernial sac into the abdominal cavity.

A direct inguinal hernia in men is diagnosed if it forms through the upper opening of the inguinal canal (hernial orifice) with stretching of the inguinal canal in the area of its posterior wall – with an exit at the base of the scrotum. A direct inguinal hernia can also come out through a weak spot in the fascia of the abdominal wall. Direct hernias account for approximately 25-30% of all inguinal hernias and, as a rule, occur in men after 40 years of age.

An oblique inguinal hernia in men is observed when the hernial sac enters the upper opening of the inguinal canal and exits through the lower one. Since part of the hernial sac remains in the canal, mechanical compression of the spermatic cord often occurs. Actually, this explains why inguinal hernia in men and infertility can have the same etiology.

In addition, with this type of hernia, its sac often descends into the scrotum, and then doctors say that it is an inguinal-scrotal hernia in men.

There is also a canal or internal inguinal hernia in men, and it is determined when, having entered the inguinal canal from above, it does not come out of it and only when coughing or straining the abdominal muscles, a bulge appears under the skin for a short time. Internal inguinal hernias sometimes include cases of localization of the hernial formation inside the muscles of the abdominal wall between the oblique and transverse layers.

Depending on which side of the pubic area the hernial sac comes out from, a right-sided inguinal hernia in men or a left-sided inguinal hernia in men is determined; there is also a hernia on both sides, that is, a bilateral inguinal hernia in men.

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Complications and consequences

The main complications of a hernia occur when the contents of the hernial sac are compressed in the area where the hernia exits into the inguinal canal. Then a strangulated inguinal hernia or strangulated inguinal hernia in men is diagnosed. This is a potentially dangerous condition, since strangulation prevents blood flow into the intestine or stops the flow of intestinal contents.

It is impossible to reduce a strangulated hernia, and patients, in addition to severe pain in the groin and lower abdominal cavity, note nausea and severe vomiting, constipation and flatulence; subfebrile temperature and pronounced tachycardia. Indisputable evidence of strangulation of the hernia is a change in its color to red-violet or blue-purple due to circulatory disorders. These signs are the most convincing argument for the need for urgent surgical intervention. Otherwise, strangulation of the inguinal hernia in men threatens intestinal obstruction, complete cessation of blood flow in its strangulated loops and their necrosis. The consequences can be fatal, since with intestinal obstruction, total self-poisoning of the body develops, and tissue necrosis can lead to peritonitis.

Surgeons also note other complications of this pathology:

• inflammation of the inguinal hernia in men (if the hernial sac is infected);
• inflammation of the testicles;
• disruption of intestinal peristalsis and accumulation of fecal matter (occurs when part of the colon enters the hernial sac);
• trauma to a hernia with disruption of the integrity of the intestines that have entered its cavity.

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Diagnostics of a male inguinal hernia

In all cases, the diagnosis of inguinal hernia in men begins with examining the patient in a lying position and standing while coughing (to increase internal abdominal pressure). A palpation examination of the protrusion is also carried out (this determines the possibility of reducing the hernia).

Instrumental diagnostics includes herniography (X-ray of the hernia) with the introduction of a contrast agent into the abdominal cavity (through a puncture in the abdominal wall).

To clarify the type of hernia, an ultrasound scan for inguinal hernia in men with visualization of the inguinal canal and scrotum may be required.

Differential diagnostics of inguinal hernia is designed to exclude possible inflammation of the inguinal lymph nodes, femoral hernia, vascular aneurysm, hydrocele, inflammation of the epididymis (epididymitis), dilation of the veins of the spermatic cord and testicles (varicocele), congenital undescended testicles (cryptorchidism), torsion of the testicle and spermatic cord, and lipoma of the spermatic cord.

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Treatment of a male inguinal hernia

Folk treatment of inguinal hernia with compresses from a decoction of plantain, callisia (golden mustache) or sauerkraut brine does not give results. And, as already noted at the beginning of the article, there is no cure for this disease.

Of course, the use of symptomatic drugs is necessary: analgesics and NSAIDs - to relieve pain or inflammation. But no pharmacological agent eliminates the cause of the pathology in inguinal hernias.

Therefore, today there is only one way - surgical treatment. It can be either planned (to avoid strangulation), or - in case of strangulation of the hernia - urgent.

Surgical treatment, which involved simple suturing of the hernia - herniorrhaphy, after which chronic pain and a high risk of relapse occur, has not become a thing of the past, but has been improved to herniotomy with plastic surgery of the abdominal wall (performed in a hospital, the standard stay is 7-10 days). Preparation for the operation, which is performed on a planned basis, includes standard general blood and urine tests, blood clotting tests, ECG, ultrasound or X-ray of the pelvic organs.

After the incision, the surgeon reaches the hernial sac from the inside and after opening it and revising the contents, moves the intestines to their "rightful" place. The operation requires great precision, since the spermatic cord passing through the inguinal canal is affected. The abdominal wall is also strengthened at the site of the hernia protrusion. If the open operation is performed using the Shoydals method, then autoplasty is used.

But most often, surgical treatment of hernia is carried out using the method of Californian surgeon Irving Lichtenstein "tension-free mesh" (Tension-Free Mesh). Every year in the USA alone, about 750 thousand operations on inguinal hernia are performed using this technology. This type of hernioplasty for small hernias is done under local (epidural) anesthesia, and the patient (after examination by a doctor) can go home on the same day or the next day.

Through a 50-70 mm incision in the groin area, the surgeon reaches the hernial orifice, returns the small hernial sac into the abdominal cavity or ties it and removes it completely, and in case of a larger hernia, performs a partial excision of the anterior wall of the hernial sac with subsequent standard actions. The dissected muscles are sutured layer by layer without strongly tightening the edges, and a specially shaped “patch” made of polymer mesh material is applied between the muscle layers of the abdominal wall for their greater strength. Surgical meshes are used as a reinforcing material for the ingrowth of new tissue.

But laparoscopy of inguinal hernia in men is losing its popularity among both patients and doctors. Despite the minimal external traumatic effect (three punctures are made in the abdominal wall, and there are practically no scars), the negative consequences after the operation performed endoscopically force Western surgeons to resort to it only in cases where the operated hernia recurs in the same place. Firstly, it should be borne in mind that laparoscopy is performed under general (endotracheal) anesthesia. Secondly, carbon dioxide is pumped into the abdominal cavity to create a wider operating space (what this leads to - see below).

It should be taken into account that, according to statistics, after surgery, recurrence of inguinal hernia in men occurs in approximately 10% of cases.

Consequences after surgery and rehabilitation after inguinal hernia in men

First, let's look at the main consequences after surgery, depending on its type.

After open hernioplasty with plastic surgery or Tension-Free Mesh hernioplasty, long-term pain occurs in the groin after surgery (in 45-60% of cases). Experts cite a number of causes of post-herniorrhaphy pain syndrome (PHPS), including: nerve damage directly during surgery; nerve entrapment in scar tissue, mesh or suture; narrowing of the internal inguinal ring around the spermatic cord; postoperative benign nerve tumors (neurinomas), etc.

Pain after surgery affects up to 96% of patients who have undergone laparoscopic inguinal hernia surgery in men. This is known in the professional community as post-laparoscopic pain syndrome. Pain occurs at the puncture sites and trocar insertion sites (in 40-45% of cases), as well as due to intra-abdominal trauma and rapid stretching of the peritoneum with traumatic stretching of blood vessels and nerves. Doctors associate the occurrence of this pain syndrome in the upper right part of the abdomen and the projection of pain to the shoulders with irritation of the phrenic nerve due to pressure on it by the subphrenic gas bubble, which does not resolve immediately after surgery in more than 90% of patients.

In addition to pain, the following consequences are noted after hernioplasty and laparoscopy:

• a feeling of the presence of a foreign body in the groin area,
• quite a hard seal after surgery,
• damage affecting regional nerves,
• inflammation of the testicle and its atrophy,
• formation of hematomas and accumulations of serous fluid in the scrotum area,
• anejaculation or painful ejaculation due to damage to the spermatic cord or nerve (about 12% of cases),
• formation of blood clots in the deep veins of the leg (especially in older patients), etc.

In order for rehabilitation after an inguinal hernia in men to proceed without complications, it is necessary:

• do not lie down, but start walking no later than 3-4 hours after the operation;
• monitor the condition of the suture and prevent it from becoming infected;
• stop lifting heavy objects (max weight 5 kg);
• if you have a chronic smoker's cough, give up this bad habit;
• achieve normalization of bowel function and combat constipation.

By the way, prevention of this pathology consists of practically the same points. To fulfill the last point, nutrition after inguinal hernia surgery in men should be complete, but with a reduced proportion of fats and carbohydrates. What should be the diet after inguinal hernia in men - see Diet after hernia; also specific recommendations for proper nutrition after surgery - see Diet after surgery.

As clinical practice shows, 40-45 days after the operation, the life of most patients returns to normal. Sex is possible after an inguinal hernia operation in about the same time, but here everything is individual. If there are problems in this area, you need to contact your doctor, since after such a surgical intervention they can be quite serious: erectile dysfunction occurs with damage to the spermatic cord and expansion of its veins (varicocele), hydrocele of the testicles, etc.

Treatment without surgery

Taking into account the pathogenesis of the disease, it is believed that treatment of inguinal hernias without surgery is impossible.

It should be borne in mind that a bandage for inguinal hernia in men also does not cure, but only helps to ensure that the reducible inguinal hernia in men is held in the abdominal cavity.

But this aid can bring not only greater comfort to patients: it turned out that wearing a bandage for an inguinal hernia for a long time in men is harmful. Firstly, the size of the hernial orifice and the hernia itself can increase, secondly, the funiculus spermaticus (spermatic cord) passing through the inguinal canal, inside which the vas deferens, vessels and nerves are located, can atrophy under the constant pressure of the bandage and stop performing its functions.

According to some doctors, the treatment of inguinal hernia in men with physical exercises has no therapeutic effect. However, many specialists advise increasing the strength of the abdominal wall muscles with the help of exercises, but only while lying on your back or sitting. For example, the following exercises are performed:

• abdominal breathing with a weight (1-2 kg) on the abdominal wall;
• raising straight legs by 30° in relation to the horizontal position of the body;
• raising the shoulder girdle and shoulder blades from a horizontal position (with hands placed on the head);
• squeezing a ball placed between the knees (while lying on your back, with your knees bent), etc.

The most suitable yoga asanas for inguinal hernias are: uddiyana, pawanmuktasana, sarvangasana, etc. The uddiyana asana should be performed while sitting: forcefully exhale the air, “squeezing” it out of the lungs, pulling in the stomach as much as possible, hold for three seconds, and then take a deep breath through the nose. Repeat 5-6 times.

To perform pawanmuktasana, you need to lie on your back, bend your right leg at the knee (the left leg lies flat on the floor) and, clasp your shin with both hands, pull the bent leg to your chest and stomach. Then lift your head and shoulder blades off the floor, and touch your forehead or nose with the knee of your bent leg. As you exhale, take the initial position. The same action is performed with the other leg. And sarvangasana is a "birch" on the shoulder blade part of the back with the support of the lower back with both hands.

Of course, moderate physical activity – without increasing intra-abdominal pressure – is useful, especially for obese men. So strength training, for example, with a barbell, is contraindicated for inguinal hernias. For the same reason, inguinal hernia in men and bodybuilding are considered incompatible, as is weightlifting.

Forecast

Despite the fact that specialists from the European Hernia Society define the prognosis of this pathology as conditionally favorable, an inguinal hernia in men – after timely surgical treatment – allows most patients to lead a normal life.

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