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Glenn D. Braunstein, M.D. Headshot

His and Her Hernias: Pelvic Pain Culprit Tough to Diagnose in Women

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Women who complain to their doctor of persistent lower abdominal pain could be suffering from any number of ailments: fibroids, endometriosis, ovarian cysts or complications of past pelvic surgeries. With those many possibilities, there often is another that does not even occur to many doctors: hernias.

Hernias often are considered a problem that primarily afflicts men, and in fact, they are far more prevalent in males -- women account for only about 8 percent of diagnosed hernias in the United States. Furthermore, women often do not display the telltale bulge that indicates a hernia, making this an often elusive diagnosis for women who suffer from these excruciating ailments. Women also may complain first to a gynecologist, who is more likely to consider a "female" issue as the cause for the pain, rather than a hernia.

Hernias can appear in various locations. They occur when layers of the abdominal wall weaken, and then tear or bulge. This allows the inner lining of the abdomen to push through the weak spot, forming a sac. A portion of the intestine or other abdominal tissue may slip through, causing pain and other complications. The most common and noticeable symptom is a protrusion in the groin or abdominal area. This symptom may be so slight in women that it goes unnoticed, or it may not be there at all.

Hernias are classified by location. The most common include incisional, occurring in an area weakened by a surgical procedure; femoral, on the outer groin; umbilical, in the belly button; hiatal, in the upper stomach; pelvic floor; and inguinal, in the inner groin. The inguinal type accounts for 80 percent of all hernias, and most occur in men due to a natural weakness in this area. Occult -- or hidden -- inguinal or femoral hernias can cause tough-to-diagnose pelvic pain in women but also are associated with groin pain in men and athletes.

Women's hernias frequently are tiny and internal, which is why they're so often mistaken for other conditions. Because they are unsuspected, they may go unnoticed on an ultrasound or other diagnostic test. The tears themselves may be invisible even on an MRI until fat or other tissue pushes through them.

What Causes Hernias?

A combination of pressure and an opening or weakness of muscle or tissue is the ultimate cause of all hernias. That weakness may be congenital, it may be the result of a surgery, or it may occur later in life. Lifting heavy objects, straining during bowel movements or urination, fluid in the abdomen, obesity, chronic coughing or sneezing, and pregnancy can all contribute to increased risk of hernias. Age and sex also can indicate risk for hernias, with 90 percent of hernias occurring in older men.

Men's vulnerability to hernias can be traced back to the womb. A male fetus' testicles form in the abdomen, then move along the inguinal canal to the scrotum. That canal closes almost completely after birth, leaving just a small space for the spermatic cord to pass through, but not enough room for the testicles to move back into the abdomen. Sometimes, that canal doesn't close properly, creating a weak spot where a hernia will occur. Women have a similar weakness in the femoral canal, where the femoral artery, vein and nerve pass through.

Prevention techniques for hernia are the same as for most other diseases: maintain a healthy weight, eat high-fiber foods to avoid constipation and straining, and stop smoking. If lifting a heavy weight, be sure to do it properly -- bending from the knees, not the waist -- or avoid heavy lifting altogether.

Recognizing Hernias

Women may identify pain as being in their ovaries, and hernia pain may occur around that area. The pain of an occult hernia, however, will not feel like a cramp. It may be described as a sharp, shooting pain in the vagina, around the hip and the back, into the flank and through the thighs. Women also may complain of pain during bowel movements, when their bladder is full, during intercourse, or during their menstrual period. That pain may worsen with exercise, prolonged standing or sitting, lifting, bending, laughing, coughing, climbing stairs -- basically, anything that increases pressure on the abdomen.

All of these additional pains can lead patients to any number of specialists who might diagnose them with -- in the case of women -- any number of gynecological problems. Many women and men are misdiagnosed with lumbar disc, hip, psychosomatic pain, or a host of other ailments.

Finding hidden hernias in women relies on clinical examination. Even with all the sophisticated tools at physicians' disposal -- ultrasound, MRI, herniography -- examination by an MD who knows what to look for is key. If the patient is lying down, this may conceal what little evidence there is of a hernia, so standing sometimes reveals a subtle bulge. More often, occult hernias cannot be seen or felt. Vaginal examination may reveal telltale tension and tenderness in the pelvic muscles, and reproducing a patient's pain by applying pressure on the internal inguinal area is one method that has been considered effective.

Once hernias are diagnosed and identified, pain can be managed with over the counter or prescription medications until they can be surgically repaired. For some, minimally invasive surgery is an option. Laparoscopic procedures in which the hole is patched with mesh have shown to be effective and to significantly alleviate pain.

For men, inguinal hernias not only have been a historic bane -- the afflicted have included Galileo, Michelangelo, Lord Nelson, Sir Winston Churchill and even Sir Astley Cooper, a pioneer in corrective surgical procedures -- they also long led to an industry of gear and protective, or supposedly rehabilitative, wear and devices. With advances in surgery and technology, the once-extensive ads for trusses and the like largely have disappeared, although an online search will still bring up a number of products and suggestions. In fact, while a truss might be recommended as a short-term support, it will not prevent a hernia from worsening or treat the hernia itself.

For women, chronic pelvic pain can be tough to diagnose -- and even tougher to live with. It means they might not be able to bend down to pick up their child. Sex may be too painful to endure. It can impair their ability to work. Lack of awareness of hernias in women can lead women to multiple doctors and multiple treatments, and endless frustration when they don't work. That's why it's important for patients and doctors alike to be aware of the possible causes, and keep looking until an answer is found.