162. Hidden Hernias Hurt

This week, the topic of discussion was:
- Hidden Hernias
- Occult Hernias
- Femoral Hernias
- Groin Pain
- Testicular Pain
- Vaginal Pain
- Inner Thigh Pain
- Lower Back Pain
- Radiating Pain
- Pelvic Pain
- Pelvic Floor Spasm
- Urinary Frequency
- Austria
- Diagnosis
- History
- Ultrasound
- CT scan
- MRI

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh, call +1-310-358-5020 or email info@beverlyhillsherniacenter.com.

Link to my MRI Protocol for Inguinal Hernias: https://beverlyhillsherniacenter.com/...

Link to my research on best imaging for occult hernias: https://jamanetwork.com/journals/jama...

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Transcript

Speaker 1 (00:10):

Hi everyone. It’s Dr. Towfigh. I hope you’re well. Welcome to Hernia Talk Live. Today’s another Tuesday Hernia Talk Tuesday. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist joining you from beautiful Beverly Hills, California. Thanks for everyone who’s on live via Zoom link or as a Facebook Live. And as you know, you can always find me on social media. I could find me on Twitter, and that would be @hernia doc. Also Instagram @Hernia doc. Don’t forget this. And all prior hernia talk episodes, I believe we’re at number 160. will be and is available for you on YouTube at my channel @Hernia Doc. And if you prefer the podcast, you can also use this as a podcast, Hernia Talk Live as a podcast. So today I’m super excited to have our talk pick be on Hidden Hernias.

Speaker 1 (01:14):

I’ve always wanted to say the term hidden hernias hurt because besides the fact that it’s a beautiful alliteration, it’s true. And why do they hurt? We’re going to discuss that. What are hidden hernias? We’re going to discuss that. And all I can say is I’m passionate about occult hernias, hidden hernias because so much of the patients that I see are people that have been denied care, delayed care told they’re nuts because they were seen by doctors who thought that all hernias must be a bulging hernia. And they don’t understand the concept of occult hernias or hidden hernias. In fact, they believe that if a hernia is small, that it is inconsequential and cannot cause any problems and therefore should not be touched. So of course that’s not true. And we’ve published on this and if you guys come to the SAGES meeting, yeah, Sage’s meeting, which is the annual big laparoscopic meeting of the year, you will hear more about our research and we titled it the same thing.

Speaker 1 (02:35):

Hidden hernias hurt. They accepted it as our research project, and soon it will be published as a paper. That’s our goal. And hopefully, besides all the talks that I give, people will read this because not everyone comes to my talks, right? There are only so many surgeons that come to these meetings and even though the talks are often available online, I’m still not reaching out to medical doctors and obstetricians and gynecologists and urologists and family medicine doctors and physician assistants and physical therapists, all of whom need to understand, or orthopedic surgeons that hidden hernias hurt. And the reason for people’s pain may be a groin hernia. We’re talking groin mostly by hernias. I’m talking by angle hernias, but a groin problem that is not an obvious bulge. Now, why is this important? It’s important because the concept that all hernias must be bulging is what’s taught in medical school.

Speaker 1 (03:40):

And then if you don’t do a surgical residency after that, then that’s all you know is that if there’s a bulge, there’s a hernia. They never say if there’s no bulge, there is no hernia. It’s kind of implied, but that’s incorrect. And so people think that way, okay, bulge equals Hernia, but if there’s no bulge, then I’ve completely ruled out a hernia that’s completely incorrect. The story is what’s most important is your pain activity related. Is it better when you’re not active resting, laying flat? Is it worse towards the end of the day? Do you have pain that’s radiating in let’s say the groin pain? Is it radiating to your inner thigh around your lower back into your vagina or into your testicle? Do you have nausea or bloating associated with it? Is it worse with a bowel movement or after a bowel movement? Is it worse with a enlarged bladder?

Speaker 1 (04:30):

Do you have pain with orgasm or intercourse? These are all potentially hernia related problems. Do you have a family history of hernias that’s important? So the story is more important than the physical exam, and this is super important because soon we’re going to launch our hernia score, which is an algorithm where you can go online, your doctor can do it, you can do it’s completely free, can go online, put in your symptoms, your story, and then based on that story, it’ll shoot out a percentage chance that your pelvic pain or groin pain or testicular pain is due to an inguinal hernia, which means this is all before even anyone touches you. So here’s how it should happen. You have pain, it’s in the groin, pelvis, testicle, labia, vagina, those areas. It’s usually activity or positional related. But then the question is, is it from a hernia?

Speaker 1 (05:38):

Now, it can be from a hip, it could be a muscle tear, sports injury, it can be diverticulitis, appendicitis, it could be ovarian cyst endometriosis. You could have testicular problems due to various types of urologic problems. The question is, could a Hernia be causing any of these symptoms? Now, if you go to a hernia surgeon expert, someone like me that does this for a living, I can tell you based on just hearing your story, whether I think it’s a hernia or not, and then I’ll look at your physical exam, see if there are suggestions of a Hernia. And then if it’s not obvious, then an imaging will kind of break the tie. However, if you go to a doctor that’s not aware that you can have hernia related pain without a bulge in the groin, then what happens is you’ll be told it’s not a hernia.

Speaker 1 (06:37):

So you incorrectly take that out of your list of potential things it can be, and you go to the orthopedic doctor and the pain doctor and the urologist, the gynecologist, the physical therapist and so on, spine doctor, and you’re basically years can go by. We’ve shown that in people that have hidden hernias or colon hernias about over a year of delay in diagnosis. In the meanwhile, they’re spending all this time and money seeing doctors getting a CAT scan, ultrasound, MRI, another CAT scan, multiple doctors visits. Some people even get surgery, they get hysterectomy, neurectomy, they get their gallbladder removed, appendix removed, none of it helps. Why? Because no one has figured out that this pain is due to a Hernia. And here’s a question. What about a lipoma or a mask causing a Hernia? Well, okay, if you have a lipoma which is a fatty, benign non-cancerous fatty tumor, usually that’s palpable on exam.

Speaker 1 (07:38):

And if it’s a mass or a lymph node, that’s usually also palpable on exam. Or you can do kind of imaging either an ultrasound CT scan or MRI and have that be the cause of your symptoms. In fact, just yesterday, yesterday was Monday, yeah, just yesterday I had a patient that flew in from out of state and she did not have a hernia. She thought she had a hernia. It was a bulging. She’s very thin. You can feel like a small bulging, couldn’t really see it very much. Definitely can feel it. And it was a lymph node and she needed to have a workup for why you can have enlarged lymph nodes. Could be from infection or cancer usually. So it was not a hernia. Now usually what I mean by hidden is it’s not only you can’t see it, but you often can’t even feel it.

Speaker 1 (08:35):

In fact, what you feel may be tenderness, if you do have tenderness in specific areas in the groin, that’s very diagnostic of a Hernia even if there’s no hernia. And the other is if you have just a slight swelling, I wouldn’t say bulge, it’s just slightly more in that area that is typical for an inguinal hernia than is typical for a normal part of the groin. So the question is provided here, do you do phone consultations? I’m in Oklahoma. I do online consultations. So for those of you that are out of state or cannot come to see me in person for whatever reason, out of state, out of country, we do offer what’s called online consultation. So it’s really a review of your chart by me and an email correspondence. It’s not really, I can’t really have a doctor, doctor-patient relationship in states where I’m not licensed or practice. So if you come to see me, that’s great. If you’re in California, that’s great, but anything outside of that, I do want to still help you. So we do offer what’s called online consultation. Just contact my office directly and we can tell you all the details for that.

Speaker 1 (09:53):

Okay, so where was I? How do these occur? So these are the initial parts of a hernia. Most surgeons who treat hernias are used to seeing a bulge. And in fact, so many people say if it hurts, then it’s not the hernia. So doctors don’t even believe a subset of doctors. Even really good doctors don’t even believe that you can have a hernia that can cause pain. In fact, they say if it hurts that it’s not a hernia told. That makes no sense. I was very junior, I was like, I’m going to say it was the first five to seven years I was in practice. So I was somewhat junior and I was sitting at a conference with literally the gods of hernia. People that invented techniques, their name is on the technique, and some of them were legit people that I highly respected that are really good about chronic pain.

Speaker 1 (10:57):

And they said, if there’s pain associated with the hernia, then it’s not the hernia. You’re going to look for something else. It’s something else. It’s not the hernia. Hernias don’t hurt. And I’m like, I’ve literally treated hundreds by then thousands of patients with hernias that hurt and then I fix it and then the pain is gone. That makes no sense. Why would you even say that? But this is what happens as patients, doctors have these feelings or ideas and then there’s no evidence behind it. So I said, okay, how do I try and change, take this boat and turn it around so that these doctors don’t all discount patients’ pains as not being from hernias. And so then I started doing my research and I started gathering data. Every time I saw a patient with an occult hernia, I took note of it and then we published about how imaging can help identify occult hernias, specifically ultrasound and MRI.

Speaker 1 (11:59):

CAT scan is not very good for the groin. It’s good for the abdominal wall, but not for the groin specifically. Ultrasound and MRI are much better. And then we start talking about, oh, it seems like mostly women that have these occult hidden hernias. Why is that? And as a female surgeon, I tend to attract more females than maybe proportionally there would be for hernias. So 51% of my practice are females. So I started seeing a trend. I started seeing more and more women presenting with chronic pelvic pain, which is not a thing, it’s like a bucket of lists of a lot of different things. And the patients were women, they were often thin, but they didn’t have to be. And they had this chronic pelvic pain, no one could figure it out. And it turned out it was little itsy bitsy hernias. And why do women have it worse?

Speaker 1 (12:59):

We don’t know exactly scientifically. My thought is this. My thought is if you look at the inguinal canal, it’s wider in men than in women. In men, there’s a lot going through the inguinal canal. It’s the artery vein, veins, nerves, muscle lymphatics, and the vas deferens that carry sperm all going through the inguinal canal. In women, they’re just a little nerve and a little noodle looking thing called the round ligament. That’s all you have. So automatically the Inguinal canal space and the hole through which everything goes, which is called the internal ring, is wider in men than in women. So in men, if you already have a big hole, you can get a lot of other contents to go in there. You’re going to see big bulge. If women, you start with a really small hole, the less fat can start going in at the early stages of a hernia and therefore women tend not to present with bulge, they present with pain.

Speaker 1 (14:02):

You’re now pinching this itsy bitsy little piece of fat into that little itsy bitsy hole. Whereas in men, that’s a much larger hole and people are presenting with a bulge. I see there’s a question here. Can you rely on symptoms alone to diagnose a recurrent hidden Hernia in someone with chronic postoperative inguinal Hernia pain where pain from the initial repair such as stitches or nerve injury may confuse the source of symptoms? Does that cloud things or muddy the waters? And how do you handle that to assign symptoms to a hidden hernia? Okay, so good question.

Speaker 1 (14:38):

You’re right. The hidden Hernia diagnosis is more complicated if they’ve already had surgery there. So let’s say you had surgery and now you have an itsy bitsy hernia and you’re symptomatic from it. However, the symptoms are similar, right? Hernia symptoms or hernia symptoms, like I said, it’s groin pain, often breathing into the testicle, inner thigh or around to your lower back, maybe associated with bloating. It’s it’s worse with standing for a long time sitting for a prolonged time bending. It’s better when you’re lying flat, sometimes crossing your legs hurt. Sometimes it’s nerve type pain, but not constant nerve type pain only when the hernias are exacerbated. So yes, you can initiate a diagnosis for hidden Hernia even in a complicated patient with multiple prior operations. However, just because the clinically everything sounds right, if the physical exam is not diagnostic, which means there’s no obvious bulge, there may be a hint of it, then often you need a tiebreaker, right? You need an extra modality that’s more objective to identify whether there truly is a hidden hernia, small little piece of fat that’s being pinched or pushed into a little hole. And that goes with imaging. So if you had surgery before, MRI is the right imaging form with Valsalva. So with pushing out, so MRI with Valsalva without any contrast, if it’s the first time an ultrasound may be good enough and you don’t need, don’t need an MRI. So that’s kind of the gist of it.

Speaker 1 (16:32):

My goal, it’s been several years that I’ve started this podcast and we’ve talked about occult inguinal hernias, but I’ve never really had a single hour dedicated a hundred percent to it and I don’t know why not because we talk about it all the time, but it occurred to me since we started this research project and got accepted for the sages meeting to present our findings and we termed it hidden hernias hurt. I thought it’d be kind of cute to have the same going on for our Hernia Talk Live today. And I just want to stress how important it is that the people listen to their patient’s stories and not so much just on the physical exam. There are a lot of places, Shouldice clinic being one of ’em where they don’t operate on people with because they go purely by physical exam and not by the story.

Speaker 1 (17:35):

They recently posted something about how it’s all about the story and then the next sentence they said was, but if there’s no hernia on exam, we don’t operate on it. And that just makes no sense to me. So I’ve had a couple of patients too that I’ve operated on and I’d like to share their stories with you so you can understand how important it is to listen to a patient and their story because that will tell you first and foremost whether they have a hernia and whether the Hernia should be worked up. Okay, before we do that, let’s go to some questions because some were sent in and I always love it when you guys send in questions and I really appreciate that work that goes into it. So some weeks I don’t get to go through your questions and I feel guilty. So let’s do that.

Speaker 1 (18:35):

We have some time to do that. So what kind of pain is most often associated with a cold hernias? Okay, great. I just answered that question. So it’s often local pain, right? Over the internal ring. It’s very specifically if you take a line, you draw a line between two bony points, the anterior superior iliac spine, which is a bony part of your pelvis. So people call the hip, but there’s a bone that protrudes out on your left or right side in the front of your belly, but on the left side or right side, take a line from that down to the pubic bone, which is a bone down in the front of your pelvis. That line represents the inguinal canal. And about halfway through it, about 60 40, but let’s say halfway in the middle is the internal ring. So if you have any pain within an inch of that region, then that would be diagnostic of an inguinal hernia.

Speaker 1 (19:39):

Ovarian pain is different, diverticulitis, pain is different. Appendicitis pain is different. Those are all much higher. So if you have pain down low there, you should consider a hernia as a reason for it. And the kind of pain can be dull, sharp. It’s often radiating. It can radiate to your inner thigh testicle or labia around to your lower back also where the nerves kind of run and a lot of the pain can be nerve pain even though it’s not a nerve problem. And then some people have pain that is activity related, so when they’re like, I just saw a patient yesterday, he only has pain when he runs, he has no other pain, it’s only when he runs. So of course he thought maybe he’s got a hip problem because he’s a prolific runner and the orthopedic surgeon told him it’s not his hip. That’s good that he got that evaluation, but the imaging missed the fact that he had a Hernia.

Speaker 1 (20:42):

So he came and saw me. I looked at his imaging going, oh, here’s your hernia. He was an interesting one because his hernia is very small. He’s probably had it for many years. He’s had pain running for three or four years and it’s not his hip. So you got to think of other things in the region. The area of pain is diagnostic of an inguinal hernia is right at that 50 50 mark where I mentioned where the two lines, the line between the anterior superior iliac spine and the pubic tubercle, which is your inguinal canal and the internal ring is right in the middle. However, on examination I could not feel anything. It felt pretty normal. He’s kind of a fit guy, so it doesn’t mean I have to operate on him, but at least he has a diagnosis, it’s not his hip, he doesn’t need physical therapy for that.

Speaker 1 (21:35):

He can modify his running, he can wear maybe a more of, what do you call it, a compression type underwear or truss to help ’em with that. Here’s a question. Can you have testicular tenderness? Hold on, hold on, hold on. Can you have testicular tenderness to squeezing the testicle or pulling the testicle downward but not spontaneous pain? Does it carry the same diagnostic significance as spontaneous pain? So yeah, with regard to testicular pain, if you have testicular pain that’s due to something going on in the groin, then yes, touching the testicle can also be tender of the testicle can be tender, but it’s more referred pain, kind of like shooting pain from the groin to the testicle. It’s uncommon to have isolated testicle pain though I have seen patients with just testicle pain. If you’ve had prior surgery, that’s a totally different ballgame because now you have mesh and or scar tissue at the level of the groin where the spermatic cord and all of its contents which eventually feed down to the testicle are interacting with the scar tissue in the mesh.

Speaker 1 (22:56):

And so you can have pain with any movement of the testicle or pulling on the spermatic cord and so on. That’s a totally different issue that has nothing to do with a hidden hernia that has to do with the interaction of the testicle with the mesh and or the scar tissue upstream from it. So for, we’re kind of focusing on primary hernias where if they have testicular pain, it’s not so much touching the testicle, but actually just without touching it hurts. Whereas if you actually have an injury or obstruction or any problem at the groin level, let’s say from surgery or a mesh or scar tissue, then yes, that could cause either nerve problems or obstruction or other problems at the testicle level. And so squishing it can hurt.

Speaker 1 (23:51):

Can you talk a little more about symptoms and rare pelvic hernias like posterior peroneal hernias? How would you feel or how would you feel for or try to image this type of hernia? Well actually we had an entire hour dedicated to rare pelvic hernias. So I recommend you go backwards on my YouTube channel or on the podcast and search for rare pelvic hernias, which includes perineal hernias and see and watch that hour. We really just focused just on that. And then I’ve had a good amount of experience with that. I’ve been really lucky to have had experience of treating things like perineal hernias, sciatic notch hernias, obturator hernias and posterior anterior perineal hernias and recurrent hernias from prior prolapse repairs. So I just kind of shared all my experience with that and I’ve given some talks on it as well. So that would be a good episode to look at.

Speaker 1 (24:58):

But specifically pelvic or post or perineal hernias, they tend to be in the pelvic floor. That’s what it means by perineal hernias, their pelvic floor hernias, they go through the muscles that hold your rectus and uterus and bladder up. And in doing so you can have hernias often due to trauma or due to some, let’s say a bad car accident or due to some type of direct injury. Let’s say you had an episiotomy or some surgery that you’ve had there before. So it could be like, well, I had a patient with a coccygeal hernia, so you had coccygeal pain and needed surgery for that. They took out the bone and so then she got a hernia from that, for example. So yes, when you sit, you may feel like you’re sitting on something and you either move yourself left or right depending on where the perineal hernias or use like a donut to sit because what you’re doing is you’re kind sitting on the hernia when you’re having a bowel movement.

Speaker 1 (26:07):

You may have pain just before the bowel movement because for two reasons. One is the contents in the rectum are filling of space and competing with space in the pelvis with this perineal hernia. Or by having the bowel movement you are contracting and or stretching the pelvic floor muscles. And in doing so you’re pinching the perineal hernia. They tend to be very difficult to repair. You need a good imaging to figure out exactly where it is. It’s often through the pelvic floor, levator anai muscles, so the iliococcygeus and pubococcygeus and those type of muscles. And unless they’re super small, you do need some mesh in there. So make sure whoever reviews your imaging understands your biology, why do you have this hernia? And then discusses the surgical way to manage it. Alright, going back to this question about what kinds of pain. So for women you can have pain that’s actually worse during your periods For men you can’t have pain that’s worse with the orgasm or ejaculation, there’s a lot of lotta, different reasons for pain.

Speaker 1 (27:32):

Next question, apart from pain, are there any other common symptoms to be aware of? Yeah, so it’s really that kind of not bloating. Sometimes bloating can cause problems. People get tested for bacterial overgrowth called SIBO and they get endoscopy, colonoscopy, dietary changes, FODMAP diet, anti-inflammatory diet, high fiber, low fiber, lactose-free diets and their bloating doesn’t go away, then you fix their Hernia. That could be an umbilical Hernia, it could be a ventral Hernia, it could be a groin hernia, perineal hernia. And you do fix the hernia and the bloating goes away. So hernias can cause bloating. Part of it is if there’s intestine involved, that’s a very obvious reason for it, but bloating can be a reaction to pelvic pain. So people with pelvic pain sometimes get nausea and or bloating as their symptom and you fix their cause of their pelvic pain and their bloating goes away. So kind of uncommonly understood problem.

Speaker 1 (28:41):

Alright, next question is separation of mesh from muscle, a cause of a hidden hernia or interstitial Hernia? And how do you handle making the correct diagnosis in the scenario? So you can’t tell if there’s separation of Mesh from a physical exam. You can’t tell if the Mesh is pulled away from the muscle on a physical exam. But yes, you can get an interstitial Hernia, which means the hernia is in between layers and then the specific scenario is between the muscle and the mesh. And the only way to diagnoses that is by imaging. You can’t tell that by history or by physical exam. It’s a cause of a hidden hernia, but it doesn’t mean that your symptoms are any different. It just is a one of the ways you can have a herniation in someone who’s had prior surgery and specifically interstitial hernias occur due to Onlay mesh. So the Mesh placed on top, the mesh, sorry, the mesh is placed on top of the muscle or the hernia repair and then that mesh can be pulled away from the repair. And what happens is you get a bulging of stuff in that space where it gets pulled away. So yes, that could happen.

Speaker 1 (30:04):

Okay, let’s do some more questions. Let’s see. Can a Hernia recurrence present as an occult hernia? Oh, okay, that’s kind what we’re talking about. So yes, more commonly recurrent hernias, that means a hernia after a prior surgery present with pain, it’s harder to get to see a bulge usually because there’s layers of scar tissue and mesh and so on. So if you have someone with pain, let’s say they had a hernia repair with Mesh and they did fine, any hernia actually, not just groin, and then five years later they’re having pain that’s a hernia recurrence until proven otherwise. And they may come in and you’re like, oh, it feels fine. But in fact the reality is that they do have a hernia recurrence imaging is the tiebreaker there. And so imaging will kind of prove your clinical diagnosis, which is based on your story, we’re doing fine.

Speaker 1 (31:09):

And now you’re not. That’s probably because now you have a hernia recurrence and that’s the situation of that. So yes, it’s actually not uncommon for someone to present with a hernia many years after a hernia repair and not show an actual bulge and the recurrence. It really is due to pain. Now this is very important because what we need to understand is that again, the story is important. So you’re dealing with a patient that was doing fine and now not doing fine and hernia repairs, people want it to last forever, but they don’t. And there’s going to be a certain percentage of patients that will get hernias that recur. And when they recur, it’s often due to presenting with pain. So what happens? You have pain and then you go see your GI doctor let’s say or whatever. So they’re like, oh, you’ve got abdominal pain, although really it’s pain at your Hernia repair, but they don’t understand that you had a hernia there, for example.

Speaker 1 (32:17):

So then they’ll do endoscopy colonoscopy, or you go to your gynecologist like, oh, you’ve got pelvic pain. So they start working on physical therapy, pelvic floor, physical therapy, or you go to your medical doctor, you’re like, oh, you’ve got chronic pain. So then they send you to medical to a pain doctor who injects you for nerve pain and eventually you end up with a spinal stimulator because no one could figure out why you have chronic pain. And it was always because it was pain at the area of your Hernia repair. You have a scar there or not, and it’s just a hernia recurrence. I’ve seen so many patients with hernia recurrences. I mean it’s obvious, right? You had a hernia, you fixed it, you were doing fine, five years later you’re not doing fine, 10 years later you’re not doing fine. Why come up with a new diagnosis?

Speaker 1 (33:06):

But people think they always have to feel a big bulging hernia before they call it a Hernia. Can you see an interstitial Hernia and ultrasound? Yes. So couple things about that. Your ultrasonographer needs to know what an interstitial hernia is and you need a good ultrasonographer to capture it. In patients that have had surgery before, I don’t recommend ultrasound unless you’re going to a like magician ultrasonographer that’s super gifted, does 3D ultrasound and really understands hernia repairs because ultrasound is often not a good reliable study in patients that have had prior surgery because there’s scar tissue and there’s maybe mesh and or sutures or metal objects which can cause distortion of interference of the ultrasound imaging. So if people know what that is, great. If the ultrasonographer knows what that is, great, but if they don’t really know, then they don’t understand the anatomy and the anatomy and the way the tissues should be or shouldn’t be and do not interpret the ultrasound correctly.

Speaker 1 (34:23):

So do you have magician ultra sonographers? I do not. I have a great ultrasonographer for primary hernias, yes, and I hope he never retires. He’s a radiologist. He loves hernias, he does his own hernia ultrasounds on patients. Usually most places a tech does it and the radiologist almost never even sees or talks to the patient. He personally does the ultrasounds and he’s great. I do not send him patients that have had prior surgery. I only send them call hernia patients or people that I need a femoral hernia rule out or something like that. He’s really, really great. But from what I understand, there’s a 3D ultrasonography team at Cleveland Clinic at their chronic pain clinic that does do those ultrasounds. In my experience, I just get an MRI because I like to understand what images I can read myself and understand the three dimensional interaction of let’s say the mesh or the Hernia recurrence with everything around it. But yeah, if you have access to a magician ultrasonographer, then they can be very, very valuable as part of your team.

Speaker 1 (35:46):

Let’s see, another question. How often are occult hernias misdiagnosed and how do you diagnose with certainty? One of them are imaging studies with Valsalva maneuver Still relevance and there’s no obvious words. Yes. Okay, great. This is super intelligent question. So the whole issue with occult hernias is A, people don’t understand that it exists. B, they don’t believe that it exists. And C, the it is typically a female problem more so than a male problem. And so many doctors don’t even believe women get Hernia. That’s a totally different topic that we’ve discussed before in early podcasts. So that’s a problem. So yes, they’re often misdiagnosed because they’re occult, they’re hidden, no one knows it’s there and no one thinks that it should be there. They don’t even understand that concept. So it’s never part of the differential diagnosis in a patient with let’s say chronic pelvic pain or testicular pain or let’s say vaginal pain.

Speaker 1 (36:53):

So you diagnose them with certainty by having a good history, you have to have a history that makes sense. If they have ear pain, you’re not going to correlate that, right? So the history needs to make sense. The physical exam needs to be at least suggestive, which means the area of pain is consistent with a hernia or you feel like either a slight fullness or tenderness in that one specific area I told you about over the internal ring. And then the imaging study needs to be the tiebreaker, which is an objective way to look, and that includes ultrasound or MRI. For these occult hernias, CT scan is not as reliable. And here’s a follow-up question. Does MRI have a very high sensitivity for interstitial hernia? No one’s actually looked at that specific diagnosis because interstitial hernias are uncommon. However, MRI has the highest sensitivity for occult inguinal hernias, and that’s the study that we published many years ago and stand by it.

Speaker 1 (38:01):

And because of our studies and the talks I’ve given, now more and more people are ordering MRIs and understanding the weaknesses and limitations of the CAT scan because CAT scan’s so easy to order and understanding that if the story is right and an ultrasound, let’s say doesn’t show a hernia, then an MRI would be a more sensitive view. Okay, next question. In past videos, you’ve said that in general, bodybuilders don’t typically get hernias. That’s true. If I start weightlifting after hernia surgery, will that lessen my risk for Hernia currents? Yes, it will. So people who exercise weight lift have core strength are not overweight, have excellent muscle strength, will support that Hernia repair, and in doing so, they will reduce the risk of a hernia that recurs. Why do hernias recur? Because you have weak tissues, can’t really change your genetics. You use nicotine, which makes the collagen even weaker or you’re S strain, increasing your abdominal pressure with chronic cough or constipation or obesity. Exercise including weightlifting, has not been shown to increase your abdominal pressure. In fact, it engages your muscles and keeps ’em strong. So yes, weightlifting after hernia surgery is great. Talk to your doctor to see what they recommend in terms of timing and always be careful how you do it. So the same way, you don’t want to mess up your back with weightlifting, you also want to maintain your abdominal core. So that’s kind of what I’d like to kind of promote. Let’s see.

Speaker 1 (39:53):

Next question. You previously said that femoral hernias are the most dangerous due to their high chance of causing intestinal incarcerated or strangulation and death. So if you end up with an incarcerated or strangulated, let’s say you end up at the hospital with a obstruction due to femoral hernia, you have a 5% chance of death. So that’s just unheard of for any other hernia. How often do femoral hernias present as a cult? Hernias? Almost always. And how often are they symptomatic before they become a medical emergency? Almost never. So that’s the problem with, that’s a problem with, sorry, femoral hernias and that is when you have a femoral hernia, most people don’t know they have it. Now if you do have it, it must be repaired. That’s just a no-brainer. But if you don’t have it, the risk is say, if you don’t know that you have it, the risk is that you won’t know that you have it until it’s too late.

Speaker 1 (41:00):

Where a loop of intestine, let’s say, gets stuck into the femoral hernia. So currently femoral hernias are not so common that we recommend everyone have it surveyed. So for colon cancer, relatively common, unfortunately everyone should get endoscopy colonoscopy, but femoral hernia is not that common. So not everyone should have an ultrasound, let’s say, to rule out a femoral hernia in their lifetime. However, if they have an femoral hernia, regardless of whether it’s symptomatic or not, those should be repaired because you’re helping save a life, usually a female life. So how often do they present as occult hernias? Almost always. When I say occult or hidden hernia, I mean one that’s symptomatic. So you have a hernia that needs to be addressed, but no one knows it’s the problem because it’s an occult hernia, it’s hidden, you can’t see or really feel a bulge. Are there people that run around with hernias that they don’t even know they have and have zero symptoms?

Speaker 1 (42:11):

A hundred percent. It’s such a common diagnosis there. People walking around, there are people posting their bikini pictures on Instagram with hernias. They don’t even know they have a Hernia. And sometimes I DM them, Hey, you have this hernia just FYI, but whatever. Obviously if they have no symptoms, there’s no indication to treat it. My point is this, when I use a term occult hernia or hidden hernia, I mean symptomatic. I mean these are with symptoms, not like you got a CAT scan because you had a car accident, someone did a CAT scan on you, and then oh, by the way, you have a hernia. Those I’m not talking about, I’m talking about people that can actually be helped because they have chronic pelvic pain or groin pain or testicular pain or vaginal pain and no one knows that it’s from a Hernia because a hernia is occult or hidden.

Speaker 1 (43:11):

And so either they’re told you don’t have Hernia hernia, even though your story’s a perfect one for it, they’re incorrectly told they don’t have a hernia or the doctor doesn’t even think of hernia as a potential diagnosis. I told you I was going to share some stories. I’ll give you two quick stories. One, this patient almost two decades ago was pregnant first pregnancy, and right around the third trimester she started getting right groin pain and they told her, oh yeah, because you’re pregnant and the round ligament is being pulled on, round ligament syndrome, et cetera. There was no obvious Hernia at the time, but that’s what started her chronic pelvic pain. So ever since 20 years ago when she had her first pregnancy, she has had this groin pain. Now the groin pain was then kind of, what do you call it? Discounted because she had a lot of, then she started having urinary problems.

Speaker 1 (44:18):

So her urine was a frequent urgent burning. And what I didn’t mention is occult angle. Hernias can cause pelvic floor spasm. So pelvic was pelvic floor spam. The pelvic floor is like a salad bowl and within it you get, everyone has a rectum go through the pelvic floor muscle. Everyone has a urethra empty their bladder through the pelvic floor. And in women there’s also the vagina. So if you have spasm of that pelvic floor for whatever reason, you can get rectal pain, right? The rectum goes through that muscle. You can have pain with urination or frequent urination or both because the urethra, which empties your bladder goes through that you can have painful intercourse as a female because your vagina goes through that muscle and so on. So what can cause pelvic floor spasm? A variety of things. Birthing injuries can occur, trauma can occur at a car accident, but also inguinal hernia, it’s one of the more common reasons and the least known reason for pelvic floor spasm.

Speaker 1 (45:31):

So if you have pelvic floor spasm and no one knows why the hell you have it, please, if you learn nothing from this hour, go get it worked up. So this young lady, she was told you have pelvic floor spasm and that’s what’s causing you your urinary discomfort. And they just said, oh, because you had births and a episiotomy and all these other things and it was always a hernia. So after 20 years of getting Botox into her pelvic floor, injections into her pelvic floor, pelvic floor, physical therapy, cystoscopy and all these urinary studies, antibiotics for her bladder, she was told she has interstitial cystitis, she had to change all of her diet to prevent burning of the bladder, et cetera.

Speaker 1 (46:23):

Guess what? She had a hernia. A smart urologist sent her to me saying, this just sounds so bad. I think you just need to see Towfigh. She can help maybe figure it out. And now she can sit. She couldn’t sit before. She couldn’t sit in the exam. She would sit on a donut because her pelvic floor, so much spasm and every urination for the past 20 was burning. Now she wants to go play tennis and have intercourse with her husband because for 20 years it’s been a problem. So that’s kind of what I mean when I say it’s occult, it’s hidden. People don’t appreciate it. These are people that are completely destroyed potentially by all the side effects of having this inguinal Hernia. And no one figures out that that’s the hernia. So that’s patient number one. Let’s see. Here’s a question. During hernia repair, are the holes sewn closed before a Mesh is placed?

Speaker 1 (47:25):

I was told a femoral hernia is never sewn closed. You were told correctly. Femoral hernias cannot be so enclosed because it’s not a muscle hole. It’s a space that opens up between a ligament and a bone. So to close that would cause severe pain and we don’t close it. So there’s most hernias of the abdominal wall we close as part of the hernia repair with or without mesh In the groin there are methods to close and there are methods not to close. And specifically for a femoral hernia, we almost never close it. Next question, are there patients with an acute injury, either due to athletics or lifting at work who develop a complex core injury plus inguinal canal injury? How can you determine whether symptoms are coming from a occult hernia versus non canal muscle tendon tears and enthesopathy, thank you so much for another great presentation.

Speaker 1 (48:24):

Well, thank you very much. So yes, sports hernia is completely different situation than inguinal hernias. Inguinal hernia is, like I said, groin pain radiates into the testicle inner thigh around the lower back. It’s activity related, but when you’re at rest, it’s better enthesopathy, which are like a hip labral tear, completely different story. You can have groin pain, but it also radiates to your buttock where you’re lying flat doesn’t go away. You prefer to sleep with a pillow under your feet. Non canal muscle tendon tears. It’s typically pain at the level of the tear itself. It’s often radiating within the muscle group and not in any other way. Or if you have a nerve involved, it involves a nerve but it doesn’t go away. And there are only certain activities that make it worse, like a wide stride or going up hills or stairs. Whereas standing, it doesn’t hurt it.

Speaker 1 (49:21):

So the story is super, super important. It’s very important that doctors understand how to have a good story. Okay, I’m going to tell you story number two. A young lady, early twenties, oh maybe late teens actually when this all started had lower abdominal pain, went to the er, they said, oh, you have appendicitis, right? Young lady, otherwise healthy, what else would it be? They got a cat scan, didn’t really show appendicitis. They said, oh, but you’re so sick, let’s take you to the for surgery. I think she had fevers and was vomiting, so there was some more to the story. Anyway, took out her appendix, she didn’t get better. So fast forward years go by, she still has this groin pain. Someone finally says, you know what, go to this doctor. He seems to do these magic tricks. So he went to see a doctor and the doctor’s like, oh, it’s your nerves.

Speaker 1 (50:18):

Your nerves are injured. First of all, no one’s nerve is injured unless it’s being directly injured in the groin. No one shows up one day and has nerve entrapment or neuroma or nerve injury in the groin unless they literally had trauma, direct trauma to it prior surgery. They’re an athlete that’s constantly tearing their muscles and causing scar tissue. If you have groin pain that someone says is nerve related, it’s a hernia until proven otherwise, hernias can cause nerve related pain. Again, their nerve is fine, it’s just the hernia tickles those nerves. So don’t let anyone operate on your nerves unless you actually have a true injury to it. So she was told it’s your nerves takes her to surgery on one side, I don’t know what he does with the nerves. Says, oh, there’s a lot of scar tissue, I fixed it. And then she’s better for a short while.

Speaker 1 (51:20):

Pain comes back. By the way, the other side has the same problem. He does the same thing on the other side, four surgeries later. She’s now in a wheelchair and all she’s had done is some very superficial operation looking only at the nerves. Never looked for a hernia, which by the way, she’s had this entire time. Hernias were small, granted they were occult hidden hernias, but all four times that she had surgery, no one ever looked like two centimeters over, barely an inch over and deeper to see if there was a hernia. She literally had surgery where you would get surgery for a hernia. No one ever thought about it. So wheelchair bound due to the pain. And as a consequence of the surgery, because the surgery, every time they went in they’re like, oh, you’ve got all this, your nerve is this and that.

Speaker 1 (52:13):

So long story short, I fixed one side. I said, let’s just do one side. See how you do fix the Hernia on one side. And guess what? She had a neuroma, traumatic neuroma from the nerve surgery that was done that probably should have been never done. And she just needed her Hernia repaired. Long story short, listen to the patient’s story. Her story was classic pain with bending, pain with prolonged sitting pain with prolonged standing and now she can’t even stand anymore because it’s so painful. So I feel like I’ve spoken way too fast, but it’s because I’m so passionate about these hidden hernias, these angular hernias. We will do a full hour on pelvic floor spasm because it’s such a problem. But listen, people need to understand pelvic floor spasm go hand in hand with hernias. Any hernia can cause pelvic floor spasm. If you’ve been totally normal person, you’re told you have a tense pelvic floor, male or female, go get your hernia repaired, most likely. What’s wrong with you? Let’s see. Do we have any more questions? Yeah, here we are. Let’s share a screen.

Speaker 1 (53:41):

Alright, so here’s the next question and that is, can you have an occult hernia that is not in the groin region? I mean, yes, a occult Hernia implies any hernia that is hidden or not readily visible. I’m really focusing on the groin for example. Have you ever seen a recurrent abdominal wall hernia that presents as an occult hernia? Not as much. Not as much. Mostly because two reasons. One is imaging is pretty straightforward for abdominal wall, whereas the pelvis is much more complicated. And so you can readily identify a hernia on those images. And on physical exam you can have areas where it’s painful and there are only certain areas where you can even get hernias. So they often present with a little bulge. But every so often, I would say every so often I get a person with an occult hernia at the belly button in fact.

Speaker 1 (54:44):

Oh, okay. Patient situation number three. This was a Canadian kid. He was I think 10 years old and for several years I would say, I think by the time he was 11 or 12, maybe 13, he’s having chronic abdominal pain. He wouldn’t go to school, he would lay in fetal position and they emailed me from Canada to try and help them. This is one of my online consultations. Anyway, long story short, they’re like, he’s super sensitive around his belly button. He will let you touch it. And he’s lost weight because he won’t eat because he gets a lot of pain to the side, to the side of his belly button or at the belly button. You can get pain to the side of your belly button or at your belly button if you have a belly button. Hernia, umbilical hernia. So he add to the pain to the side, they’ve injected him with steroids, which is really hard to do in a 10 or 11-year-old.

Speaker 1 (55:47):

They’ve given him creams, they give him medication and I’m like, did they at least ultrasound the belly button? Yeah. I said, well send me the ultrasound. So they sent me the ultrasound and he had a Hernia. I said, he has a hernia. They say there’s no hernia. I said, listen, just have ’em go in there surgically and fix the Hernia. Umbilical Hernia repairs are very low risk even for a little kid. So they had to go around Canada to find a pediatric surgeon that would believe them and offer them surgery. And he’s had dietary changes. He’s had endoscopies and colonoscopies and a lot of different medications and he was told he is like, maybe he doesn’t want to go to school and he just a good kid anyway. Yes, umbilical hernias can cause pain either at the belly bind like a hypersensitivity or to the sides of the belly bind without actually seeing a very obvious belly bind. Hernia, it’s not very common. I don’t want to oversell this one. It happens every so often and it’s worth repairing because it’s such a simple, straightforward operation. Anyway, this, he had surgery, pain, went away to school, totally normal kid. Now he’s playing sports and just the doctors were not listening to the kid, they weren’t listening and they would just look at his belly, how big can a 10-year-old be? And they’re like, yeah, it looks normal. And they weren’t, weren’t believing the story. So it’s all about the story.

Speaker 1 (57:25):

Do you find that most surgeons are open to consulting with you about patients who have contacted you for online consultations? Have you advised them on how to do repairs? How do you feel about that type of situation? Listen, I’m always available. I have a lot of friends in the hernia world. We talk to each other. We share patients, we ask for each other’s help. When I do online consultations, you will get a full evaluation written in writing by me. And many patients choose to take that to their doctor. Now hopefully you have a doctor and will be like, huh, lemme read this. That’s interesting. Lemme look into it. And they can call me if they want. However, there are doctors that are offended by it or they feel like slighted by it or something, I don’t know. Or they’re like, oh, she’s a quack. I don’t know.

Speaker 1 (58:15):

They’ll make up some things. So yes, there are doctors that would be open to it and I’m happy to collaborate if that will help you. But that’s not very common. So great. Guys, that was a great hour. I really enjoyed it. I hope you enjoyed as well. We had a lot of viewers this time. And that’s the end of our Hernia Talk Live, thanks for watching. We’ll be here again next week. We got a great guest. I think you’ll really like her. Thanks for being on Hernia Talk Live. I am your host, Dr. Towfigh. See you next week. And don’t forget to subscribe and my, I’m not a quack. I know I’m not a quack, but people say things. What was I saying? Don’t forget to subscribe and like my YouTube channel and leave your review on my podcast, her Talk Live. See you all next week. Talk to you later. Bye.