Hernia: Causes, Types, Signs, Symptoms, Prevention, And Treatment

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Types Of Hernia

A hernia is a painful sac containing a part of a displaced organ or a fatty tissue, usually around the belly button or in the groin, which if left untreated, can be fatal. It can either be congenital or may develop due to activities like heavy lifting or strenuous sports or health conditions like constipation or chronic cough that increase pressure on the abdominal wall. Almost all hernias, except hiatal hernia require surgery. So prevention is the safest choice.

A hernia is a painful sac containing part of an organ or a fatty tissue that has become displaced and pierces the wall of the cavity that contains it and protrudes from it. The region for hernias extends from the chest to the groin. The organ most involved in hernias is the small intestine, which protrudes through the abdominal wall into various areas.

The common types of hernia are:

1. Inguinal Hernia (In The Groin)

An inguinal hernia is the bulging of the small intestine into the inguinal canal in the groin. The inguinal canal is a tube-like structure in the lower abdomen on either side of the groin. About 20% of males suffer from inguinal hernia compared to 2% women.1

Indirect Inguinal Hernia

During the development of male babies in the womb, the testes come down into the scrotum through the inguinal canal. Usually, the abdominal lining closes the entrance to the canal shortly before or after birth. But if the passageway is not closed properly, a loop from the small intestine enters it and travels down along the spermatic cord, emerging near the scrotum. This is indirect inguinal hernia, which is most often a birth defect.

It is the most common type of inguinal hernia, occurring mostly in male children. While 2–3% of male babies are affected, less than 1% female babies have indirect inguinal hernia.2 This is because while women also have the inguinal canal, it is very small and ovaries do not usually descend like the testes. Indirect inguinal hernia in female babies is caused by a sliding hernia that contains the ovaries, fallopian tubes, or the uterus.3

Direct Inguinal Hernia

Direct inguinal hernia occurs later in life as the abdominal wall becomes weak with age and heavy pressure may puncture a hole through which the small intestine or a fatty tissue then protrudes. It is most common in men above 40 and rare in women. This is because the broad ligament of the uterus adds another layer of barrier behind the abdominal wall.

Signs And Symptoms

The symptoms of inguinal hernia are felt mostly on the right side, with a right-left ratio of about 68:23. In about 8.5% of the cases, it can affect both sides.4

If your hernia recedes when you lie down, you have reducible hernia. If it doesn’t, you have non-reducible hernia. This type often indicates that the hernia is trapped and blood supply to it may soon stop. Please see a doctor immediately. 

  • A small bulge under the skin near or on the crease between the abdomen and the thigh or in the scrotum that is visible when you stand or do anything that strains the abdomen – like coughing, sneezing, swimming, cycling, or lifting weights – and invisible when you lie down
  • Pain, weakness, or discomfort in the groin, especially with any activity that strains the abdomen
  • An enlarged or swollen scrotum

Complications

If the loop of the small intestine, or any herniated organ, gets trapped within the scrotum and does not recede back into the abdomen even when you lie down, it leads to an incarcerated hernia. If this hernia is not treated, it receives no blood supply and eventually dies. This type of hernia is known as strangulated hernia and is a fatal condition. It needs immediate surgery. Indirect inguinal hernias are mostly responsible for this condition.

Treatment For Inguinal Hernia

There is not much difference in the treatment for direct and indirect inguinal hernias. But because indirect hernias are more likely to obstruct blood flow to the small intestine, they need stricter monitoring. Surgery is the main form of treatment where the hernia is moved back into place and a supportive screen is added to the abdominal wall. However, if your symptoms are not severe, you can delay the surgery with close monitoring5 and with a truss that keeps the hernia in place.

At a glance: Indirect inguinal hernia is mostly a birth defect, affecting 2–3% of male babies and less than 1% female babies. It happens when the passage through which the testes descended into the scrotum is not closed off naturally and the small intestine loops through it. Direct inguinal hernia is common in men above 40 and is caused when weak abdominal muscles undergo excessive strain. Symptoms include pain and discomfort in the groin. Surgery is the only treatment but can be delayed depending on the severity of symptoms.

2. Femoral Hernia (In The Thigh)

A femoral hernia is the bulging of the small intestine through the upper thigh near the groin. These are often confused with inguinal hernia. But in this case, the loop of the small intestine enters the femoral canal and not the inguinal canal. It affects women more than men – 20% women compared to 5% men6 – because of the wide pelvic area in women and the larger opening of the femoral canal. In very rare cases, the fallopian tube may also herniate and enter the canal.

Though the hernia is mostly seen in women between 40 and 70 and rarely in younger people,7 it is not clear whether it is a birth defect or acquired. But increased pressure inside the abdomen due to bronchitis, pregnancy, or constipation has a role to play in its development and suggests an acquired nature.8 Other causes include chronic coughing, heavy lifting, fluid accumulation in the abdomen, chronic pulmonary obstructive disorder, dialysis, and surgeries to remove excess brain fluid.9 In the rare cases that it appears in children, it is preceded by a disease or condition that raises pressure within the abdomen.

Symptoms Of Femoral Hernia

Worryingly, you may totally disregard the symptoms of a femoral hernia until a complication like strangulation arises because they rarely disrupt your life. Here are the key symptoms of femoral hernia.

  • A bulge in the upper thigh
  • Mild discomfort, especially during strenuous movements

Treatment For Femoral Hernia

Like indirect inguinal hernias, femoral hernias have a high risk of strangulating because of the narrow space within the femoral canal and the rigidity of the femoral ring at the opening of this canal. But if you’ve been diagnosed with femoral hernia, it’s best to get a surgery done without waiting for complications to arise like you can if you have inguinal hernia. This is because, often, the first signs of the hernia show up only when strangulation has occurred. When the hernia is strangulated, it causes intense and increasing pain within a short time, redness and tenderness in the bulge, fever, and nausea. Go for an immediate surgery because the strangulated portion of the small intestine may die within 8–12 hours and then become gangrenous.10

At a glance: About 20% women suffer from femoral hernia, especially between 40 and 70 years age, compared to 5% men. It may be present at birth but may show up much later as a bulge in the upper thigh. Often, the first sign of a femoral hernia may show up when it has become strangulated and needs immediate surgery. So if you know you have one, don’t delay your surgery waiting for complications.

3. Umbilical Or Paraumbilical Hernia (Near The Navel)

When the baby is in the mother’s womb, it has a hole in the abdominal muscle through which the umbilical cord passes. After birth, this hole closes naturally. But in 20% of all newborns, this hole in the abdominal muscle doesn’t close, and the small intestine bulges through.11 This is umbilical hernia in children. Premature babies, babies with a low birth weight, and African American infants are more prone to this condition.

Umbilical hernia in adults occurs when the small intestine pushes through a weak spot in the abdomen. It is caused by obesity, excessive pressure on the abdomen due to chronic cough, constipation, accumulation of fluid in the abdomen, or even lifting heavy objects. In women, multiple pregnancies might weaken the abdominal wall enough to increase the risk of hernia.

Symptoms Of Umbilical Hernia

A tiny soft bump above the belly button is one of the main umbilical hernia symptoms. It is visible when the baby cries, laughs, or sits up. It might disappear when your baby lies down.

Treatment Of Umbilical Hernia

Umbilical hernia in babies usually disappears before they turn 1. But if it’s still present when the baby is 4, opt for surgery to push the hernia back in and stitch the abdomen.12 Larger hernias may spontaneously heal by the time the child is 11.13 The chance of a hernia strangulating is very rare in babies, so it’s usually not a cause for worry unless you notice the lump becoming tender, more swollen, red or discolored and your child vomiting or running a temperature. In that case, it needs an immediate surgery.

Umbilical hernias in adults must be surgically treated as soon as possible to avoid complications. They are unlikely to disappear on their own. Surgeons usually put a mesh to strengthen the abdominal wall.

At a glance: Low birth weight and premature birth are risk factors for your baby’s developing umbilical hernia. So make sure you take precautions to avoid these. In case your child has it, delay surgery till they turn 4, by which time the hernia usually heals naturally. Your reasons for getting umbilical hernia are same as those for other hernias. And surgery is the only treatment.

4. Epigastric Hernia (In The Upper Abdomen)

Epigastric hernia is usually a protruding lump of fatty tissue between the upper abdomen (epigastrium) and the belly button. It happens when the abdominal wall is so weak that a hole forms through which a fatty tissue or, in rare cases, the small intestine loops out. Straining, heavy lifting, physical injuries, and obesity are potential causes of epigastric hernia in adults. In children it is mostly a birth defect caused by the improper closure of the abdominal fatty tissue during development.

Symptoms Of Epigastric Hernia

In the beginning, discomfort is the only sign. But more advanced epigastric hernia symptoms are pain and swelling during vigorous tasks.14 The bulge usually disappears when you lie down.15

Treatment Of Epigastric Hernia

To treat an epigastric hernia, surgery is the best choice because it does not naturally heal. Surgery can repair the hole before it gets large and worse. Epigastric hernia often shares symptoms with other diseases like peptic ulcer, gallbladder disease, pancreatitis, and upper small-bowel obstruction. So it’s important to rule these out before a surgery is performed.16 It may even be confused with a hiatal hernia.

At a glance: Epigastric hernia is caused by a fatty tissue, and in rare cases, the small intestine, looping out through a hole in the upper abdominal muscle. It starts as discomfort in the abdomen but may develop into pain and swelling during strenuous activities. Surgery remains the only option as this does not heal naturally.

5. Hiatal Hernia (In The Upper Abdomen)

A hiatal hernia develops when the stomach bulges up over or through the diaphragm. It occurs mostly in people above 50. If kids have this form of hernia, it’s congenital.17 Note that the fault in this type of hernia lies with your diaphragm and not with abdominal walls.

The esophagus passes through a hole in your diaphragm called the hiatus. There is a gate-like structure in the esophagus at this junction, marking the boundary between the esophagus and the stomach. It is known as the lower esopahagal sphincter (LES) and it allows food to pass into the stomach from the esophagus but not the other way around.

Sliding Hiatal Hernia

In hiatal hernia, the hiatus is weak and the lower esophagal sphincter along with a portion of the stomach slides up into the chest cavity. It then forms a lump in the upper abdomen and may keep moving up and down the chest cavity. This lump is known as a sliding hiatal hernia. About 95% of hiatal hernias are of this type. 

As the LES moves up from its correct position, it loses its ability to close properly and avoid back flow of stomach acids into the esophagus. This usually sparks gastroesophagal reflux disease (GERD), which is characterized by heartburn and acid reflux.18 Night-time heartburn is also more frequent and severe for patients with hiatal hernia.19 The cause of hiatal hernia is unknown, but age, smoking, and obesity are contributing factors.

Both epigastric and hiatal hernias are located in the upper abdomen. So it’s not easy to distinguish between the two. But most hiatal hernias cause symptoms of GERD, such as acid reflux or heartburn, which can be taken as a differentiating symptom.

Paraesophageal Hernia

Sometimes, however, the LES stays in place but the upper part of the stomach bulges above the diaphragm such that it lies next to the esophagus. This type of hernia has greater risk of causing incarceration and strangulation. So a paraesophageal hernia needs immediate attention. The caveat here is that it often manifests no symptoms.

Sometimes, paraesophageal hernia may be accompanied by sliding hiatal hernia. More rarely, along with the stomach, parts of the spleen, pancreas, and colon may also slide above the diaphragm. All these types together make up 5% of hiatal hernias.20

Symptoms Of Hiatal Hernia

Sliding hiatal hernia symptoms in women and men are from the reflux. It leads to pain, heartburn, and difficulty swallowing. Paraesophageal hernia is mostly without symptoms but may cause chest pain, pain in the upper abdomen, difficulty swallowing, and shortness of breath. Some patients might have GERD too. It may even lead to a type of stomach ulcer known as Cameron’s erosion.21

Treatment Of Hiatal Hernia

Unlike most hernias, sliding hiatal hernias can be treated with medicines to regulate stomach acid and esophageal muscle strength. The goal is to control the back flow of gastric acid. To do this naturally, avoid heavy large meals.22 Don’t eat acidic foods like tomato sauce, soda, caffeine, garlic, alcohol, and mint. Choosing small low-fat meals can prevent hiatal hernia symptoms. Paraesophageal hernia, if incarcerated, requires surgery or laparoscopy.

At a glance: Hiatal hernias occur mostly in people above 50 but can also be congenital. Sliding hiatal hernia, which makes up 95% of all hiatal hernias, is the bulging of a part of the esophagus and the stomach in the chest cavity, causing heartburn and acid reflux. It can be treated by treating the GERD. Paraesophageal hernia occurs when the stomach bulges up above the diaphragm. Though mostly without symptoms, it may cause pain in the chest and upper abdomen. It may require surgery if blood supply to the herniated part gets cut off.

6. Incisional Hernia (Wounds In The Abdomen)

An incisional hernia is the hernia caused by a tissue or an organ protruding from an incision from a previous surgery. If the incision doesn’t heal right, because of wound infection or the rupture of the suture or other factors like obesity, diabetes, and smoking, a hernia can develop. About 10–15% of abdomen surgery patients get an incisional hernia,23 and about 3.1% of women who have undergone C-section (caesarian section) get incisional hernia, but it is mostly associated with improper surgery technique, wound infection, a distended abdomen after surgery, sepsis, fever after surgery, and malnutrition. Further surgeries could complicate matters.24

Incisional hernia symptoms may show up right after surgery or even years later. The bump will be more obvious under pressure, but it’ll go away when you lie down. Pain and discomfort will also lessen in this position. An incisional hernia usually grows over time. It might also get stuck in the abdominal wall, so repair is crucial. But a corrective surgery must be performed by an expert, preferably using a mesh to provide support to the abdominal wall.

At a glance: Incisional hernia develops when a wound from a surgery doesn’t heal or ruptures, making it possible for fatty tissues to poke through. It grows large and cab cause pain and discomfort. You will need yet another surgery to repair it. Proper post-operative care, watching your weight, and avoiding smoking are must if you want to lower the risks.

7. Sports Hernia

Sports hernia or athletic pubalgia is actually a tear of muscle, tendons, or ligaments in the groin caused by a sudden and intense twisting movement during any sports activity, especially football, ice hockey, and soccer. It does not bulge like other hernias, but it is very painful. You’d experience a severe pain right after the injury. It might seem to get better after rest but will typically come back when you resume your sports activities. It may even develop into an inguinal hernia. Typical treatment includes rest, physical therapy, and anti-inflammatory medicines. But sometimes, surgery may also be required.25

Prevention Of Hernia

You can’t prevent certain types of hernia, especially the congenital versions like indirect inguinal, umbilical, epigastric, or hiatal hernia. But the rest of the hernias can be prevented if you follow these:26

  • Maintain a healthy weight.
  • Exercise your core muscles to strengthen them.
  • Do not smoke.
  • Avoid lifting heavy objects. If you have to lift, use your legs rather than your back.
  • Eat high-fiber foods to avoid constipation and straining when you clear your bowel.

Home Remedies

While surgery is the only cure, natural remedies can control symptoms:

  • Apply ice to ease the pain.
  • Traditional Chinese medicine suggests taking hawthornia to strengthen the abdominal muscles. It is meant to correct the flow of qi in cases of inguinal and femoral hernia and some cases of umbilical hernia.
  • Marshmallow root, ginger root, licorice root, and chamomile can reduce stomach acids and calm down the digestive system.
  • Acupuncture targeted toward stomach hernia symptoms may decrease discomfort and pain.
  • Exercise to keep fit. But please bear in mind that you shouldn’t exercise the muscles around the hernia. Speak to your doctor before you embark on an exercise regime.
  • Avoid smoking and alcohol.
  • Avoid stressful and strenuous activity.
  • Work toward losing weight to reduce pressure and painful abdominal hernia symptoms.

If any of the hernia signs we have mentioned above sound familiar, see a doctor immediately. The sooner you get it checked, the faster you can stop future problems.

The symptoms of a strangulated hernia, wherever it may be located, are a red or purple bulge, intense pain, nausea, and fever. It is a fatal condition. So see a doctor immediately if you experience these.

References   [ + ]

1, 3, 4.Chawla, S. “Inguinal hernia in females.” Medical Journal Armed Forces India 57, no. 4 (2001): 306-308.
2, 5, 26.Inguinal Hernia. National Institute of Diabetes and Digestive and Kidney Diseases.
6, 8.Nikolopoulos, Ioannis, Eshan Oderuth, Eleni Ntakomyti, and Bengt Kald. “Intestinal Obstruction due to Bilateral Strangulated Femoral Hernias.” Case reports in surgery 2014 (2014).
7.Atmatzidis, Stefanos, Grigorios Chatzimavroudis, Dimitrios Dragoumis, and Konstantinos Atmatzidis. “Incarcerated femoral hernia containing ipsilateral fallopian tube.” Case reports in medicine 2010 (2010).
9.Femoral (Thigh) Hernia. University of California San Francisco Division of General Surgery.
10.Femoral Hernia. The British Hernia Center.
11, 12.Umbilical Hernia. John Hopkins Medicine.
13.Umbilical Hernia. The British Center For Hernia.
14.Epigastric hernia repair. Royal United Hospital Bath
15.Epigastric Hernia. Yale School of Medicine.
16.Muschaweck, Ulrike. Umbilical and epigastric hernia repair. Surgical Clinics of North America 83(2003):1207-1221.
17, 22.Hiatal hernia. U.S. National Library of Medicine.
18.Guidelines for the Management of Hiatal Hernia. Society of American Gastrointestinal and Endoscopic Surgeons.
19.Karamanolis, Georgios, Dimitrios Polymeros, Konstantinos Triantafyllou, Adam Adamopoulos, Charalampos Barbatzas, Irini Vafiadis, and Spiros D. Ladas. “Hiatal hernia predisposes to nocturnal gastro-oesophageal reflux.” United European gastroenterology journal 1, no. 3 (2013): 169-174.
20.Hyun, Jong Jin, and Young-Tae Bak. “Clinical significance of hiatal hernia.” esophagus 17 (2011): 18.
21.Paraesophageal Hernia (Hiatal Hernia). Medical College of Wisconsin.
23.Kingsnorth, Andrew. “The management of incisional hernia.” The Annals of The Royal College of Surgeons of England 88, no. 3 (2006): 252-260.
24.De, Utpal, and Ramdip Ray. “Spontaneous rupture of incisional hernia associated with pregnancy.” Surgical Practice 12, no. 3 (2008): 97-98.
25.Sports Hernia (Athletic Pubalgia). American Academy of Orthopaedic Surgeons.

Disclaimer: The content is purely informative and educational in nature and should not be construed as medical advice. Please use the content only in consultation with an appropriate certified medical or healthcare professional.

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