An unusual bulge
In conjunction with Men’s Health Week (June 15-21), we take a look at hernias, which affect one in four men at some point in their lives.
IT all started when M. Sambath hit the golden age of 50.
He noticed a small bulge on his left groin.
Thinking it was nothing sinister, the former civil servant ignored it and continued with his usual activities, which included running marathons and lifting heavy objects.
With every passing day, the bulge grew and became painful, especially when he coughed or jumped over drains while exercising.
Still, the trim and fit Sambath was too embarrassed to see a doctor or discuss this problem with anyone – after all, whenever he lay down, the pain and bulge subsided. A chance conversation with a male neighbour about illnesses afflicting the elderly led Sambath to reveal his condition and his neighbour immediately took him to see a physician.
“The hernia was about the size of a chicken egg and had to be surgically repaired.
“They put a mesh in and I was fine. “I strictly followed the advice of the doctors, but three years later, I had another hernia on the right side,” the 77-year-old recalls.
This time, he learnt from his male friends how to push the bulge back in, but when it became too painful, it warranted another visit to the doctor and another surgical repair was on the cards.
Two months later, the right hernia recurred.
Sambath says, “Perhaps the mesh was too thin or not effective.
“Unfortunately, three years ago, the hernias recurred, this time, on both sides, and I had to do the surgery again.
“I’ve done it five times so far!” Since then, he has been extremely cautious in the activities that he performs.
“For some reason, my muscles must be weak.
“I’ve learnt to be more careful, and these days, I don’t lift more than 5kg at one time as I still get a little pain now and then.
“I also do qigong and tai chi exercises daily,” he shares.
An abnormal protrusion
Like Sambath, one in four men develop a hernia at some point in their life.
“Hernia is referred to as angin pasang in Bahasa Malaysia (or breuk in Dutch, rompure in French and keal in Greek).
“It is known to have affected mankind for centuries and is well documented in Babylonian and Egyptian medical histories.
“Sage Shushrutha, the father of Indian surgery, had described hernia as the protrusion of viscous fluid or contents out of a cavity in which it is contained.
“Generally, an internal organ or tissues can protrude through the abdominal wall that normally contains it, due to weakness of the muscle or a defective hole.
“As the abdominal pressure increases, the contents are pushed out of the abdomen through the weak areas,” says general and colorectal surgeon Dr Anantha Kumar Chinnaswamy.
Hernias mostly occur in the abdominal cavity between the chest and the hips, and can be external or internal.
“The external ones are seen as a bulge on the tummy wall, while the internal ones cannot be seen and require high clinical suspicion and radiological investigation,” he says.
“Internal hernias can develop in both children and adults.
“An example is the diaphragmatic hernia, which develops through a rent in the diaphragm muscle that separates the abdomen from the chest.
“Usually, the stomach/colon/intestine passes through the hole and enters the thorax.
“The danger is that if the contents become gangrenous, it can be fatal.”
Although hernias can affect any age group and gender, it tends to affect men more than women.
Common hernias
There are many types of external hernias, the most common being the inguinal hernia (75%), which occurs in a ratio of seven males to one female, and the femoral hernia (3-5%).
Approximately 25% of men and 2% of women are at risk of developing inguinal hernias in their lifetime, with 10% of the overall population at risk for hernia, including 3% of children.
Inguinal hernias occur when a part of the lower intestine protrudes through a weak point in the abdominal wall.
This can manifest itself as a bulge that comes and goes based on whether or not the patient is stressed, or lying down or standing.
Dr Anantha explains: “Groin hernias are common in men because there is a weak area in their groin.
“The testes develops inside the abdomen when the foetus is in its third week.
“By the seventh month (of pregnancy), they move to the groin, and before birth (2535 weeks of pregnancy), they will be pushed into the safe zone (scrotum), which keeps them at the right temperature (3°C lower than core body temperature).
“As the testes come down, they form an oblique track through the abdomen to reach the scrotum.
“Later, this track will close up, but as abdominal pressure increases, the track can be reopened.
“So, in men, inguinal hernias are common through the weak area of groin as a result of the testis descending into the scrotum from the abdomen.
“In females, the ovaries are always inside the body, but there is a thin string that goes down to the labia majora, which resembles half a scrotum.
“However, females can also get inguinal hernias, more so than other hernias.”
Meanwhile, a femoral hernia may occur through the opening in the floor of the abdomen where there is space for the femoral artery and vein to pass from the abdomen into the upper leg.
Because of their wider bone structure, femoral hernias tend to occur more frequently in women.
Some other external hernias include scar/ incision/ventral hernias (where tissue protrudes through the site of a scar from a prior abdominal surgery or Caesarean section), umbilical hernias, epigastric hernias and traumatic hernias.
Rarer hernias can also occur near the inner thigh, loin and in the muscle layers.
Each external hernia presents differently and the ultimate treatment is surgical.
In fact, hernia surgeries are one of the most commonly performed elective operations in the world.
More than 700,000 groin operations are performed annually worldwide; in Malaysia, the figure is around 12,000 to 14,000 surgeries.
There are many reasons why people get a hernia:
> Difficulty in urinating due to an enlarged
prostate
> Straining to clear the bowels due to chronic constipation or a narrowed anus as a result of a bad haemorrhoid surgery > Chronic coughing related to smoking,
tuberculosis or bronchitis
> Lifting heavy objects
> Pregnancy, and
> The use of blood thinners that can cause bleeding in the muscle layers due to trauma.
“Obesity doubles the risk as fat is the pile driver that makes the muscles weak.
“Even a simple operation such as an open appendectomy can put you at risk.
“After an open surgery, the muscles regain nearly 70% of their original tone, hence there is a high chance of incisional hernias developing.
“However, nowadays, many surgeries are minimally invasive and can be performed laparoscopically, which has managed to reduce the hernia occurrence to 1-5%.
“Even hernia surgery can be done using the laparoscopic technique, which is currently considered the gold standard of treatment, compared to the open, robotic or hybrid techniques,” says Dr Anantha.
Slow development
Groin hernias do not suddenly appear, instead, they develop over time with some early warning signs.
The pain threshold of a person decides how fast he or she will consult a doctor.
Pain increases in tandem with complications.
Dr Anantha says, “Initially, a hole is created by the muscles splitting, which causes acute pain.
“Most patients experience a sharp pain in the groin on lifting weights, coughing or when doing vigorous sports, which lasts for few days and will usually be ignored.
“During examination, we may not see any swelling in very early cases.
“But later, there will be noticeable swelling when doing the activities mentioned above.
“The swelling reduces itself when lying down or pushed inside.
“A few patients will also feel a pulling sensation in the lower abdomen.
“With scar hernia patients, they will be able to see the swelling in the operative scar.”
To check the seriousness of the hernia, he says: “A simple measure is to support the groin by pushing back the swelling into the abdomen while lying down and coughing.
“But if the bulge cannot be pushed back, you must consult a doctor immediately.
“And there is to be strictly no strenuous exercise or weight-lifting once you have a hernia.”
A smaller hernia can sometimes be more painful than a football-sized one.
He says, “When the patient feels extreme pain even on touching and the swelling becomes tense, he’s already at the stage of extreme complications.
“As the content cannot be pushed back in, blood supply is reduced and the area becomes blackish.
“There is tissue strangulation, and if not treated urgently, it can cause death.”
For defective holes, only a surgery via suturing or placing a mesh with no tension can close them.
“A defect will not close on its own.
“If a patient has other medical problems, they need to be stabilised first before proceeding with surgery.
“Some unfit patients may have to learn to live with it as long as it is not life-threatening.
“And please, say no to groin support/truss and do not treat it with traditional massages!” he advises.
Patients under local anaesthesia can be discharged within two days, but large incisional hernia repairs take longer to heal.
The smaller the defect, the lesser the chance of recurrence.
The overall recurrence rate is small (10%), says Dr Anantha, although Sambath belongs to the minority of patients with more frequent recurrence.
Sports ‘hernia’
Sports hernia is a common term used among sportsmen, although it can be difficult to distinguish between a groin strain and a hernia.
A sports hernia is a strain or tear of any soft tissue (muscle, tendon, ligament) in the lower abdomen or groin area.
As different tissues may be affected and a traditional hernia may not exist, the medical community prefers the term “athletic pubalgia” or “Gilmore’s groin” to refer to this type of injury.
“Sports hernia is a chronic pain syndrome, which is common in sports such as football, rugby, basketball, tennis, cycling, etc, where a sudden turn or twist can injure the attachment of the thigh muscles.
“It is more of a disruption injury as they have a weak inguinal area and pain in and around the pubic bone.
“Ten percent of females are also affected by this.
“It is difficult to diagnose as an MRI (magnetic resonance imaging) may only show an injured muscle.
“There may be a dilated hernia ring, but an obvious hernia will not be evident.
“Symptoms may subside after resting for a month, but may recur with activities,” Dr Anantha explains.
If symptoms persist for more than three months, laparoscopic repair of the inguinal region is beneficial, with the individual able to return to sports in three to four months’ time.
And no, weightlifters and bodybuilders are not necessarily more prone to developing hernias.
He says, “Before doing any exercises, the muscles must be trained gradually to increase mass and tone.
“You cannot lift an unusually heavy weight all of a sudden.
“Untrained weight-lifting causes more of a spinal disc prolapse than hernias.
“Remember, graduated training and building is the principle.”
While there is nothing you can do to stop hernias from occurring, you can prevent them by getting treated for chronic coughs and constipation issues; maintaining abdominal tone via exercise; applying pressure on the navel/groin while coughing post-surgery; reducing obesity; and stopping smoking.
Once a hernia has developed, do get treated before performing any strenuous exercises that will worsen it.