Adult Inguinal Hernia

What is Adult Inguinal Hernia?

Every year, over 20 million inguinal hernia repairs, which involve a type of abdominal wall hernia, are performed across the globe. Nearly 800,000 of them are conducted in the United States, making inguinal hernias one of the most common issues dealt with by general surgeons. Interestingly, the ureter, an organ hidden in the back of the abdomen, rarely gets affected by an inguinal hernia. In fact, only around 140 cases of a ureteral inguinal hernia were reported up until 2009.

Sometimes, the involvement of the ureter may go unnoticed before an operation. This is why it’s crucial for a general surgeon to be well aware of this possibility. Damage to the ureter during the operation—or “intra-operative iatrogenic damage,” to use its medical term—can lead to severe issues.

What Causes Adult Inguinal Hernia?

Inguinal hernias are categorized into two types: congenital and acquired. Congenital hernias are linked to an opening called the processus vaginalis, which is part of the tissue lining of the stomach cavity. This opening aids in the descent of the testicles through a passage in the lower abdomen called the inguinal canal during their development in the womb. Instance of these hernias bulging out through the inner ring of the inguinal canal next to the blood vessels leading to the stomach or heart are referred to as indirect inguinal hernias. They occur about twice as often as direct inguinal hernias. Recent discussions suggest that all indirect inguinal hernias are caused by a processus vaginalis that never properly closed. Some studies also propose that in adults, these indirect hernias may develop after long-term pressure on a processus vaginalis that had fully closed except at the neck of the hernia pouch.

On the other hand, acquired inguinal hernias are usually caused by a weakening or damage of the tissues of the stomach wall due to various factors. These can include older age, smoking, increased pressure inside the abdomen due to factors such as persistent coughing or pregnancy, and abnormal connective tissues. Acquired types of inguinal hernias, which are generally direct hernias, occur when contents from within the abdomen push through a particular area (Hesselbach’s triangle), located on the medial aspect of the blood vessels at the lower end of the abdomen.

Risk Factors and Frequency for Adult Inguinal Hernia

First recorded in 1880, most instances of a groin hernia involving the ureter (the tube that carries urine from the kidney to the bladder) are called ureteral inguinal hernias. Other types, including ureterofemoral (involving the femoral artery area) and ureterosciatic (involving the sciatic area), can also occur. Though it happens in both men and women, ureteral inguinal hernias are more often seen in men.

• Being male, older, and having a history of a kidney transplant can increase the risk of developing a ureteral inguinal hernia.
• On the other hand, ureterofemoral hernias are more frequently seen in women.
• The bladder can also be involved with an inguinal hernia, usually associated with a specific type called a direct inguinal hernia.
• If the bladder is involved, it can lead to bladder outlet obstruction symptoms such as trouble with urination, frequent urination, and blood in the urine.

Signs and Symptoms of Adult Inguinal Hernia

A ureteral inguinal hernia is a condition where part of the ureter, the tube that carries urine from the kidney to the bladder, gets trapped in a hernia in the groin area. Most of the time, these hernias present much like typical groin hernias, meaning they don’t have unique symptoms. However, they can sometimes cause problems with the urinary system, no matter how much of the ureter is involved.

Some of the symptoms that might suggest a ureteral inguinal hernia include side pain, discomfort when urinating, blood in the urine, sudden difficulty or inability to urinate, and the need to use pressure to start or stop urinating. These symptoms, along with a presence of an inguinal hernia, could point to the presence of a ureteral inguinal hernia. If a doctor suspects this diagnosis, they might perform laboratory tests, which might identify an acute kidney injury.

• Side pain
• Discomfort when urinating
• Blood in the urine
• Sudden difficulty or inability to urinate
• Need to apply pressure to start or stop urinating
• Presence of an inguinal hernia
• Findings from laboratory tests, like an acute kidney injury

Testing for Adult Inguinal Hernia

In the process of checking for an inguinal hernia, which is a protrusion of abdominal-cavity contents through the inguinal canal, doctors won’t usually order specific imaging studies. These might be necessary, however, if certain alarming signs or symptoms pop up. In these cases, a pre-surgery ultrasound might show an enlarged kidney on the affected side.

Another test that might be used is intravenous pyelography. This imaging test can show a characteristic spiral or loop-the-loop shape in the ureter (the tube that carries urine from the kidneys to the bladder), which is a distinctive sign of an inguinal hernia.

If the kidney function tests are unexpectedly abnormal, a CT scan could be done to confirm a ureteral inguinal hernia. This involves taking multiple images layers which are then combined using a computer to give a detailed 3-D image. Alternatively, an MRI scan which uses strong magnetic fields could also indicate the ureter entering the inguinal canal or going beyond the bony pelvis.

Finally, the imaging scans might reveal nephroptosis, a condition where the kidney drops down into the pelvis when a person stands up. This can accompany a ureteral inguinal hernia and is likely due to the loss of the surrounding supportive tissue into the hernia sac rather than the ureter pulling on the kidney.

Treatment Options for Adult Inguinal Hernia

If detected early enough, the best way to repair a ureteral-inguinal hernia, a condition where a portion of the ureter drops into the inguinal canal, is through open surgery rather than a keyhole (laparoscopic) approach. The repair process could involve simply putting the ureter back into place along with the hernia sac.

The extent of the surgery depends on how much of the ureter is involved. This can range from cutting out the redundant (extra) part of the ureter and joining the ends, a primary anastomosis, to more complex techniques such as ureteroneocystostomy, psoas hitch, Boari flap, or transureteroureterostomy. These are different methods used to reroute and secure the ureter. The surgeon should remove any dead or expanded areas of the ureter as well.

After a complicated repair, postoperative CT imaging will be done to make sure the ureter is open (patent) and in its proper place in the body. If it is known preoperatively, inserting a ureteral stent, a tube used to keep the ureter open, can help with identifying an affected ureter.

In cases where the patient can’t tolerate surgery, reducing the blockage of urine (obstructive uropathy) can be achieved by inserting a tube into the kidney (nephrostomy tube) or a tube running from the kidney to the bladder (nephro-ureteral stent). These devices help to drain urine from the kidney.

What else can Adult Inguinal Hernia be?

When a bulge shows up in the groin area, it could be an inguinal hernia, which occurs when tissue pushes through a weak spot in the groin muscles. This fairly common condition affects 1% to 4% of all inguinal hernias and can also involve the bladder, more frequently than it can involve the tube that carries urine from the bladder (the ureter).

To be precise, if someone has an inguinal hernia and experiences issues with their urinary system, like pain while urinating or urinary incontinence, it could be that the hernia occurs in conjunction with an issue in a urologic organ, which includes kidneys, bladder, ureters, etc. Therefore, doctors always pay attention to these symptoms when dealing with inguinal hernia patients.

However, it’s important to note that there are several other conditions that may present similar symptoms and should be considered as possibilities. These include:

• Inguinal hernia involving the bowel, omentum (the fat that covers some of the organs in the belly), or extraperitoneal fat (fat located outside the layer covering the stomach)
• Femoral hernia (a bulge near the groin or thigh)
• Problems with the veins in the male reproductive region, like hydrocele (swelling in the scrotum) or varicocele (an enlargement of the veins within the loose bag of skin that holds your testicles)
• A tumor related to the urinary system
• A tumor of the pelvic organs or space at the back of the abdomen

What to expect with Adult Inguinal Hernia

The prognosis is generally good for patients who undergo inguinal hernia repair, as this type of surgery is safe and effective. After open surgery, patients can typically return to their usual activities within a week or two. However, it’s advisable to avoid heavy lifting for six to eight weeks following any hernia surgery. This allows time for the muscles and other tissues to heal fully.

Possible Complications When Diagnosed with Adult Inguinal Hernia

Inguinal hernia complications may include the potential entrapment or strangulation of the hernia. Strangulation is considered a serious, life-threatening emergency. If these hernias are not treated, they usually get larger over time.

Possible Complications:

• Entrapment of the hernia
• Strangulation of the hernia, a life-threatening emergency
• Enlargement of the hernia if it is not treated in time

Preventing Adult Inguinal Hernia

After having surgery, it’s essential for patients to be given advice about keeping their body weight healthy and steering clear of heavy lifting or straining when going to the bathroom. If these instructions are followed, it can help prevent a hernia from coming back.