What You Should Know About Direct versus Indirect Hernias

Both an indirect and direct inguinal hernia can cause a bulge on either side of the groin if the hernia is large enough. The bulge is usually most noticeable when standing and when straining or coughing. In many cases, hernias cause no pain until they get larger. In men, pain may be felt in the scrotum if the intestine pushes down into that region.

An indirect hernia usually first occurs in infancy. That’s because it’s often a congenital condition. An indirect hernia in an infant may be most noticeable when the baby is crying.

A direct hernia almost always develops in adulthood, usually later in life, unless the problem is the result of a specific injury.

A direct hernia is usually caused when the wall of the abdominal muscles becomes weak. That allows a portion of the intestine to push through the abdominal wall. This weakening can develop over time, due to everyday activities and aging. In some cases, improperly lifting something heavy can put extra pressure on those muscles, allowing them to weaken and tear.

An indirect hernia is not caused by weakened or injured abdominal muscles. Instead, it occurs when an area of abdominal muscle tissue called the inguinal ring fails to close up while a baby is in the mother’s womb. In boys, the ring allows the testicles to drop into the scrotum, and then usually closes. When it remains open, a part of the intestine can also push through it.

Risk factors for direct hernias include:

• being a man, though women can also develop hernias
• having a family history of hernias
• smoking
• having a condition that leads to chronic coughing, such as cystic fibrosis
• having a low body mass index (BMI)
• having collagen vascular disease

It’s unclear whether heavy lifting makes it more likely that people will get hernias.

There are no real risk factors for developing an indirect hernia, other than being a man. Men are 9 times more likely than women to develop an indirect hernia.

A hernia is usually diagnosed through a physical examination. Your doctor may be able to identify a bulge in the groin as a hernia. It can be difficult to distinguish an indirect hernia from a direct hernia. Most people in their 20s or younger who have a hernia have an indirect inguinal hernia.

If you’re a man and your doctor finds that the hernia has extended into your scrotum, the diagnosis is usually an indirect hernia. A direct hernia doesn’t follow that path through the inguinal ring into the scrotum. That means a hernia that forms one side of the groin or the other is most likely a direct hernia.

An indirect hernia may also cause bowel obstruction if it slips into the inguinal ring and becomes swollen in the abdomen. This condition can worsen into a phase known as “strangulation,” which can affect blood flow in the intestines. A direct hernia is less likely to cause strangulation of the bowel.

If a hernia is mild and causing no symptoms, you may not need to do anything other than take a “watchful waiting” approach. Hernias do not heal on their own so you may need surgery in the future whether it’s a direct or indirect hernia.

Surgery for indirect hernias in babies and children is usually quite safe. It’s typically an outpatient procedure. The hernia sac is moved away from the scrotum and other sensitive areas, and closed up with sutures.

A small percentage of children with an indirect hernia on one side also develop one on the other side. There is some debate in the medical community about the need to investigate a possible second hernia. If you have questions about the risks and benefits of this procedure as part of the surgery, talk with the surgeon ahead of time.

In adults, open surgery is often done to repair a direct hernia. A large incision is made and the hernia is moved back into place. The abdominal wall is repaired, sometimes with a small mesh device that provides added strength to the affected wall.

Laparoscopic surgery is a growing option for many types of abdominal surgeries, including hernia operations. A doctor uses special instruments that can be inserted through a few small incisions. One of the instruments is a tiny camera that allows the surgeon to see the hernia and treat it.

Laparoscopic surgery involves less scarring of the larger abdominal muscles, so it’s a good choice for recurrent hernias.

If you’ve had either an indirect or direct hernia, you have an increased risk for developing another hernia.

Surgeries to repair hernias are common and have high success rates, so you should expect a full recovery. It may be several weeks before you’re back doing all your usual activities. And you may also be advised not to lift anything heavy for a while. You should consult with your doctor, or a physical therapist or occupational therapist, for tips on lifting in the future.

You can’t prevent a congenital problem such as an indirect inguinal hernia. But there are some steps you can take to reduce your risk for direct hernias.

• Lose weight if you’re overweight or obese. Weight loss won’t eliminate your risk of a hernia, but it will ease the strain on your abdominal muscles.
• Quit smoking partly because of the damage it causes all the tissue in your body, and partly because coughing a lot raises your risk of developing a direct hernia.
• Be careful when lifting heavy objects, and always lift from the legs, not your lower back. To do this, bend at the knees to pick things up, and then straighten your legs to stand. This reduces strain to your lower back and abdomen.