Risk Factors for Hernia
It is super important to understand risk factors for hernia development, as they also predict hernia recurrence, or failure rates. Correction of some of these risk factors will reduce hernia symptoms and improve outcome after surgery.
Yes, hernias run in the family. In fact, in my professional experience, I have noticed that having a female in your family who had a hernia is a stronger risk factor for hernia formation than if a male in your family had a hernia.
To date, some research has been done on the underlying genetic predisposition to hernias. Unfortunately, not many resources are devoted to the study of hernias. We know that in most patients, there is an underlying tissue problem in those with hernias. For example, there may be an imbalance of collagen, with more of the Type III, immature, weaker, collagen, and less of the Type I collagen, which is more mature and stronger. Also, their collagen is laid in a pattern that is not organized. In others, there may be a deficit in the matrix metalloproteinase.
Sorry, men…you are at a greater risk of inguinal hernia than women. The same is not true of other types of hernias. Most of us believe it is based on pure physics: the male pelvis is narrower than the female, thus more downward gravitational force is focused on the groin region.
To date, there is no evidence that race or ethnicity has any correlation with developing a hernia.
A low fiber diet may result in constipation and straining with bowel movements. This increase in abdominal pressure increases your risk of hernia. Read our Preoperative Instructions booklet [ADD LINK HERE] for a list of non-prescription remedies to prevent constipation.
Most of us herniologists agree that being obese, or morbidly obese increases your risk of hernia formation. While no study has yet proven that obese patients have more hernias, studies have shown that weight is very closely related to risk of incisional hernia occurrence after an operation, including a higher recurrence rate after hernia surgery. Thus, if you are having abdominal surgery or hernia surgery, it is very much to your benefit to be as close to your ideal weight for your height as possible, with body mass index no more than 30kg/m2.
Good news! Exercise can protect against forming a hernia. Here is how it works: if you strengthen your core abdominal muscles (rectus, transversus, obliques), you are preventing the naturally occurring holes in the body from stretching out. Also, almost all exercises have been shown to be safe, without any increase in abdominal pressure. So, feel free to do situps, pullups, weight lifting, treadmill, cycling, running, hiking, or nearly any physical activity you prefer. Yoga and Pilates are especially good options for core abdominal muscle strengthening. If you are diagnosed with a hernia, please do NOT stop exercising. This will only worsen your problem, causing weakening of your muscles, weight gain, and thus even more stretching out of your hernia. Even after surgery, I strongly recommend that these exercises be performed to keep your weight down and keep your muscles (and therefore your surgery repair) strong. NOTE: Only a few exercises were shown in studies to increase abdominal pressure and thus may not be recommended for hernias: these include leg squats and jumping (think: No Cross-fit). If you are prone to hernias, have a hernia, or just had hernia surgery, take leg squats and jumping out of your exercise routine!
Work-related injuries are often associated with hernia development. When lifting heavy weights on a regular basis, especially while at work, it is possible that you are increasing your risk of getting a hernia. Interestingly, this is not true of heavy lifting at the gym or as a form of exercise. We just showed that exercises that involve weights are protective of hernias. Is that conflicting? Well, most people who lift at work or at home – outside of an exercise regimen – often do it without engaging the abdominal muscles. The back and abdomen are both left at risk for excessive pressure. If you do have to lift at work, engage the abdominal muscles (tuck in your abdomen) and tilt the pelvis under. This will help protect the naturally occurring holes in your body from splaying open.
Cough, Bronchitis, Asthma
Coughing has been shown to raise your abdominal pressure much more than any type of heavy lifting or abdominal crunches. Each cough exerts a lot of pressure on the abdomen. Patients who cough incessantly, due to smoking, bronchitis, asthma, COPD, acid reflux, or post-nasal drip are increasing inguinal hernia risk factors. The best solution is to aggressively treat any coughs. If you have asthma, make sure it is under optimal control with medications, environmental exposure, etc. If you have postnasal drip, use nasal sprays, irrigate your sinuses (with the Neti-Pot) and take anti-allergy medications as necessary.
Whether you smoke it, chew it, or patch it, nicotine will cause poor healing by affecting blood flow through your small vessels. Nicotine in and of itself is actually not among the risk factors for inguinal hernia. However, if you have hernia surgery, or any kind of operation for that matter, your healing will be compromised if you smoke cigarettes, e-Cigs that contain nicotine, chew tobacco, or use a nicotine patch. That is when you will get the hernia. I request all my patients to be off nicotine prior to their hernia surgery, especially if it is a large, complex hernia repair. If you must smoke, nicotine-free e-Cigs are okay.
Smoking tobacco, marijuana, or other inhalants will cause you to cough. The repetitive coughing is a known risk factor for hernia formation and can cause a hernia in and of itself. See the “Cough” section below for more details about this.
In my opinion, this is the #1 contributor to most hernias that I see. The straining associated with constipation severely increases abdominal pressure. Constipation should be treated as if it is an illness: take medications and/or change your diet. A high fiber diet and fiber supplementation are the best options. Certain fruits, vegetables, teas, supplements can be added to your diet to help with constipation. If these are not enough, then I also recommend adding other over the counter medications such as mineral oil, Milk of Magnesia, and/or Miralax. Stool softeners do not work.
If you have abdominal or hernia surgery, constipation after surgery is an especially bad problem, as it will pop those new sutures, tear your repair, and cause a hernia. I absolutely urge that any constipation tendencies be controlled before surgery, as the anesthesia and pain medications for surgery will themselves cause constipation.
Pregnancy and Labor
Pregnancy alone causes an increase in abdominal pressure. We don’t have any evidence to suggest that this pressure can cause hernias, but certainly if you have a hernia or a tendency toward one, you may notice a bulge during your pregnancy. The pressure that is exerted during labor is much more severe. This can certainly result in the beginnings of a hernia in some women. We find that women who have undergone labor are slightly more likely to have hernias than those that did not. Also, those who have had 2 or more pregnancies or twins/triplets, are more likely to get Diastasis Recti. [LINK TO THE DIASTASIS RECTI PAGE]
In men, a slow urinary stream, incomplete emptying of the bladder of urine, and frequent urination especially at night can all be signs of an enlarged prostate. It is important that the cause of this is determined and treated early. A general medical doctor or urologist should be involved in this process. If the prostate is enlarged, men tend to strain to make the weak urinary stream faster or to completely empty their bladder at the end of their stream. Similar to constipation, this can result in increased pressure in the abdomen and a tendency toward hernia formation. Also similar to constipation, the prostate problem must be treated (either by medication or by surgery) prior to any hernia operation, otherwise, straining will continue after surgery and the hernia will recur.
Straining to Urinate
In women, straining to urinate may occur in those with prolapsed bladder or cystocele. Similar to men, this problem must be treated prior to any hernia surgery.
This has been correlated with various factors that lead to increased hernia risk. The cause is unknown, but may be due to poor oxygenation and health of the tissues as well as the pressure from snoring against a closed airway.
Hernias that occur at the incision after an abdominal or pelvic operation are referred to as incisional hernias. All incisions of the abdomen, pelvis, or flank are at risk for hernia development. Factors that increase the risk of hernia formation include infection of the wound, if the surgery was an emergency, as well as other factors listed here, such as constipation, chronic cough, obesity, and nicotine use.
Steroids, Immune Suppression or Chemotherapy
Medications that reduce healing potential, such as steroids, immune modulators, anti-rejection medications, and chemotherapy agents may all result in weakening of prior incisions and a higher risk of incisional hernia development. These include patients who undergo liver, intestine, kidney, and/or pancreas transplantation, patients who receive chemotherapy after colon cancer surgery and ovarian cancer surgery, and patients on chronic steroids or immune modulators for other problems, such as rheumatoid arthritis or lung problems. Fortunately, we don’t believe that these medications make you more likely to develop a stretching out of a naturally occurring hole, or a new hernia.
Patients with ascites, usually due to liver failure, are at very high risk of hernia development. Similar to many of the other factors listed here, ascites causes an increase in abdominal pressure, resulting in stretching out of the naturally occurring holes in the abdomen. Often, the hernias contain fluid. The treatment of these hernias is best performed if the ascites can be controlled.
Patients with diabetes have problems with healing. After an abdominal or pelvic surgery, if the diabetes is poorly controlled, then the closure of the muscle and fascia layers will not heal well, resulting in an incisional hernia.