Would an increase in the size of the visible lump in the groin area, but no pain or other symptoms, suggest seeing a doctor rather than continuing to monitor the situation? It had been a palpable right groin lump and is now a somewhat larger lump at the approximate location labeled inguinal hernia in https://my.clevelandclinic.org/-/scassets/images/org/health/articles/15757-hernia
The doctor who first noticed the lump suggested monitoring, but did not provide guidelines for how to deal with developments. Continuing to monitor would be my preference absent pain or other symptoms, unless that is likely to be dangerous.
Iâm not looking for individual medical advice, just how one should generally deal with such a situation.
Welcome back! Unfortunately, there is no single guideline for following something like this, especially without a diagnosis and knowing someoneâs medical history. Sorry to say, but this would qualify as medical advice and require more information.
Asking your physician who noticed it for specific guidance on what theyâre looking for, at what intervals, and so on may be helpful, though it could be inappropriate based on other variables. If youâd like to schedule a consultation to discuss it with one of us personally, thatâs an option as well.
Sorry that I couldnât be of more help, but there are limitations to what we can do here.
There is not a single âbestâ approach here; it comes down to a variety of individual pateint-specific factors, as well as surgeon-specific factors (e.g. their overall expereince with a particular approach). This is the kind of thing best worked out as part of your consultation with the performing surgeon.
Do you have any guidelines for training with an inguinal hernia?
Iâm not looking for individual advice, just general guidelines, e.g., stop deadlifts or avoid low rep sets or just avoid anything that causes pain or discomfort in the hernia area.
Unfortunately we have nothing to base any specific guidelines on here, due to both a lack of specific evidence on things like low vs. high rep sets, as well as the wide variability in the presentation of inguinal hernias. Some patients are more symptomatic, some less so / asymptomatic.
For a mildly symptomatic, reducible inguinal hernia without any immediate indication for surgery, I would treat it similar to a ârehabâ scenario by training and adjusting based on my tolerance. If something is more provocative of symptoms, experiment with other adjustments to see if there is something more well-tolerated.
I met with a surgeon today. He said there was no immediate indication for surgery, but not having surgery risks a problem developing. He prefers laparoscopic for easier recovery.
He agreed with your advice about exercising to tolerance. The only movement Iâve had an issue with is barbell squats (hack squats seem fine). Deadlifts have not been a problem, despite common warnings about heavy lifting.
He listed many possible risks from surgery, which appeared to add up to an approximate 15% risk of some complications, which seems in line with research. This appears to be much higher than the risk of incarceration or worse from no surgery. However, complication risk from surgery seems generally much milder and shorter term than possible complications from no surgery. One alternative may be to wait for pain or other worsening, such as the UK NHSâs âMedical advice is to âwatch and waitâ if your hernia is not causing you pain or discomfortâ. Is this a widely accepted view?
He also recommended eight weeks recovery before heavy lifting (more than 20 pounds) or travel (possible pain or problems accessing treatment away from home). When I asked if there was research supporting this he said six weeks. Do you know of any research on hernia surgery recovery?
It also has a faster recovery timetable than mentioned by the surgeon I saw, including â4 â 6 weeks you should be fully recovered and be able to lift things and drive a car. If you exercised before surgery, gradually build back up to full exercise over 4 â 6 weeks.â
No data on recovery times with and without exercise, but the current guidelines no restrictions on return to exercise. We discuss that in our podcast and video on hernias:
Unfortunately, all of these guidelines are made up. You would think there would be some interest in this topic, but apparently not.
We are able to work with you if you like peri-operatively, but you may prefer a DIY approach using the recommendations from Dr. Baraki and our previously published materials.
Thereâs no evidence that lifting causes hernias or that lifting to tolerance exacerbates hernias.
Watchful waiting is the recommended approach to asymptomatic and minimally symptomatic hernias, where symptoms mean pain or discomfort. This is due to the low risk of complications in these cases and the possibility of complications from surgery. If and when symptoms develop (which is likely), surgery is recommended.
Following surgery patients are recommended to resume normal activities without restrictions as soon as they feel comfortable.
BTW, a couple of the links from the podcast are broken. I suppose at this point I shouldnât be surprised that many doctors recommend things that are not supported by published research or official guidelines.
Thanks again. Much appreciation for all you guys do.
Yep, Iâd agree that thereâs no evidence that lifting âcausesâ inguinal or abdominal hernias per seâ. Instead, something else happened and lifting heavy can be the mechanism by which the hernia presents.
I donât think that watchful waiting is the recommended approach for all hernias, no. I tried to take special care discussing that point, as most inguinal hernias should probably be repaired when identified, for example. Waiting typically produces an older patient who are at a higher risk from complications, generally speaking. There are many different types of hernias and situations, so this is not universal advice for all hernias.
Yes, the current guidelines for inguinal hernia repair do not recommend limiting physical activity after repair.
Thanks for the kind words. We try our best to provide useful information when we can.
âI donât think that watchful waiting is the recommended approach for all herniasâ
It appears to be the recommended approach for asymptomatic and minimally symptomatic inguinal hernias, as I read the International Guidelines, the European Summary and the NHS. The NHS explicitly says âIf your hernia does not make you uncomfortable or cause you pain, you should not do anything.â Europe: âAsymptomatic or minimally symptomatic male IH patients may be managed with âwatchful waitingâ since their risk of hernia-related emergencies is lowâ. The International Guidelines at KQ05.f appear to be in accord. I would think if there are unusual issues raising risk the balance may change, things such as the NHS view are rather straightforward.
OTOH, âSymptomatic groin hernias should be treated surgicallyâ.
Yes, I think you may be misunderstanding both the recommendations (and their validity) and my response. On the other hand, Iâm not sure youâre disagreeing with me either. Hard to tell via this medium,
In any case, yes, asymptomatic inguinal hernias CAN be managed with watchful waiting. These patients should be counseled on reducing risk factors, e.g. smoking, weight loss (if indicated), exercise, medical optimization, and so on.
That said, about 40% of patients with asymptomatic inguinal hernias will require surgical repair at 3 years and closer to 3/4 will require repair at ~ 7 years. Some additional data shows that people tend to have progressively greater symptoms that can affect health. This is one of my main reasons that I believe most inguinal hernias should be repaired when identified rather than watchful waiting.
The decision to wait or repair is obviously based on shared decision making. Guidelines essentially provide either option and clinical context is key. I donât think itâs accurate to say that all people with minimal symptoms or asymptomatic inguinal hernias (and certainly not all hernias period) should wait, nor do I think they should all be repaired. I am not sure this is really a controversial take, as your recapitulation of various sources say the same thing.
Opinions vary among professionals (surgeons). Ultimately, the decision should be a reflection of shared decision making as mentioned above. Hopefully that was conveyed in the podcast and video. I suppose since weâre having this conversation, maybe it wasnât.
The NHS appears to be the outlier here, with a flat statement against surgery for an asymptomatic hernia âIf your hernia does not make you uncomfortable or cause you pain, you should not do anything.â
The International Guidelines and European Summary are more nuanced (as are you), suggesting a balance between the risks of waiting and the risks of surgery. A risk of waiting is the possibility of a sudden problem, requiring emergency surgery. The risks of surgery are complications from surgery which appear to arise in more than 15% of cases. Conditions specific to an individual may push in one direction or the other. This all requires a discussion with the surgeon, a discussion unfortunately omitted by my surgeon.
What do you mean by âmedical optimizationâ for reducing risk factors - use a good experienced surgeon?