Information on Symptoms
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Your Hernia Questions Answered:
A hernia is a common condition. It occurs when tissue, such as a part of the intestine or even just fat bulges through weak spot in the muscle. Hernias often occur around natural areas of weakness such as the belly button (UMBILICAL hernia) and in the groin between the abdomen and either thigh (INGUINAL or FEMORAL hernias), or through a surgical scar (INCISIONAL hernia).
Other less common abdominal muscles hernias include LUMBAR and OBTURATOR hernias. If a hernia occurs into the chest through the diaphragm it is called a HIATAL hernia.
There will be a bulge usually – the swelling is usually more noticeable when you’re standing or coughing or lifting something heavy and you may be able to feel this.
An ache or pain around the area- this tends to get worse on straining and worse at the end of the day than first thing in the morning.
You should see your doctor if you develop a painful or noticeable bulge in any of these areas in the picture.
If the swelling stays there when you are lying flat and you can’t push it back in or it causes pain when you do it may suggest that the opening through which the tissue bulges through is narrow. You should see your doctor more urgently as soon as feasible- the IRREDUCIBLE hernia is called an INCARCERATED hernia.
We would be happy to assess your symptoms and treat your hernia. For further information or to make an appointment, please e-mail Mr Chitsabesan’s Secretary Sarah Hunter Email : [email protected] or phone on 07807 118169
If, as above you can not push the hernia back in then the contents of the hernia may be trapped (incarcerated). An incarcerated hernia can become STRANGULATED which occurs when the blood flow to the tissue that’s trapped. A strangulated hernia can be life-threatening if it isn’t treated. You will need to see a doctor as an emergency!
- Sudden pain that quickly intensifies
- Nausea, vomiting or both
- A hernia bulge that turns red, purple or dark
- Inability to move your bowels or pass gas
If you have any of the above symptoms we advise for you to go to A and E.
- Increased pressure within the abdomen- such as chronic coughs, straining when going to the toilet or strenuous activity and obesity
- A pre-existing weak spot in the abdominal wall such as the umbilicus or groins.
- Weakness after a surgical incision
- Pregnancy
In the majority of cases an examination and a history of your symptoms taken by an expert who regularly sees patients with hernias is all that is needed.
Occasionally we may request an ultrasound to confirm our thoughts in patients with vague swellings or symptoms. The reason it is not always used is that it is very ‘operator dependent’ and has a chance of misleading the diagnosis of a hernia that is present or not.
Very occasionally we may use a CT scan or an MRI scan – this is usually reserved for recurrent and very complex large hernias or a persistent suspicion of an abnormality.
Occasionally we may also decide to laparoscope (Keyhole or minimally invasive operation) you to allow us to diagnose if there is a definite hernia there and also allow us to treat it at the same sitting.
Most hernias will be operated on.
If we decide that the hernia needs to be repaired we can do this by an open or laparoscopic (Keyhole) approach. The repair can be done by using sutures only or adding a piece of mesh.
Open Hernia Repair
The surgeon makes an incision near the hernia site, and the bulging tissue is gently pushed back into the abdomen. The hernia sac is removed. Then the weakness repaired.
- Suture-only repair: Then the tissue along the muscle edge is sewn together. This procedure is often used for small weaknesses in the muscle.
- Open mesh repair: Mesh is placed beneath the hernia site. The mesh is attached using sutures into the stronger tissue surrounding the hernia. The mesh extends beyond the edges of the hernia. Mesh is often used for large hernia repairs and reduces the risk that the hernia will come back again.
For all open repairs, the skin fat and then layers are closed using sutures, staples, or surgical glue.
An open repair may be done with local anaesthesia and sedation given through an IV.
We would be happy to assess your symptoms and treat your hernia. For further information or to make an appointment, please e-mail Mt Chitsabesan’s Secretary Sarah Hunter Email : [email protected] or phone on 07807 118169
Laparoscopic Hernia Repair
The surgeon will make several small incisions in the skin. Using specialised surgical tools, the surgeon will operate through these openings with a lighted camera. The abdomen is in inflated with carbon dioxide gas to expand it to allow the surgeon to operate. For incisional and umbilical hernias, we will close the weakness in the muscle wall with sutures, in accordance with current guidelines, to decrease recurrence rates of new hernias and to bring the muscles together so they work better. Not all surgeons do this. Mesh is then sutured or stapled to the muscle around the hernia site. The tiny incisions are closed with sutures, surgical clips, or glue.
Abdominal Wall Reconstruction
Complex or large hernias require a greater procedure called abdominal wall reconstruction and are performed while you are asleep. Small drains may be placed going from inside to the outside of the abdomen. You will likely remain an inpatient for a few days afterwards.
Watchful waiting is only recommended for very small hernias that don’t cause any symptoms or those patients who are not fit enough for an operation. The hernia will not get smaller but can increase in size with time because of constant pressure from the hernia and abdominal muscles weaken with age. Most men with inguinal hernias and no symptoms will develop symptoms and require surgery.
You can, however, reduce strain on your abdominal muscles and tissues. For example you can reduce your weight, reduce the amount of heavy lifting you do, and reduce straining in the toilet by taking regular laxatives. Abdominal binders or a hernia truss can also apply pressure and push back the swelling thereby giving some relief- but it will not repair the hernia nor are they proven to decrease the need for a future operation.
Many patients who develop a hernia have demonstrated that their tissue is ‘weaker’ and so give way leading to hernias. We know there is a higher recurrence rates of hernias after just repairing with stitches. The mesh helps cause a stronger scar tissue and helps support this weaker tissue to prevent recurrence of the hernia. For the vast majority of patients, mesh poses little if any additional risk, and coupled with a lower recurrence rate, has resulted in the use of mesh becoming the gold standard in hernia
Implants include hip and knee replacements and breast implants as well as mesh. Implants undergo significant testing before they can be used in any surgery. Meshes used in surgery are tightly regulated and requirea CE-mark to be used in patients in the European Union (EU). Patient safety is a critical component of this regulation and regulatory compliance is subject to periodic reviews by authorities in the EU.
Mesh implants have recently been on the news and there have been worries that it could be causing significant complications. The mesh, however, that is at the centre of this controversy are those used in treating urinary or faecal incontinence.
Hernia mesh is used in a slightly different way to incontinence procedures and inguinal hernia surgery is almost certainly one of the most commonly performed general surgical procedures in the Western World, if not worldwide. The use of mesh to repair the majority of hernias has been the preferred method in the UK and worldwide for over 25 years. It is very safe and has less risk than many other implants. It has a very good safety profile and due to the high numbers of procedures using it we have a large volume of data on the outcome of various hernia operations and different meshes. Indeed when surgeons themselves have hernias they opt for mesh repairs as they know that the chance of mesh problems are in fact very low.
We would be happy to assess your symptoms and treat your hernia. For further information or to make an appointment, please e-mail Mt Chitsabesan’s Secretary Sarah Hunter Email : [email protected] or phone on 07807 118169
The Royal College of Surgeons of England issued an article looking into recent media inaccuracies concerning mesh. It is a fair document that puts patients at the heart of this debate.
Please see the abstract from a leading article in the British Journal of Surgery, by Mr Neil Smart, about the use of mesh for fixing hernias.
https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11240
The International Guidelines For Groin Hernia Management (2018) also make a strong recommendation for the use of mesh in repairing inguinal hernias.
We can perform inguinal hernia and small umbilical or epigastric hernia surgeries without mesh but there is a higher chance of recurrence but Mr Chitsabesan would be happy to discuss this possibility and the risk/benefits associate with it with you.
Are there disadvantages to a mesh repair?
Mesh is foreign material, like any synthetic implant (hip replacements, dentures, crowns, heart valves etc). It can become infected but this is a rare event. Some patients can develop chronic pain after surgery. There is no firm relationship with the use of mesh and chronic pain, and non-mesh repairs can equally result in this problem.
Groin Hernias:
Inguinal hernias are one of the most common hernias – they can occur on both groins and in men and women though they are more common in men. About 25% of males, and only about 2% of females, will develop an inguinal hernia in their lifetime.
What are the symptoms of an inguinal hernia?
Inguinal hernias may be painless or cause no symptoms, especially when they first appear. Symptoms can include:
- A bulge on one or both sides of the groin that disappears when lying down but gets bigger with coughing.
- Pain in the groin, especially when lifting, coughing or bending.
- A dragging feeling or burning in the groin.
- A swollen scrotum (the sac-like a part of the male genitalia underneath the penis).
An inguinal hernia is usually not dangerous. However, it can be painful, especially when lifting, bending, straining with a bowel movement, or coughing.
Inguinal hernias can be repaired through open incisions or laparoscopic (keyhole) procedures. Inguinal hernias should be repaired with mesh
We would be happy to assess your symptoms and treat your hernia. For further information or to make an appointment, please e-mail Mt Chitsabesan’s Secretary Sarah Hunter Email : [email protected] or phone on 07807 118169
Femoral hernias are less common than inguinal hernias but unfortunately are more likely to become INCARCERATED and STRANGULATED and so all femoral hernias should be repaired as soon as feasible. Femoral hernias are more common in women than men.
They have similar symptoms to inguinal hernias but can be more difficult to feel or see. These are repaired through a small incision in the groin crease and can be fixed with or without mesh. They can also be repaired laparoscopically (Keyhole) however the dissection and risks are greater than with an open repair but there is a lower recurrence rate.
Depending on where it is it could be:
Glands/lymph nodes similar to the ones you may get in your neck after a sore throat.
An enlarged vein like a varicose vein (Saphena Varix)
In men it could be a collection of fluid called a hyrdrocoele and a varicocoele or even an undescended testis
Skin lumps such as sebaceous cysts or boils
Groin pain- other causes
Arthritis of the hip/knee, muscular injuries, adductor ensethitis (inflammation of the bone where the tendons of the muscles that pull your thighs inwards attach), ‘sports groin’ or ‘gilmore’s groin’.
Sometimes overly tight trousers in overweight patients can trap nerves and cause pain in this region or trapped nerves in the back occasionally.
Please see this excellent website regarding groin hernias from the British Hernia Society.
Abdominal Hernias:
These are common hernias that occur at or next to the umbilicus. They often occur after pregnancy as there is a natural weakness here. Many are asymptomatic. If it is causing you symptoms such as pain, a dragging feeling or getting bigger then we can repair it with an open operation or by keyhole. However the pros and cons will be discussed with you at the time of your review as it will often depend on your own circumstances and the size of the hernia etc.
We would be happy to assess your symptoms and treat your hernia. For further information or to make an appointment, please e-mail Mr Chitsabesan’s Secretary Sarah Hunter Email : [email protected] or phone on 07807 118169
These occur at a site of weakness due to a surgical incision. They are relatively common and greatly vary in the size and shape and how best to manage them.
Operations that lead to hernias include laparotomies for emergencies (large cut down the middle of your abdomen), caesarian section scars and after keyhole surgery from the small cuts especially around the umbilicus.
The best assessment is by examination and a history performed by a hernia expert. We will be able to determine the ideal management plan and also the pros and cons of having a repair as some hernias repairs may carry a significant risk.The smaller hernias (less than 6 cm) have an option to be repaired laparoscopically (by keyhole) but again it will depend on your own previous operations and diagnosis as well as how you are at the moment.
For very large and complex hernias we would manage you though a multidisciplinary approach and ensure that we improve all the risk factors we can prior to operating. It is vitally important to do this as it reduces the chance of complications and recurrence of the hernia. The best chance of repairing the hernia is at that first time so feel it is very important to counsel you through this process.
These are uncommon hernias that are difficult to diagnose but can be treated readily. They often do not have a large bulge but tend to have vague swelling and symptoms. They are much more easily felt when standing rather than lying down or straining.
We find the easiest way to diagnose these and repair them is by laparoscopic (Keyhole) techniques. An open operation is sometimes used when these hernias are more readily identified and are small.
These are very frequent as having a stoma essentially means you will have a hernia as we have had to make an opening in the abdominal wall for the bowel. Symptoms usually include an obvious bulge but also may include the stoma bag not fitting any more or peeling of more frequently.
They can be very difficult to treat and can be repaired by and open or laparoscopic procedure. The evidence suggests that a mesh must be used to reinforce a repair. Complication rates are higher for this as essentially it is a contaminated site and the defect cannot be completely closed. Occasionally it may be better to move the stoma site.
This is not a true hernia but a thinning of the covering of the muscles in your abdomen- this would mean that the recti (the muscles that give the look of a six-pack) spread apart and you get a bulge in between. This commonly occurs after pregnancy and its important to see the ‘womens’ health physiotherapist’ who will give you exercises to try and bring the muscles back into position. This should be performed within a few weeks after pregnancy to have the best effect. The divarification can also happen in obese patients.
These don’t necessarily need to be fixed, as there is no true hernia hole that would trap bowel contents. Most divarifications / diastasis of the recti are epaired for cosmetic reasons as they look unsightly. However, divarifications / diastasis of the recti can also predispose patients to a hernia if divarication remains, back problems due to instability in your core muscles as rectus abdominus muscles do not function as well in flexing the torso and hence affect your stability. Some of this can be helped with improving your core muscles.
We do occasionally operate on divarification when there is a hernia within it- this necessitates repairing the whole area of weakness as otherwise there is a much higher chance of recurrnce. It also requires a much larger piece of mesh to reinforce this area within the abdomen. The whole area must be repaired as fixing one small site means the tension may move elsewhere and new hernias are likely to be created elsewhere.
This can sometimes be performed laparoscopically (keyhole) with small scars rather than one very large scar providing better cosmesis. The excess skin will usually flatten out but where there is a large excess of skin it may mean you will need to be referred for an abdominoplasty or ‘tummy-tuck’ separately at a later date.
We are happy to discuss this with you in more detail during a consultation.
We would be happy to assess your symptoms and treat your hernia. For further information or to make an appointment, please e-mail Mt Chitsabesan’s Secretary Sarah Hunter Email : [email protected] or phone on 07807 118169
If there is a recurrent swelling after a hernia repair we would evaluate it in the same way as a new hernia. Managing these can be quiet complex though.
Groin hernias that have had an open operation should have a laparoscopic repair and vice versa. A recurrent incision hernia or ventral hernia (on your abdominal wall) will more likley need further evaluation and a tailored approach depending on multiple factors including the number of previous operations, skin changes and laxity, obesity and other medical issues the patients have.
Our significant experience in managing complex abdominal wall reconstructions and recurrent hernias is vitally important in reducing the risk of complications from this type of surgery and the chance of recurrence.
There are other abdominal hernias such as lumbar hernias around the back and obturator hernias that are rare and extend into to inner aspect of the thigh but are rarely felt.
Bowel:
Have you had a change in your bowel habit?
If you have thought –
‘I am looser or going more often than normal’
‘My stools have changed’
‘There’s blood in my stool’
‘I’ve lost weight’
‘I’m feeling very tired all the time’
‘A pain or lump in your tummy’
Then it is important you have this investigated if it is persistent and unexplained. You should arrange an appointment to see you GP who can arrange a referral to the hospital. Most patients who have these symptoms do not have bowel cancer as other problems can cause similar symptoms such as:
Constipation, Diarrhoea, Irritable bowel syndrome (IBS), Diverticula disease, Inflammatory bowel disease. Find out more about these conditions on nhs.uk.
Bright red blood on the tissue or in the bowl is usually due to haemorrhoids or a tear in the back passage (fissure). Darker blood is usually from further in the bowel or intestines. If the bleeding is unexplained you will need a camera test called a colonoscopy or flexible sigmoidoscopy to investigate this.
A change to you bowel habit will often be for dietary or stress reasons. However if it is persistent and you have not changed anything you are eating you should tell your GP. You may have looser poo and you may need to poo more often than normal. Or you may feel as though you’re not going to the toilet often enough or you might not feel as though you’re not fully emptying your bowels when you go to the toilet.
There are many reasons for this. It is a less common symptom. Speak to your GP if you have lost weight and you don’t know why. You may not feel like eating if you feel sick, bloated or if you just don’t feel hungry.
Again there are numerous reasons for this but Bowel cancer may lead to a lack of iron in the body, which can cause anaemia (lack of red blood cells). If you have anaemia, you are likely to feel very tired and your skin may look pale. Your GP can arrange to check your thyroid function to ensure it is working normally and check for anaemia. There are many other causes of anaemia- for example the commonest is women who are still having periods, especially if they are heavy. However, it may still be important to have your GP check this.
You may have pain or a lump in your stomach area (abdomen) or back passage. If they are persistent then you should see your GP.
If possible try and keep a diary. Bowel cancer UK have a great diary, pioneered by Beth Purvis, that is downloadable at this site https://bowelcancerorguk.s3.amazonaws.com/BCAM%202019/SymptomsDiaryApr2019.pdf
You should then see your GP regarding these symptoms but we are also happy to review you in clinic and arrange a full series of investigations including blood tests as well as faecal tests and then further ongoing investigations to rule out a serious cause such as bowel cancer or inflammatory bowel disease and to help manage your symptoms.
Bowel cancers can often lead to tiny amounts of blood in poo, which can’t normally be seen.
If you are 60–74 you will receive a screening test in the post every two years from the NHS screening team.
However we know that much younger patients can get cancer also and one of the aims for the NHS is to diagnose it as early as possible to help patients achieve a cure. Every year in the UK over 2,500 under-50s are diagnosed with bowel cancer, a 45% increase since 2004. To this end there has been recent guidance from NICE (National Institute for Clinical Excellence) suggesting that younger patients without significant symptoms may benefit from FIT testing.
You are more at risk if you are:
- over 50
- have a strong family history of bowel cancer
- have a history of non-cancerous growths(polyps) in your bowel
- have longstanding inflammatory bowel disease, for example Crohn’s disease or ulcerative colitis
- have type 2 diabetes
- have an unhealthy lifestyle
FIT testing is thought to be a better test for bowel cancer then the old FOB test. FIT has a high chance of not missing a cancer but does also pick up patients who may have polyps and diverticula disease. Not everyone who is positive will have bowel cancer and depending on the results at least half of the patients with positive results will have a normal bowel. The test is relatively easy to perform and you have a picker that takes a tiny sample of stool that can be placed in a special container and then sent off for testing. We can then arrange further tests as necessary. If you have a change in your bowels though it is best to be reviewed in clinic by your GP or an expert.
However, if the test is negative it doesn’t 100% mean you don’t have bowel cancer or will not develop it in the future. So if you have persistent undiagnosed symptoms or you develop new symptoms you may still need to be investigated and so you should see your GP.
If you would like to request a FIT test but have no change in your bowel habit then please contact us. We can arrange ongoing investigation or review in clinic if needed
Please see bowelcanceruk.org.uk for lots of useful information on this as well as bowel cancer screening and FIT testing and if you have been diagnosed with bowel cancer.
Bowel incontinence, or faecal incontinence, is when you have problems controlling your bowels.
It can be very upsetting and embarrassing, but it’s important to get medical advice if you have it because treatment can help.
What are the symptoms of incontinence?
Bowel incontinence affects people in different ways.
There are different degrees of incontinence:
- you may have sudden urges to poo that you can’t control
- you soil yourself without realising you needed the toilet
- you sometimes leak poo – for example, when you pass wind
- you may leak some faecal fluid or mucus
- and it happens regularly every day or from time to time rather than being a one-off “accident” when you’re ill with food poisoning or viral diarrhoea
- it’s affecting your daily life – for example, it stops you socialising
Other symptoms can occur too and may give us an idea of what is happening e.g. constipation, diarrhoea, passing wind or bloating, as well as urinary problems and problems having intercourse due to prolapse into the vagina.
Why do I have this?
Incontinence is usually caused by a mixture of problems.
Loose stools-
- there are a number of causes such as irritable bowel syndrome (IBS) or inflammatory bowel disease, such as ulcerative colitis
- Sometimes severe or long-lasting constipation leads to a build up of watery stool in your bowels that then overflows uncontrollably – a little like a blocked pipe.
- Occasionally there are other causes such as malabsorption of food due to chronic alcoholic problems or gluten intolerance (celiac disease) or your thyroid gland working overtime (Hyperthyroidism).
- Medication that you are on such as antibiotics, special ant-acid tablets etc
- Diet- e.g. too much caffeine or fruit
Damage to the muscles that control your bowels- anal sphincter
- This can often happen during childbirth or after an operation such as haemorrhoid surgery or anal dilatation which is an old operation
Prolapse-
- This is often associated with chronic constipation and pelvic floor failure-
- This can be mucosal prolapse or the inner lining of your bowel. Haemorrhoidal prolapse can also lead to leakage
- Or the whole bowel prolapsing out of the anus and its usual position- full thickness prolapse
Nerve damage-
- Childbirth or surgery damaging the nerves you use to control your bowels
- Conditions that can affect the nerves in your bottom – such as diabetes, a stroke or spina bifida
It’s important to not self-diagnose the cause of your problems. Get medical help so the underlying cause can be identified and treated.
Who tends to get this
Women tend to have more of a problem than men- this is for a number of reasons
The sphincters or muscles are much shorter in women than in men and childbirth can lead to further damage and nerve problems which can predispose women to incontinence. As we all get older all our muscles get weaker and this also applies to the muscles that maintain continence.
Always get medical advice
Don’t be embarrassed about talking to someone about it. This is a common problem and all of us clinicians, GP’s and Surgeons see this condition regularly and we see it as a condition we can help with and want to help with.
We can often make things better with simple measures and occasionally we may need further information and tests, we may refer you for physiotherapy to build the muscles around your bottom end and very occasionally we may need to operate.
So please do remember it’s not something to be ashamed of, we see this regularly and we can almost certainly help.
It is ALSO IMPORTANT to ensure there are no diseases such as inflammatory bowel disease or possibly polyps or a tumour causing problems in the bowel that leads to looser stools. This can be ruled out by a simple camera test and we would normally organise that as we manage your incontinence.
So what will we do?
We offer an empathetic service. Mr Chitsabesan has trained in several pelvic floor centres, which provided a full service to patients with this distressing condition. He is an expert in the management of these conditions and has taught on several courses and runs the Cadsim teaching course. He is a member of the regional mesh salvage team led by Mr Hilmy and has been the main colorectal expert in the pelvic floor MDT for the last 7 years for York NHS Trust. He works very closely with the specialist urologist and gynaecologist in the more complex cases and has published and had videos presented in these areas.
When you are referred to him he will review you in clinic and find out what the main issues are with your problem in relation to the areas mentioned above- the consistency of your stool/poo, your muscles and how they are controlled and if you have any prolapse.
We will always question you about your medical history and your diet and how you go to the toilet and then ensure there is no serious cause for your problems with a camera test (flexible sigmoidoscopy or colonoscopy with biopsies). This all forms an important picture of your specific case as everyone if different and we need to tailor your treatment.
Once we have this information we have several options:
- Ask you to keep a diary
- Suggest changes to your diet – such as avoiding foods that make diarrhoea worse
- Use medicines to reduce constipation or diarrhoea- these may be tablets for travellers diarrhoea such as immodium, a bulking agent such as fybogel or laxatives for constipation
- Continence products – such as pads you wear in your underwear or small plugs you put in your bottom (Please see the NHS website about the types of continence products and how to get them.)
- Refer you for physiotherapy or retraining of your muscles and pelvic floor
(The Bladder & Bowel Community website has more about pelvic floor exercises for incontinence.)
- Arrange special tests of your muscles to see how they function (anal manommetry), if they are intact (Anal Ultrasound scan) and if the nerves work (endomucosal sensitivities)
Very occasionally we may operate to:
- repair damaged muscles in your anus (sphincteroplasty)
- inject a substance (such as silicone) into the muscles in your anus to help make them stronger (injectable bulking agents)
- place a small electronic device under your skin that helps the muscles and nerves in your anus work better (sacral nerve stimulation)
- fix a prolapse of the rectum
We will treat your case individually, sensitively and empathically to improve your quality of life. We can not promise to return your function to what it was when you were much younger but we will almost certainly help improve it if we can’t.
More information
For more advice, information and support, see:
- NHS advice on living with incontinence – including more information on continence products
- Bladder & Bowel Community – including more on treatments, ways to cope and patient stories