Should You Worry About a Hernia? Signs, Risks, and Care Options

What Is a Hernia?

Interviewer: Hernias are extremely common. About 1 in 4 men and 1 in 30 women will develop a groin hernia sometime in their lifetime. Symptoms can look different from person to person and even between men and women, and they might vary by the type of hernia that you have. And if you think that you have one, it's worth knowing when to watch and when to treat.

Today, we're joined by Dr. Joanna Grudziak, a surgeon and hernia specialist at University of Utah Health. Now, Dr. Grudziak, let's start with the basics. What exactly is a hernia?

Dr. Grudziak: I think of hernias as holes where there shouldn't be one. So you can get them in many different places in your body. When we're talking about a hernia of the groin, we're really talking about what's called the inguinal hernia. And as you said, they're way more common in men because men, when they are developing, their testicles are up by their kidneys in the back, and then they migrate down into the scrotum. And so they leave behind a naturally weak spot. And as we get older and we gain weight or we start heavy weight lifting, or just because we have genetically inherited a predisposition for them, those holes enlarge over time, and they can have things stuck in them.

When I think about a hernia, I think about the size of the hole and also what is poking through it. And paradoxically, the smaller the hernia, the more likely it is to hurt because the contents of the hernia, which are the things that are poking through it, have to squeeze through a very small opening, and that causes discomfort and pain.

Interviewer: And when you say things that are squeezing through, what exactly makes up that stuff?

Dr. Grudziak: So the most common thing that is inside a hernia is just a piece of fat that everybody has to a varying degree in between different abdominal wall layers and groin layers. But fat is a living tissue, and it has a blood supply, and it has nerves. And so what causes the pain with that hernia is either pressure from that globule of fat pushing down on nerves, or the fat itself getting squeezed and getting angry from not having enough blood supply. The bigger the hernia, the more likely there are other things can be found in it. In the groin specifically, it can be anything from small intestine to large intestine to bladder, to appendix, to stomach, even for the really gigantic hernias.

Who Is Most at Risk for Developing a Hernia?

Interviewer: Now, you've mentioned a couple of times that there are maybe different types of hernias. What kind of hernias are we talking about today?

Dr. Grudziak: So we're talking about the hernias of the groin. For men, they're usually predominantly inguinal hernias. Same for women, but women can also have what are called femoral hernias and obturator hernias, which are in the same general anatomical location, but they can present with different kinds of symptoms; they are repaired the same way.

Interviewer: Who are the types of people who can get a hernia? I know we already talked about how men have a, you know, naturally weak spot that can get through. But are there other elements, maybe behavioral or individual genetics, that kind of make up when and where they might get a hernia in their life?

Dr. Grudziak: You know, specifically for groin hernias, being overweight can definitely cause pressure on the groin and pressure on the inguinal canal. Smoking and diabetes, classically, heart tissues and make them become weaker over time. Genetics can play a role. This is not quite as well studied here as it is in some places in Africa, where there's even something called the hernia belt. But things that increase intra-abdominal pressure, so a lot of heavy weight lifters, people who have a job that is heavy into lifting or pushing, or such as, you know, construction workers or restaurant workers, do develop them more often. And then people who cough chronically can also have them. And then anything that systemically endangers tissues, so something like chemotherapy or immunosuppression, being on high doses of steroids can definitely just weaken tissues in general. And so if you already have a predisposition to having a hernia from being a man, then that will be something that makes it potentially worse.

Interviewer: That was a lot of different people. Like, is there anyone who is immune to a hernia, or is it just about anyone?

Dr. Grudziak: Well, you are a man . . .

Interviewer: Right.

Dr. Grudziak: . . . so about 25% of you will have them.

Interviewer: Okay.

Dr. Grudziak: But yeah, no, it's one of the most commonly seen conditions by general surgeons.

Common Warning Signs That You Might Have a Hernia

Interviewer: What are some of the common signs or symptoms?

Dr. Grudziak: You know, it can be anywhere from pain that's disabling to pain that's occasional. A lot of people tell me, you know, they were either remodeling a house or helping their grandmother move out or doing some strenuous activity, and they felt a pop in their groin. One patient I had described it as a guitar string snapping . . .

Interviewer: Oh, wow.

Dr. Grudziak: . . . which was a pretty good description, I think. And then afterwards, they usually feel a bulge. And that bulge can be there, usually classically with changing in position. So anything that pulls on your groin, like gravity or standing up or whatever, can make it pop out. A lot of the time, the pain is worse at night because you've gone through a whole day of standing up and doing things, and it goes away during the night when you sleep. Those are kind of the most common symptoms that are not alarming in terms of being, you know, something that needs to be looked at sooner rather than later. But those are the most common reasons why people seek help, because it hurts.

Interviewer: Do hernias ever heal on their own? Like, I guess, you know, is it just like a sit and wait, or is it like we need to get in and see someone?

Dr. Grudziak: Yeah, unfortunately, they don't. But just because you have a hernia doesn't necessarily mean you should get it fixed. And you know, I think of it as the same class of surgery as, say, a knee replacement or something of that kind, where you do it because your quality of life is poor with your condition, and you're hoping to make your quality of life better. But a very, very small percentage of these are a life-or-death kind of situation. The overwhelming majority of them are performed to improve your quality of life.

How to Recognize a Hernia Emergency

Interviewer: And is there ever a point at which a hernia would become, say, dangerous? Like it's something that might need to be immediately figured out? With my basic research, I've seen strangulation or incarceration words being utilized. When is it an emergency?

Dr. Grudziak: Yeah, sure. So I tell all my patients to watch out for, you know, some of them are common sense things, so pain that doesn't go away with your standard maneuvers. Some people get good at supporting their scrotum or putting a little bit of pressure on the bulge or changing their position to fix the gravity pull on this. But if that doesn't work and you're having pain that's more severe, that's a warning sign.

Another one is any kind of skin changes over the top of the hernia. So if the area gets really red or inflamed or really angry looking, that's something that needs to bring you to the hospital immediately. If you're having nausea and vomiting, you can't eat, can't pee, and then have fevers, and most people report just excruciating pain that just does not go away. And that's usually a sign of, you mentioned both incarceration and strangulation.

So incarceration is a word that's used for... remember that I mentioned the contents of the hernia when they can't go back to their normal home, and they're forever stuck in a hernia. That's called incarceration. But strangulation is when that is the emergency, and that's when the blood supply to those things that are stuck in a hernia becomes compromised. So if it's just a piece of fat, then the pain will be severe, but it is not a life-threatening complication. But if it is a piece of bowel, then that's something that again, causes that excruciating pain and the nausea and vomiting, and potentially a fever, and it has to be repaired surgically, or that can be life-threatening.

What Patients Should Know About Hernia Surgery

Interviewer: What does a surgery for a hernia actually look like these days? Is it full open surgery, or are we doing something more or less invasive?

Dr. Grudziak: I think that's one of the biggest shifts in the last say five years. The standard of care, even up until recently, used to be an open operation, where a surgeon would make an incision kind of right by your pubic bone, going up towards your hip bone. That was about five to eight centimeters long. And we would basically identify the contents of the hernia, put them back into the abdominal cavity where they belong, and then we would put a piece of mesh that was attached to your pubic bone and kind of sewn, or close to your pubic bone, sorry, and sewn along the edge of your ligament to reconstruct that space.

Whereas now we've shifted more towards doing these hernia repairs laparoscopically or robotically. And so those are done from the abdominal approach, and you usually end up with three small incisions, kind of placed differently around the abdomen depending on which approach you use. The mesh itself will go between your abdominal wall layers. So I think of the abdominal wall as kind of an onion, and the surgeon will peel back one of the layers of the onion and place the mesh in between there.

The other kind of big improvement in terms of postoperative complications recently that we've really embraced is minimizing how we attach the mesh to the body. I personally use two sutures that dissolve over about a six-week period of time to just secure the mesh temporarily until your own body takes over the securing and the scarring-down process. Hopefully, that will reduce over a long period of time the incidence of chronic pain, which is one of the kind of most serious long-term complications of an inguinal hernia repair.

Mesh and Repair Options

Interviewer: Now, when it comes to mesh, in my basic research, I was seeing that there are some people who, you know, say, "Hey, no mesh." "Hey, we should use mesh." What is kind of the standard operating procedure, and what do you tell patients when they have that kind of question?

Dr. Grudziak: It's really important, I think, to appreciate the degree to which people are worried about having a permanent piece of foreign material placed in their bodies, and I 100% understand that. I think of the mesh as it's not really the strength layer of the repair. It's more of kind of like an intelligent scaffolding that tells your body the best way to put down the scar tissue. And so you're really helping your own body kind of create the optimal way of healing this repair that is going to support healing and prevent recurrence over a long period of time.

The meshes that we use and that most surgeons use are synthetic. They've been in use for 50-plus years. They are engineered in a way that your body should not see them. In other words, your body doesn't see it as a foreign body, doesn't try to reject it, and doesn't try to form an inflammatory reaction to it.

A small amount of patients do have scar tissue that forms around the mesh that then potentially scars down to their nerves, and that can cause chronic pain. But there are meshes on the market that are either very quick to dissolve, which are called biologic meshes, and those are usually derived from either pigs or sheep, kind of their intestines or their stomachs. Obviously, you know, cleaned up and manufactured in a way that your body doesn't respond to it that way. But those meshes usually dissolve too quickly. And recent studies have shown that they've caused more infections, so we tend not to use those.

But there are intermediate kinds of longevity meshes that stay in place for about 18 to 24 months. But those have not really been very well researched when it comes to groin hernias. They're kind of meant more for abdominal wall hernias.

So I have a conversation with people, and I usually try to allay their fears and kind of answer their questions. But if they're 100% opposed to using mesh, then I will use the dissolvable meshes, the ones that are kind of intermediate-weight ones or intermediate duration ones, and hope that they're okay with that.

How to Choose a Qualified Surgeon for Hernia Treatment

Interviewer: So that brings me to my next question is, say someone has maybe noticed something, or they've been diagnosed with a hernia. What sorts of surgical centers or doctors, what sort of things should they be looking for to make sure that they're getting a good quality surgeon?

Dr. Grudziak: One of the things that I think is really exciting about these new hernia centers of excellence kind of developments, I think if they get a standardized set of requirements, and that will be a very nice way for people to know who to go to. There are multiple places where you can go online to kind of have ratings for surgeons. I think one of the most important things that you have to have is trust. So if your gut tells you that your surgeon is not a good fit for you, then you should not go with that surgeon.

But it's really important to emphasize that hernias, especially kind of the simple hernias in otherwise healthy people, are really bread and butter for most general surgeons to perform, and most people are comfortable doing those. I think if you have a specific approach that you prefer, so if you want to get it done open or you want to get it done minimally invasively, also most surgeons are comfortable doing them both ways. If you are someone who is maybe struggling with some chronic illness, or you've had prior repairs, or you've had a lot of surgeries, then those would be people that I would point more towards places like the U, where we specialize in taking care of patients who are complex and in problems that are complex.

But really, simple hernias that happen in healthy people, every surgeon should be able to kind of take care of that adequately. You can ask your surgeon what their recurrence rates are. An acceptable number should be somewhere between 3% and 6%. And you can kind of ask them how they approach their repairs and how they approach patient care. But a lot of it is just also a feeling that you get from talking to them.

The Abdominal Core Health Quality Collaborative, the ACHQC, has a website that lists surgeons who are certified through them and also centers that have collaborated with them. It is trying to become a national website, and they're really doing a good job of driving the push to make sure that people are submitting data there and everything like that, but it has not become like a national thing quite yet.

What to Expect During Recovery After Hernia Surgery

Interviewer: After a surgery, when it comes to a hernia, what does the recovery usually look like when we're doing say either an open or a minimally invasive?

Dr. Grudziak: You know, most people have some element of pain for up to two weeks. If you are in Europe, you don't usually get prescribed opioids at all. A lot of the time, I don't. I hear from my patients that they never use opioid pain medications after the hernia surgery. I usually send everybody home on scheduled high doses of ibuprofen and Tylenol, if they can take it, because that really significantly addresses the kind of pain that postoperative pain is.

And then I usually tell people, you know, don't start a heavy weight lifting program for about six weeks. I tell them to do anything they want to do as long as it doesn't hurt. And then with the exception of heavy lifting, I usually tell people for the first two weeks to avoid anything greater than a gallon of milk, and after that kind of gradually increase it. Most of your body's healing takes place in the first two weeks or so, and so you just want to give yourself a little bit of time to really form that nice scar tissue and close up that hernia defect. But I want you moving around. I want you to do things as long as it's not hurting you.

And then, because of the type of dressing that I put on your incision, I usually tell people not to go swimming or bathing for about two weeks until the incisions heal up. But they can shower in 48 to 96 hours afterwards, and that's really it. You know, especially with the small incisions, people get kind of tricked into thinking they should not be having pain. Sometimes it also just depends on, you know, how long you've had your hernia and how stuck things are. But most people are back to feeling almost normal by the two-week mark.

What to Do When You First Notice a Bulge in the Groin

Interviewer: So, for someone who may have just noticed, let's say, a bulge today, what is the practical next step?

Dr. Grudziak: Bulges in the groin can be from many different causes, but a bulge that kind of goes back and forth, you can push it back in, it hurts when you're standing, it hurts when you're lifting, it hurts when you're coughing, those are kind of the classic symptoms for a groin hernia. If you just have a bulge and it doesn't hurt, it's okay to watch it. But if it starts bothering you, or if you're just really nervous, it's always good to get checked out. Your doctor might just do a physical exam.

A lot of these hernias do not need imaging, and they're just diagnosed on a good physical exam. But some of them, when you're having maybe the bulge goes back in when you're seeing your doctor, which they always do, or you maybe have not classic symptoms, your doctor might order an ultrasound with what's called a Valsalva, and that's basically a fancy word for people asking you to bear down like you're having a bowel movement or like you're coughing, and that's meant to push forward that bulge or push out the contents of the hernia so it's easily visible on the ultrasound. Or your doctor might also order a CT scan.

And then if that scan shows a hernia, you know, I tell my patients, if the pain is interfering with your quality of life, then you should get it fixed. And if it's something that's bothering you, then seeking care with a surgeon is a good idea. Urgent care, I think, should be reserved for, again, those warning signs, like just pain that just does not go away. You're seeing this bulge be really hard, and you don't know what's going on. If you have a fever or nausea, vomiting, that kind of stuff, you should definitely be checked out sooner rather than later. But a hernia, very infrequently, becomes a real life-threatening emergency. Most of the time, these are situations that threaten your quality of life, but they're usually not life-threatening.