INGUINAL HERNIA SUMMARY

In males, about two months before birth, the testicles descend into the scrotum, passing through a gap in the groin, followed by the spermatic tubes, which later will convey sperm from the testicles to the penis. The gap is normally tightly closed and tensed, just relaxing enough to allow sperm to squeeze through but otherwise fitting pretty snugly together. The gap is called the 'inguinal canal'. It is 4 cm or about an inch and a half long. Sperm from the testicles passes up and through this gap and into the urethral canal where it is bulked up with extra fluids to help it swim more strongly. As the sperm passes through, the gap momentarily relaxes by a few mm of width, then closes tightly again. There are three layers of muscle holding this gap shut, like tightened sheets, ensuring that the gap stays shut when sperm isnít passing through. These muscles stretch right across the abdomen. Like tent ropes, they are anchored on the ribs and the hips. Their lower end is the inguinal ligament, a strong band that stretches from the hip to the crotch and holds the ends of the muscles down. Sometimes the gap comprising the inguinal canal loses its tightness. When this happens, and the abdominal wall is also weak, coughing, lifting or overexertion can force some of the peritoneum or intestine to bulge through it. This bulge is known as an inguinal hernia.

 

What is an inguinal hernia?

In males, about two months before birth, the testicles descend into the scrotum, passing through a gap in the groin, followed by the spermatic tubes, which later will convey sperm from the testicles to the penis. The gap is normally tightly closed and tensed, just relaxing enough to allow sperm to squeeze through but otherwise fitting pretty snugly together.

      An inguinal hernia occurs when the gap weakens, usually from within. This can be caused by a number of superficial factors such as lifting a heavy weight or pulling something or overexerting oneself in sport. But thatís just the straw that breaks the camelís back. The actual strain is something that develops over a prolonged period. If you read this before you develop an inguinal hernia then you can take steps to prevent it ever happening. If you have an inguinal hernia, knowing what it is can be the first step towards curing it.

hernia picture

The inguinal canal

The gap is called the 'inguinal canal.' It is 4 cm or about an inch and a half long. Sperm from the testicles passes up and through this gap and into the urethral canal where it is bulked up with extra fluids to help it swim more strongly. As the sperm passes through, the gap momentarily relaxes by a few mm of width, enough to let it pass, then closes tightly again. The outer ring that the sperm pass through is smaller than the internal ring. There are three layers of muscle holding this gap shut, like tightened sheets, ensuring that the gap stays shut when sperm isnít passing through. These muscles stretch right across the abdomen. Like tent ropes, they are anchored on the ribs and the hips. Their lower end is the inguinal ligament, a strong band that stretches from the hip to the crotch and holds the ends of the muscles down.

      Coughing or lifting can strain the gap; the inguinal canal opens a bit and the peritoneum, or intestines, press through. This is the bulge of an inguinal hernia. The inside of the inguinal canal is called the deep inguinal ring and the outer part is called the superficial inguinal ring. When the deep inguinal ring is weakened it allows the intestines to bulge through and this eventually finds its way through the superficial inguinal ring, which cuts through the triple wall of the 3 abdominal muscles mentioned above. These are attached to the conjoint tendon. The deep inguinal ring opens through the transversalis fascia and is attached to the inguinal ligament.

The transverse abdominal muscles

The cure of an inguinal hernia focuses on these muscles and ligaments, but cannot be effective unless the 'anchors' of the tent ropes are secure and firm. So a total abdominal approach is necessary to close the superficial inguinal ring by firming up the triple wall; to close the deep inguinal ring and to ensure that the inguinal ligament is secured fast to it and that the transversalis fascia is strong and well-toned. Securing the 3 outer layers of muscle systems is fairly easy. The front lines of the battle against abdominal weakness lie at the deep inguinal ring. This is where the pressure from the intestines is strongest.

Intestinal transit time

It is also important to reduce the downward pressure of the abdomen and its contents, as this constant pressure hinders the healing and strengthening process for an inguinal hernia. This means strengthening the attachments under the ribs that suspend the large intestine and keep it in the shape with which we are familiar from anatomy lessons. The other way to reduce the downward pressure of the abdomen is to reduce its size. Most of the size of the abdomen reflects the presence of food or swollen organs. The way to reduce the presence of food is to eat less food and to speed up the digestive process, or 'transit time'. Few people enjoy a natural transit time, which can be as little as 12 hours and should not exceed 18 hours. Factors which slow down intestinal transit time include:

  • Food choices such as white bread, beef and cheese. These are all sticky foods that slow down peristalsis.
  • Overeating
  • Poor intestinal tone
  • Bad bowel habits (waiting until the pressure is irresistible before going to the toilet)
  • Toilet training in childhood that leads to excessive anal sphincter control.

Indirect inguinal hernia

An indirect inguinal hernia protrudes through the inguinal ring and is ultimately the result of the failure of embryonic closure of the internal inguinal ring after passage through it of the testicle and the trailing supply of blood vessels and nerves which make up the spermatic cord. The internal ring is normally closed as part of normal development but when it remains open the stage is set for an indirect inguinal hernia. An indirect inguinal hernia occurs when the intestines go through the ring to enter the inguinal canal. If nothing is done, the inguinal hernia may enlarge, extend down the full length of the canal, and sometimes even drop down into the scrotum.

Direct inguinal hernias

A direct inguinal hernia protrudes through a weakened area in the transversalis fascia, the corset-like sheet of muscles which stretches between the rectus abdominis muscle (or 'six pack') that runs down the middle of the front of the body and the inguinal ligament which runs from the groin towards the hip. While these inguinal hernias do not involve the inguinal canal directly, they weaken the structures of the inguinal region. When a patient suffers a simultaneous direct and indirect inguinal hernia on the same side, the enlarged result is called a 'pantaloon' hernia.

Theories of inguinal hernia formation

It was previously thought that inguinal hernias arose as the result of abnormal stress on the abdominal wall, such as by coughing too much or lifting heavy objects. Most researchers still point to a failure of the abdominal wall 'shutter' (an involuntary movement of the abdominal muscles that closes off the inguinal canal during increased intra-abdominal pressure) as the root cause of indirect inguinal hernias.

      Current research indicates that patients with direct inguinal hernias are heavily predisposed to herniate elsewhere, perhaps due to obesity, lack of exercise or some nutritional deficiency. Direct and indirect inguinal hernias tend to run in families. Some researchers now believe that all direct inguinal hernias and many indirect inguinal hernias are a symptom of a deficiency of collagen, the major structural fibre in connective tissue. Lack of collagen would result in weakened connective tissue, allowing a hernia to form at the weakest points.

 

 
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