So You've Got a Femoral Hernia - Now What?

Hernia: A general term referring to a protrusion of a tissue through the wall of the cavity in which it is normally contained. More specifically, a hernia often refers to an opening or weakness in the muscular structure of the wall of the abdomen. This defect causes a bulging of the abdominal wall.
-- MedTerms

Hernias are generally grouped according to their location -- abdomen or groin -- and there are different kinds of hernias within each group, depending on what's gone wrong and where.

In the groin, between the lower abdomen and the thigh, a hernia may be either an inguinal or a femoral hernia.

According to The Doctor's Guide to Gastrointestinal Health, an inguinal hernia occurs in "the groin, the area between the abdomen and the thigh. Intestines push through a weak spot in the inguinal canal. This is a triangle-shaped opening (Hesselbach's triangle) between layers of abdominal muscles near the groin."

A femoral hernia is also located in the groin area, but lower down -- "at or very near the leg crease." In this case, the "gap" through which the intestines protrude is a triangular area that's bordered by the inguinal canal, the femoral vein, and the pelvic bone.

Femoral hernias are one of the less common types of hernia, accounting for only 3% to 5% of all hernias. Femoral hernia are more likely to develop in adults than in children, and in women rather than in men.

It is possible to have both an inguinal and a femoral hernia at the same time, says The Doctor's Guide, and it can be difficult clinically to tell the difference between the two kinds. However, "finding a painful lump or bulge on the leg crease adjacent to the pubic area suggests a femoral hernia."

In everyday terms, then - if your hernia is well below the bikini line, think femoral.

The US government's National Library of Medicine website, Medline, has an excellent diagram of a femoral hernia you can look at, if you are having trouble getting a clear picture of exactly where a femoral hernia is located and what's involved.

The diagram is one of the A.D.A.M. Medical Image Library illustrations, protected by copyright and licensed to Medline by A.D.A.M. Inc. It is similar to the same kind of medical illustration you may have seen in a high school health or biology class. That means, for most of us, the diagram will be less disturbing to look at than a photograph of a real person with a hernia, and it also makes it much easier to see clearly the nature of the "mechanical problem" that is a femoral hernia.

According to The Doctor's Guide to Gastrointestinal Health, "People don't always know when they get a hernia. They may get a painful or painless lump that may change with position." With a femoral hernia, you may notice a lump or bulge at or near the crease where your leg meets your hip. That's because the hernia occurs at the femoral canal -- the passage where the large blood vessels (femoral artery and femoral vein) go between your thigh and your abdomen.

Harvard Medical School - InteliHealth patient information notes that "Some hernias can cause twinges of pain or a pulling sensation, but most do not cause pain. Hernias are usually easier to see with coughing or straining. They also tend to be more prominent with standing and often disappear with lying down. ... Most people discover their own hernias by noticing a bulge."

It will usually be easier to notice such a lump when you're standing up, as gravity moves things around, but it's worth noting that a lump may be more difficult to detect in people who are obese.

If the femoral hernia bulge can be pushed back into the groin, or goes back by itself when you lie down, it is called a reducible femoral hernia. This is quite easy to remember because "reducible" simply means that something is capable of being reduced - made smaller in size - the way you can reduce the size of the lump by changing position or pressing on it. A reducible hernia is the more common kind of femoral hernia, and it is often quite painless.

Sometimes, however, a part of the tissue can get caught in the opening in the abdominal wall and cannot be pushed back in to the abdominal cavity or go back on its own. This is called an irreducible hernia. You may also hear some medical people refer to this kind of hernia as incarcerated, meaning "trapped" or "imprisoned". An irreducible hernia usually comes with some pain and/or a feeling of illness.

Both a reducible and an irreducible femoral hernia should have prompt medical attention, as hernias will not heal by themselves. While a reducible hernia is not generally considered to be an emergency situation, there is a chance that a reducible hernia may become irrreducible. With an irrreducible hernia, there is a chance that it may become strangulated.

Early diagnosis of a femoral hernia is very important, so don't delay going to the doctor if you have any symptoms that concern you. The femoral type of hernia is more at risk of becoming strangulated than some other types of hernias, due to the narrowness of the femoral canal.

A strangulated hernia is an irreducible hernia where the blood supply to the trapped intestine gets cut off. It is always painful and usually tender. Sometimes there will be nausea and vomiting, which are symptoms of bowel obstruction, but there may or may not be a fever as well.

A strangulated hernia is a surgical emergency.

It all started with a sharp pain in the groin, when I was lifting an elderly dog who had trouble getting onto her feet on a slippery tile floor. A few weeks later, and a lot more boosting of my big old dog, I was feeling a nagging sort of discomfort in the crease where my leg joins the hip. There was also what my doctor kindly called "bladder awareness" (I was never quite sure if I had to "go" or not, or if my bladder had emptied out completely) and I felt just a general ache in my lower abdomen at times, like the rumblings after a bad Tex-Mex meal.

Your symptoms of a femerol hernia may be somewhat different from mine in the specific details, of course -- I'm just telling my experience here, so we can walk through this unpleasant experience together.

The discomfort that I felt was certainly not bad enough for me to bother calling the doctor, until I found a lump! It was a bulge kind of low down in the groin area, just at the crease. If I pushed on the lump too hard, I felt a sharp pain and almost a burning sensation at times. I couldn't tell what size it was for sure -- maybe somewhere between a marble and a big greek olive in size? -- because pushing on the lump seemed to make it move and recede into my body. But it always came back before long. And it definitely gave me a sharp twinge whenever I coughed.

Time for medical attention!

Your doctor and/or nurse will most likely start out by asking a number of questions about your condition.

It helps if you can think about your answers ahead of time, so you can clearly explain your experience. In fact, it's always a good idea to make notes of things to remember to tell your medical team, so you don't leave anything out that might be important, or find yourself struggling to remember dates and details.

If you haven't been to see this particular doctor before, the nurse will most likely take a general medical history from you to start with. This will involve a series of questions about your family health history and your personal health, any pre-existing conditions or diseases, any surgeries that you've had, what medications you're taking, allergy information, and so on.

Photo: ©123RF Stock Photos Again, it will help if you've prepared to answer these questions so you don't have to rely on your memory while you're actually in the doctor's office or clinic.

Next, with reference to your suspected femoral hernia, the doctor and/or the nurse will have a few more specific questions. You may get different questions from these, but here's what my doctor asked me:

• Where is the lump?


• How long has it been there?


• How did you discover it?


• Has the lump changed in size or shape since you first noticed it?


• Are you experiencing any pain; and if so, how would you describe it?


• Did you have a bowel movement today?


• Are there any changes in your bathroom habits; for example, are you getting up in the night to empty your bladder?


• Any other health concerns?

Next up, a physical examination.

You will likely be asked to lie down, first, so the doctor can palpitate your abdomen. He'll press quite firmly to check for tenderness in the region of your bowels and to determine if there are any masses in your abdomen that shouldn't be there.

(By the way, I'm saying "he" for the doctor here just because my own family doctor happens to be male - so please don't take it as sexist!)

When the doctor locates the lump in your groin, he may press on it quite hard to see if it can be pushed back into place. This may feel quite uncomfortable, but it can be an important diagnostic procedure -- one of the ways to tell if a lump is a femoral hernia is that the intestine can be (temporarily) pushed back into place inside the abdominal wall, given enough pressure.

If the lump goes away when you lie down and/or he presses on it, the doctor may then ask you to "turn your head and cough" -- remember that old cliche? A femoral hernia that disappears in this situation will usually appear again when you strain or increase the internal pressure, and coughing is one of the things that will make this happen.

It is also possible that the doctor will ask you to stand up while he keeps his hand pressed against the femoral hernia location. As I understand it, any change in the lump he can feel when you stand up will give your doctor a pretty good idea of how large your femoral hernia is, and generally helps to confirm the diagnosis.

Tip: If you wear loose trousers to your doctor's appointment, instead of tight jeans, your doctor may be able to examine you properly without you needing to strip down altogether. This can be important if you're the shy type, or if the doctor's examining room is too chilly!

As mentioned, a hernia is caused when too much internal pressure on a weak spot in the abdominal wall causes the "innards" (usually a part of the intestine) to bulge through. The causes of a femoral hernia are essentially the same as for any kind of hernia. It all comes down to pressure on a weak spot, usually as a result of:

• Obesity
• Pregnancy
• Constipation
• Chronic cough
• Bladder obstruction
• Heavy lifting

In my case, it's that last one on the list - heavy lifting.
Or, as I have learned to call it, "doing something stupid."



Technically, it is the weak abdominal wall that is the real cause of a hernia - but the excessive pressure or strain can trigger a hernia that's just waiting to happen, create a sudden pain that draws attention to a hernia that hadn't been noticed before, or aggravate an existing small hernia to be more noticeable.

Due to the shape and angle of the female pelvis, women are 5 times more likely than men to get a femoral hernia. Femoral hernia as a female-dominated health condition is a bit of a special case, however. When all kinds of hernias are taken into account, by far the majority of hernia surgeries (on the order of 75 to 85%, depending on whose statistics you believe) are carried out in men.

Many sources tell us that women who are significantly overweight or obese, and women who have had several children, are more likely to develop a hernia than women who don't fit those descriptions. And that does make sense, when you think about it. As we've talked about already, both pregnancy and obesity are among the causes of femoral hernia -- or, to be more precise, of the excessive pressure on a weakened abdominal wall that can lead to a hernia.

Depending on your individual condition and circumstances - such as your weight and size, and on the precise location of your hernia, and on how the support garment is designed and how well it fits - your doctor may suggest that you wear a truss or support brief on a short-term basis, to help you manage the discomfort of a femoral hernia while you're waiting for repair surgery.

Some physicians and other medical professionals are firmly against the use of a truss, however. There are a few obvious reasons why your doctor may not advise a truss, including the concern that:

• a poorly fitting support garment may put pressure in the wrong area, doing no good and possibly making the hernia pain worse;


• a patient may rely on a truss instead of getting their hernia repaired by surgery, particularly if they don't have health insurance or access to a public health care system;


• wearing a truss might encourage some patients to be less careful, leading to more strain, more damage to the abdominal wall, and possibly very serious complications such as incarceration or even strangulation of the hernia.

This third reason - risk of strangulated hernia - seems to be the most common concern in the case of a femoral hernia.

WebMD's eMedicineHealth website, for example, says:
"Trusses and surgical belts or bindings may be helpful in holding back the protrusion of selected hernias when surgery is not possible or must be delayed. However, they should never be used in the case of femoral hernias."

Patient UK says:
"In view of the high risk of strangulation, all femoral herniae should be repaired as an elective procedure, but as soon as possible. There is no place for a truss for a femoral hernia."

And on Sharecare.com, the Honor Society of Nursing (STTI) says:
"There are different styles of hernia trusses - also called hernia belts or binders. ... It's vital that the correct truss is used and worn properly to prevent the hernia from becoming incarcerated or strangulated, complications that can be life-threatening if left untreated." and "Using a truss to treat a femoral hernia is often not recommended because of the high risk of strangulation."

As always, follow the advice of your own doctor, who is familiar with the details of your particular medical situation.

Surgery to repair a femoral hernia is normally what the medical people call a non-elective but non-emergency procedure. Non-elective means it has to happen, but non-emergency means the surgery doesn't have to be done in a hurry. The exception is if your femoral hernia becomes strangulated -- in which case, yes, the repair is then an emergency -- or if you have some other health that makes it urgent for the hernia to be repaired without delay. For most of us, however, there is likely to be a considerable waiting period before the repair surgery is scheduled.

How long will you have to wait for surgery? That depends on where you live, and on what surgical resources are available to serve your community, as well as on your own personal health situation.

Just to give you an idea of my case, here in Canada, I had an appointment for a consultation with the surgeon within two months of the initial diagnosis, and a date was set for the surgery within four weeks of that appointment. Even counting in the disruption of winter holidays in there, total time from diagnosis to surgery in my case was just a few days over 3 months. If I had a physically demanding job I was unable to perform because of the femoral hernia, or if the femoral hernia was in greater risk of strangulation, the surgery date would have been moved up sooner, of course.

"A hernia is simply a hole and the way we fix it surgically is we want to either close it shut with stitches (the problem with that is they often come back), or we put a plastic mesh on top or underneath."

I love that quote. It's from If I Had... a Hernia, an Insidermedicine video interview with Dr. Daniel B. Jones, MD, FACS, of Beth Israel Deaconess Medical Center, Harvard Medical School.

"A hernia is simply a hole," he says, very matter-of-fact, like a plumber about to fix a leaky pipe! So comforting, for those of us looking at surgery to repair a femoral hernia!

In his interview, Dr. Jones goes on to explain what's involved with a laparoscopy and why that's his preference for a hernia repair. Don't worry, he doesn't say anything or show anything in the video that might upset you if you're squeamish. It's all just good clean education here.