Dear Dr G,

I am very embarrassed to share with you some problems I face in the groin.

I am a forty-two-year-old man who gained some weight during the pandemic and started smoking again during the movement control order due to stress. This has resulted in persistent smokers’ cough.

In recent weeks, I started noticing some niggly pain in the groin, but a week ago, I noticed a bulge that protrudes into my scrotum.

The strange thing is lump more obvious when standing for too long, and virtually disappears when I lie down.

Don’t get me wrong, the lump itself is painless. However, after standing for too long, the lump becomes quite large and makes my scrotum embarrassingly big.

I went to the doctors, who told me I have hernia.

He said this is a weakness in my groin and it was provoked by smoking and weight gain.

I simply don’t get why I have a weakness in the groin

I really would like to put Dr G on the spot as I know nothing about hernia.

Can you tell me what exactly is hernia, and how it happens?

Apart from causing embarrassment with this swelling in the scrotum, can hernia be dangerous?

Lastly, how do I reverse my weakness in the groin?

Weakness William

Inguinal hernia is the protrusion of abdominal contents through a natural orifice in the groin, called inguinal canal. In males, the route of the migration of the testes from the abdomen to the scrotum during gestation results in a point of weakness between the abdomen and thigh.

In women, the remnant of the canal is much smaller as it does not accommodate structures such as spermatic cord. Therefore, men are 25 times more likely to have inguinal hernia than women. Certain conditions raising the intra-abdominal pressure can precipitate the occurrence of inguinal hernia. These are obesity, heavy lifting, chronic coughing, straining with defecation or urination, resulting in weakness of the posterior wall of the inguinal canal and the protrusion of abdominal contents such as small intestine.

Inguinal canal is a common disorder with 10 % of the population diagnosed with it in their lifetime. This occurs more often in men, with the usual age group above the age of 40 years old.

There are two type of inguinal hernia – direct and indirect hernias. Indirect hernia is congenital, resulting from the failure of the embryonic closure of the deep inguinal ring, after the descent of the testicle during birth.

Direct hernia develops in older individuals as the abdominal wall weakens with advancing age and sedentary lifestyle.

Symptoms of inguinal hernia include a small bulge in one or both sides of the groin that increase in size and disappear when lying down. In men, inguinal hernia also presents as a swollen or enlarged scrotum, as the abdominal content may “drop” into the scrotum.

The lump itself may cause discomfort or sharp pain, especially when straining, lifting, or exercising. Such symptoms also improve when resting.

Oftentimes, sufferers also have a feeling of weakness or pressure in the groin, a burning, gurgling, or aching feeling at the bulge. The bulge becomes more prominent during coughing and straining.

In serious cases, inguinal hernia can result in the inability of the lump to retract back into the abdomen. This will lead to the risk of strangulation of the bowel in the neck of the hernia orifice.

Inguinal hernia is usually diagnosed clinically. Doctors will determine the diagnosis through medical history and physical examination. The individual is asked to stand and cough to demonstrate the hernia moving into the groin or scrotum. In most instances, diagnostic tests are not required for inguinal hernia.

However, for confirmation or in uncertain cases, ultrasonography is the first choice of imaging, as it can detect the hernia and evaluate changes with increased abdominal pressure.

There is currently no medical treatment for inguinal hernia. Although a truss is often used to hold back a reducible inguinal hernia within the abdomen, it is often uncomfortable to wear and not considered a cure.

Groin massages and pelvic floor exercises have also been proposed for the treatment of inguinal hernia, however these tend to worsen the hernia.

Surgical correction of the inguinal canal is the only cure. There are essentially two types of hernia repairs. Open hernia repair (herniorrhaphy), where an incision is made at the groin, the contents pushed back into the abdomen and the subsequent placement of synthetic mesh to strengthen the weakness.

The second method is a key-hole approach. Instead of making an incision, laparoscopy is used to retract and reduce the hernia. The keyhole operation is minimally invasive and the small size of incision allows for faster recovery.

Synthetic mesh is usually used for both interventions to strengthen the weakness. Although the mesh is strong enough to prevent hold back the hernia, repeated instances of unhealthy lifestyles such as smoking and obesity can result in recurrences.

The Canadian Catholic philosopher and theologian, Jean Vanier once said: “Growth begins when we begin to accept our own weakness”.

The complexity of the male reproductive organs already leaves some structural vulnerability in men even before birth. Healthy growth from childhood to adulthood can mask such vulnerability.

During the process of growth, the added strains of an unhealthy lifestyle such as obesity and smoking certainly exacerbate the weakening process.

Sadly, the only remedy for such weakness is surgical repair.

Men (and occasionally women) facing inguinal hernia often put Dr G on the spot for reasons of their weakness in the groin. His view is: “Accepting our own natural weakness in the groin may be important, but preventing the vulnerability with a healthy lifestyle is the key!”

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