The Other Battle of the Bulge: Hernias

There’s a phrase that most men learn when they’re still young, which they never forget. It unites us in our masculinity yet reminds us of our vulnerability: “Turn your head and cough.”

Utter those five words to virtually any English-speaking male and you’ll probably elicit a smirk, if not a twinge in the gut. It is, of course, the command doctors issue when checking for hernias during a physical exam. Because they are poking and prodding in a very private part of the anatomy at the same time, the hernia exam probably ranks second on most guys’ list of least-loved medical tests.

But, despite the smirks, hernias are serious business. Did you know, for instance, that hernia operations are one of the most commonly performed surgical procedures in the United States? And that hernias can grow to the size of a basketball? Doctors use the term “hernia” for any organ that protrudes into another. But when the average Joe says the word, he’s referring to an inguinal, or groin, hernia. Women can have them, but groin hernias are mostly a guy thing.

There are two different types of groin hernias. The first variety is caused by simple wear and tear. As you creep into middle age, the muscular wall around your abdomen develops a weak spot. Eventually, a hole forms and a portion of your intestine balloons through it, forming a sac kind of like a bulge in an over-inflated inner tube, says Dr. Robert J. Fitzgibbons, a professor of surgery at Creighton University in Omaha.

A second type occurs in men who are born with a slight defect in their innards that can cause problems at any time in life. It’s like this: In a male fetus, the testes start out in the abdomen, but shortly before birth they descend into the scrotum through a passage called the inguinal canal. As they drop, the testes stretch the lining of the abdomen, forming a droopy pouch. Normally, this pouch spontaneously fuses shut. But in some males, that doesn’t happen and a tiny opening remains.

All is well until one day you hoist a bowling ball or your overweight beagle--and “oomph.” The increase in internal pressure that occurs when you lift a heavy object forces part of your intestine or a pad of belly fat to wedge into that small opening in the inguinal canal. The hernia forms a lump in your groin and can even descend into your scrotum. (Which is why doctors do all that poking and prodding; the cough is to produce internal pressure, making the hernia easier to detect.)

So begins your battle with the bulge. Hernias can usually be pushed back into place with gentle massage and disappear on their own when you lie down. But stand up, sit down or do anything that places pressure on your gut and it can reappear. A hernia might be as small as a marble--or even bigger than a basketball, says Fitzgibbons.

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Regardless of size, hernias almost always hurt. The pain varies; some men describe a heavy feeling, others feel a stabbing sensation. But contrary to the stereotype of a guy doubling over in pain and crying, “I ruptured myself!” the onset of symptoms is usually more subtle, says Fitzgibbons. “One day a guy’s taking a shower and notices there’s a bulge,” he says. “Or he gets pain in the groin that causes him to feel around and, lo and behold, there’s a bulge.”

Giving up smoking is about the only thing you can do to avoid developing a hernia, says Fitzgibbons, since the inhaled fumes weaken collagen, the building block of muscle. (A smoker who gets a hernia also has an increased risk of developing a second one.) You might also choose jobs carefully. If you load trucks for a living and your buddy Felix is an accountant, you could be up to 2 1/2 times more likely than Felix to develop a hernia, according to a recent study in the American Journal of Industrial Medicine.

About 700,000 Americans have surgery to repair an inguinal hernia each year, according to Fitzgibbons. Then again, another 800,000 are diagnosed with hernias but elect not to go under the knife. “The vast majority seem to do all right,” he says, adding that a very small number develop potentially deadly complications.

In a conventional hernia repair, the surgeon makes a 6-inch incision in the groin and simply pushes the protruding intestine or fat back in place. Then he or she stitches up the hole in the abdominal wall or patches it with a mesh sheet made of plastic or Gore-Tex. The patient requires only local anesthesia and usually goes home the same day, with orders to avoid heavy lifting for up to six weeks.

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Hernia patients who opt for laparoscopic surgery only require a few tiny incisions and get up and around faster. (It’s a minimally invasive procedure in which thin tubes equipped with tiny cameras are inserted into the body through a small incision, allowing the surgeon to see inside the patient’s body.) But they also need to be put to sleep for the procedure, which involves a slightly higher risk of damage to other organs. If you think you have a hernia, see a doctor soon. But don’t assume you’ll need surgery.

Fitzgibbons is the lead researcher in an ongoing study to determine whether surgery is always the best choice for people with less-severe hernias. The study involves five medical institutions around the nation, including the Keck School of Medicine at USC. Men age 18 and over who are interested in participating in the study can call (323) 442-6243.