Obstructive Diseases:
Hernias
By: Alex Caudy, Christina Richards, Vanessa
Winnie, & Jordan Krygsheld
Overview
● About 5 million Americans of all
ages have some type of
abdominal hernia
● Hernias can occur at any age in
men and women (more common
in men)
● Most frequency occur in the
abdominal cavity as a result of
congenital or acquired weakness
of abdominal musculature.
Pathogenesis
● Weakness of the tissues around the inguinal canal leads to tears and
separation of tissue
● Structural and biochemical abnormalities of local collagen metabolism have
been proposed as factors in appearance of hernia.
● Other biological factors (such as malnutrition or vitamin deficiencies) can
alter collagen metabolism and lead to weakness as well
● This weakness leads to part of the intestines pushing through the
abdominal wall, resulting in a bulge.
Different Types of Hernias
● Indirect Inguinal-Herniation occurs through the internal inguinal ring. It can
either remain in the canal or extend into the scrotum/labia. Painful and most
common.
● Direct Inguinal-Herniation occurs behind and through the external inguinal
ring. Rarely enters scrotum. Usually painless.
● Femoral-Herniation occurs through the femoral ring and canal. Pain can be
severe.
● Umbilical-Herniation occurs through the umbilical ring. Pain possible.
● Incisional-through a surgical site which hasn’t healed properly. Usually
painless.
Clinical Manifestations
● Most common is an intermittent or persistent bulge
● Can be accompanied by pain or painless depending on the type and
location
● Pain is often localized and sharp, aggravated by changes in position,
by physical exertion, during a bowel movement, or by any activity
causing the Valsalva maneuver
● Pain is often relieved by cessation of the activity preceding it
Medical Management: Diagnosis
● Most frequently noted in inguinal canal
● Radiographic investigations to rule out other diagnoses
● MRI/CT may also be used to identify defects that can
accompany certain types of hernias
Medical Management: Treatment
● Various supports/trusses can provide temporary treatment but don’t prevent
hernia from getting associated complications.
● Watchful waiting is an acceptable treatment approach for minimal
symptoms
● Delay surgical repair if possible until symptoms are greatly increased and no
longer tolerable
○ Only curative treatment but no longer recommended
○ Depends on size, location, symptoms
● Surgical often includes mesh repair - fixed into place laparoscopically
○ Reduces risk of incisional wound infection & reduces hospital stay
Medical Management: Prognosis
● Varies with type of hernia & accompanying complications
● Incarceration incidence is higher in femoral hernias (20%) compared to inguinal (10%)
○ Incarceration: herniated tissue is trapped & can’t easily be moved back into place
● High morbidity & mortality with incarceration in adults with umbilical hernias
● Laparoscopic & open repairs produce best results
○ Laparoscopy allows earlier RTP for athletes
● After surgery, guidelines usually involved around 4-6 weeks of no heavy lifting or straining
PT Implications
● Prevention, Screening, Referral
○ Risk factors: obesity with muscle weakness and increased intra-abdominal pressure
○ Educate pts on proper lifting & breathing techniques
● Early Diagnosis
○ Recognize signs/symptoms of hernia, as well as systemic conditions unrelated to
herniation
● Post-Op Recovery
○ Avoid heavy lifting & straining
○ Be aware of potential problems that could arise following hernia surgery
■ Ex: Abnormal discomfort could indicate inguinal n. entrapment or neuroma
○ Watch alignment and scar condition
■ If they go against fiber orientation, more likely to distract wound edges
PT Implications (cont.)
● Post-Op Rehab
○ Not evidence-based for the most part
○ Depends on severity of hernia and type of surgical intervention used
○ Awareness of signs & symptoms
○ Instruct proper lifting form
○ Avoid straining & Valsalva maneuver
○ Monitor post-surgical wound healing
Question #1 Question #2
Q. Which of the following are Q. Regarding hernias, we as physical
types of hernias? therapists should…
A. Indirect Inguinal A. Educate patients on proper lifting and breathing
techniques
B. Direct Inguinal
B. Treat post-operative hernia patients by pressing
C. Femoral on the healing wound as hard as we can
D. Umbilical C. Recognize symptoms of an undiagnosed hernia
and know when to refer
C. All of the Above
D. A and C
E. All of the Above
Reference
1. Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 4th
ed. Saint Louis, MO: Elsevier Saunders; 2015.
