 Introduction : A hernia is the protrusion of viscus through an abnormal
opening in the walls of its containing cavity. An indirect inguinal hernia is
still the most common cause of hernias in females following incisional
hernias1. Indirect inguinal hernia in females is 4 % as common as in males
with an overall incidence of 1-2% in females2. It is almost always congenital
and presents usually in childhood3.
 Case Report : Our patient, 35 years, female, Para5 Living5, residing at
Panvel, belonging to a middle socio-economic strata came to our opd with
complains of swelling and itching at the vulva since 10 days. Patient had no
other complains and no significant past history. She was married since 17
yrs with history of tubal ligation done 2 yrs back. She had 5 Full term
normal deliveries with last child birth 2 yrs back and weighed 54.36 kgs
with a BMI of 21.23kg/m2. On local examination, a swelling was seen on the
right labia. Skin over the swelling was normal with no signs of fistulas or
sinuses or dilated veins. It was non tender, no redness or raised temperature,
not easily reducible, transillumination was negative and swelling decreased
on lying down with a positive cough impulse. On Palpation gurgling was felt
(peristalsis) s/o bowel. A differential diagnosis was made of indirect
inguinal hernia or encysted hydrocele of canal of Nuck. Surgery opinion was
taken and diagnosis was confirmed as an indirect inguinal hernia. Patient
underwent a right sided Lichenstein hernioplasty under spinal anaesthesia.
Intra-operatively round ligament and the right ovary was found to be part of
the contents of the hernia sac and were reposited. There were no signs of
incarceration or strangulation of bowel and no evidence of torsion of the
ovary. The posterior wall was reinforced with a polypropelene mesh. Patient
was managed post operatively on antibiotics and analgesics. Patient was
discharged on Day 5 post operatively with no complains.
 Discussion : Indirect Inguinal Hernia is the most common cause of hernia in
females with the overall risk of 1-2% of a female to develop a hernia in her
lifetime. The hernial sac may contain bowel, omentum, the appendix and
any pelvic organ such as the ovary, fallopian tube and in a few reported
cases of congenital hernias even the uterus4. In such cases there may also be
associated Mullerian Duct anomaly such as a unicornuate uterus4. The
hernial sac is lined by the round ligament in females5.
Inguinal Hernias in women are always indirect and direct
inguinal hernias almost never occur in females. It is almost always
congenital and presents usually in childhood before five years of age3. In
case of congenital hernias we need to rule out intersex syndromes especially
in cases of bilateral inguinal hernias which is usually associate with
complete androgen insensitivity syndrome (CAIS)6. The inguinal canal
widens with age. Thus in females, an indirect inguinal hernia usually occurs
in two age groups; the paedatric and the geriatric.
There are a few predisposing factors in women:1.
2.
3.
4.
5.
6.
7.
Pregnancy
Smoking because of the acquired collagen deficiency it causes
Multi parity
Chronic cough/constipation
Lifting heavy weights
Heavy strenuous exercise as in athletes and labourers
Obesity : Although obesity used to be considered as a predisposing factor
for hernias both in males as well as females with the theory that it causes
abdominal muscle weakness, a few studies have shown little or no
difference in the incidence of hernias with only obesity as the risk factor7
Nyhus described a spectrum of hernias differentiated by size,
presence or absence of a sac, and the degree of deformity of anatomy. Type
III hernias are more common in men, whereas Type I and II hernias (occult
hernias) appear to be more common in women8. Our case was unique as this
was a type III hernia which occurred in a female of a reproductive age group
with no other complains besides a genital swelling.
In adult females the most common complain is that of a groin
mass. The second most common complain is that of chronic pelvic pain or
groin pain or ovarian pain as described by patients9,10. The patient may even
complain of dyspareunia. Pain usually occurs in the incipient phase of hernia
due to the stretching of the tissues. The pain maybe a sharp, shooting pain
similar to neuralgias and may even be associated with back pains or
sciatica10.
In case of small hernias associated with pain, the patient can be
managed on analgesics and anti-inflammatory drugs and physiotherapy. In
large hernias or with signs of obstruction or strangulation, the management
is surgical. Surgery maybe an open surgery such as Lichenstein’s
hernioplasty with a mesh or today more popularly it is done
laparoscopically. However during surgery, it is crucial to explore the other
spaces of the abdomen such as the femoral and obturator canals thoroughly
because such women may have other associated occult hernias as well11.
 Conclusion : Indirect inguinal hernia in adult women of reproductive age
group is a rarity in itself and it can be easily misdiagnosed. A large swelling
can be mistaken for a cyst or a hydrocele. A small swelling may go
unnoticed. Most gynecologists and general surgeons are unaware of occult
hernias and many do not believe that they exist; and therefore, they are
controversial9. Albeit rare, inguinal hernia must be kept in mind when
diagnosing a patient with a groin swelling or chronic pelvic pain especially
in high risk women.
References
1. Inguinal Hernia in Female Infants and Children RICHARD GOLDSTEIN,
M.D., WILLIS J. POrrS, M.D., Department of Surgery of the Children's
Memorial Hospital, Chicago, Illinois
2. John T Jenkins, Patrick J O’Dwyer (2008). "Inguinal
hernias". BMJ 336 (7638): 269–272
3. Chen-Sheng Huang, Chih-Cheng Luo, European Journal of Pediatrics, July
2003, Volume 162, Issue 7-8, pp 493-495, The presentation of
asymptomatic palpable movable mass in female inguinal hernia
4. David C. Elliott, MD; Thomas E. Beam, MD; Thomas S. Denapoli, MD,
Hernia Uterus Inguinale Associated With Unicornuate Uterus, Arch
Surg. 1989;124(7):872-873
5. Ando, H., Kaneko, K., Ito, F., Seo, T. and Ito, T. (1997), Anatomy of the
round ligament in female infants and children with an inguinal hernia. Br J
Surg, 84: 404–405.
6. ASMA DEEB and IEUAN A. HUGHES,University Department of
Paediatrics, Cambridge University, Cambridge, UK,30 March 2005
7. Mike S. L. Liem, Yolanda van der Graaf, Reinder C. Zwart, Risk Factors for
Inguinal Hernia in Women: A Case-Control Study, Am J Epidemiol Vol.
146, No. 9, 1997
8. Nyhus LM. Individualization of hernia repair: a new era. Surgery.
1993;114:1-2.
9. DEBORAH A. METZGER, PhD, MD, HERNIAS IN WOMEN:
UNCOMMON OR UNRECOGNIZED?, January 01, 2004, Laparoscopy
today
10. Kavic MS. Chronic pelvic pain, hernias and the general surgeon
[editorial].JSLS. 1999;3:89-90.
11. Metzger DA, Daoud I. Occult hernias in women with chronic pelvic pain.
Plenary abstract presented at: International Congress of Gynecologic
Endoscopy, American Association of Gynecologic Laparoscopists 26th
Annual Meeting; September 24-28, 1997, Seattle, WA.