Dear Dr G,

I am a 45-year-old man who gained some weight after the pandemic.

Due to work commitments, I stopped exercising and started having late night suppers and smoking again.

A few weeks ago, during a terrible smoker’s cough in the morning, I started feeling some niggly pain in the groin, followed by a bulge that protruded into my scrotum.

The lump is more obvious when standing up for long periods of time but virtually disappears when I lie down.

Most of the time, the lump itself is painless. However, after standing for too long, the lump becomes quite large and makes my scrotum embarrassingly big.

In fact, the lump “protrudes” significantly during sex, causing considerable discomfort and resulting in a weakened erection.

I went to the doctor who told me I have hernia.

He said it is due to a weakness in my groin and can be provoked by smoking and weight gain.

The doctors reiterated there is no medicine to reverse the hernia, and recommended surgery.

I am absolutely terrified of the idea of an operation and 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 swollen scrotums, are hernias life-threatening?

I am already facing the problems of erectile dysfunction. Would the operation make my sex life worse?


Lumpy Leonard

The route of the migration of the testes from the abdomen to the scrotum during gestation in a male infant results in a point of weakness between the abdomen and thigh, namely the inguinal canal.

In women, the remnant of the canal is much smaller, as it does not accommodate structures such as spermatic cord. Inguinal hernia occurs when there is a protrusion of abdominal contents through the inguinal canal.

Men are 25 times more likely to have inguinal hernia than women. There are essentially two types of inguinal hernia, namely 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 a sedentary lifestyle.

Inguinal hernia is a common disorder with 10% risks of the population diagnosed to have the condition in their lifetime. The prevalence is higher in men, with the usual age group being over the age of 40 years old. Certain conditions raising the intra-abdominal pressure can precipitate the occurrence of inguinal hernia. These include obesity, heavy lifting, chronic coughing, straining with defecation or urination. Excessive pressure often results in weakness of the posterior wall of the inguinal canal and the protrusion of abdominal contents such as the small intestine.

Symptoms of inguinal hernia includes 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. Often times, sufferers also have the 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 risk strangulation of the bowel in the neck of the hernia orifice. Although the hernia itself is not associated with sexual dysfunction, persistent discomfort during sex may result in the inability to maintain rigidity of hardness during sex.

Inguinal hernia is usually diagnosed clinically. Doctors will determine the diagnosis through medical history and physical examination. The individual will be 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 to detect the hernia and evaluate changes with increased abdominal pressure.

There is currently no medical treatment for inguinal hernia. Although 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. Hence, corrective surgery is the only long-term solution. There are essentially two types of hernia repairs. Open hernia repair (herniorrhaphy), where an incision is made at the groin, involves pushing the content back to the abdomen with subsequent placement of synthetic mesh to strengthen the weakness.

The second method is keyhole surgery. 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 faster recovery. Synthetic mesh is usually used for both interventions to strengthen the weakness. Although the mesh is strong enough to hold back the hernia, repeated unhealthy lifestyle such as smoking and obesity can result in recurrences.

The operative and post-operative process of hernia repair is also not associated with sexual dysfunctions.

In fact, most men who have undergone hernia repairs report greater comfort during sexual activities without the protruding lump in the groin.

Men who undergo hernia repairs are often advised to abstain from sexual activities for around six weeks, as the mesh and early operative sites might give way during exertions in penetrative intercourse.

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