Confusion with gynecological issues often leave hernias undiagnosed 

I have come to discover a problem for women with inguinal hernias (IH).

Inguinal hernias occur when tissue, such as part of the intestine, protrudes through a weak point in the abdominal muscles, in an area called the inguinal canal. Unlike in men, a hernia bulge and a pain at the inguinal canal is not commonly present in women. Inguinal hernia symptoms in women can include pain radiating to the vagina or lower back, symptoms of pelvic floor spasms such as pain with intercourse and urinary infrequency. Frequently, these pains are worse during menses.

Pelvic pain symptoms caused by IH are frequently confused with gynecological issues, often resulting in a long path of GYN procedures that do not resolve the issues and leave women with inguinal hernias undiagnosed.

Naturally, GYN causes need to be pursued but a hernia should be considered if pain is persistent. If unexplored, an undiagnosed inguinal hernia may fester, leading to greater nerve damage and health depression when pain is not relieved.

I have been studying phenomenon at the Hernia Center and have found very little in the surgical literature regarding women and IH. As almost everything we know is based on studies that exclude women, it comes as no surprise that there is common misunderstanding and lack of diagnosis of IH symptoms for women, for which treatment can be misdirected and mischaracterized. I am finding solutions.

What do you need to know?
Because of the absence of a bulge, imaging is frequently required for the diagnosis of an inguinal hernia. It is commonly misunderstood that a peritoneal sac is necessary to make the diagnosis of a hernia; however, imaging with ultrasound and/or CT scan has demonstrated that frequently, herniation of peritoneal fat into the inguinal canal constitutes a hernia. Although it does not carry with it the risk of bowel obstruction, it does put pressure on nerves in the inguinal canal that can cause intermittent or chronic pain. This much more frequently the case in IH among females than males.

Surgical Guidelines, Reconsidered
The current recommendations from the 2018 Hernia Surge Guidelines are early repair of inguinal hernia in women and laparoscopic repair, which requires a 6” x 6” piece of preperitoneal mesh. Unfortunately, the results of these recommendations have been disappointing. A 2013 study[1] shows that postoperatively, women experience more pain, discomfort, and fatigue compared to men. Additional studies[2] have shown that women have a higher risk of recurrence. Also, as many as one in five women will have groin pain after laparoscopic hernia repair[3]. Consequently, there is serious reconsideration of the surgical approach towards surgical repair.

Surgical Approach for Women at Cascade Hernia & Surgical Solutions
Dr. Wright’s groundbreaking 2017 research with Stanford University demonstrated that inguinal hernias frequently cause nerve damage and ultimately, chronic pain. To address this, Dr. Wright performs an open surgical approach for IH repair in women. This provides visual range under an experienced eye, allowing observation of visible changes in these nerves and preventative removal at the time of surgery.

Additionally, should the woman opt for it, the open approach allows a tissue non-mesh repair. Mesh repairs can be performed with dramatically less mesh material (lowering risks of infection) than is necessary with a laparoscopic repair (8 cm2 of mesh versus 225 cm2 of mesh). This approach studied in men has had some results of tingling and numbness but has been shown to significantly diminish chronic pain. While studies are not final, the results for women are proving this open approach will provide significance to reduce chronic pain caused from IH.

Diagnostic Approach for Women at Cascade Hernia & Surgical Solutions

If presenting without a bulge, but with symptoms that may be indicative of inguinal hernia, women should receive imaging with ultrasound and/or CT scan to exclude the presence of a femoral hernia and to help demonstrate the presence of preperitoneal fat herniation. Some patients may require diagnostic laparoscopy to rule out gynecologic causes.  

Ultimately, the goal at Cascade Hernia & Surgical Solutions is accurate diagnosis, timely repair, and absence of chronic postsurgical pain in patients receiving treatment for inguinal hernia.

Make an appointment for a consultation today. Call (253) 840-1999. Often, you can get an appointment on the next weekday.

[1] (Hernia 2013;17(3); 321 to 327)

[2] (Surge Innovation 2015; 22 (3); 303 to 317)

[3] (Annals of Surgery 2022; 275 (2); 213 to 219)

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Publications

  • Wright R.C., Born D., Sanders T., Landes J., Sailsbury T., Kumar A., “Increased Collagen Demonstrated in Ilioinguinal Nerves Resected from Primary Inguinal Herniorrhaphy.” Hernia 24 (May 2020) 1-112 (Abstract)
  • Wright R.C., Salisbury T., Landes J. “Groin Anatomy, Preoperative Pain, and Compression Neuropathy in Primary Inguinal Hernia: What Really Matters.” American Journal of Surgery. 217 (May 2019) 873-877.
  • Wright R.C., Born D., Hurd L., Gill R., Wright D. “Pain and Compression Neuropathy in Primary Inguinal Hernia.” Hernia 2017 21; 715-722
  • Wright R.C., Born D., Hurd L., Gill R., Wright D. “Why Do Inguinal Hernia Patients Have Pain? Histology Points to Compression Neuropathy.” American Journal of Surgery. 213 (May 2017) 975-982.
  • Wright, R.C. and Wright, R.J. (2014)” Inguinal Neuritis in Open Recurrent Hernia Repair.” International Journal of Medicine, 5, 790-798. http://dx.doi.org/10.4236/ijcm.2014.513106
  • Wright R.C. ” Inguinal Neuritis Identification During Primary Inguinal Herniorrhaphy,” video abstract, HERNIA v 16 supplement. March 2012 s232-s233. Presented at the International Hernia Congress, New York. March 28-31-2012.
  • Wright R.C., E. Sanders “Inguinal Neuritis is Common in Primary Inguinal Hernia.” Hernia, Volume 15, Issue 4 (2011), Page 393-398. Online March 2011, DOI 10.1007/s10029-011-0807-z.