As summer is rapidly coming to an end, countless sports physicals have been performed to get the student-athletes eligible for their sport.

 

I recently did one of these exams on a 15 year-old football player who was going to be a sophomore. He was brought in by his dad. As I was finishing my exam, I said, “Well the last thing I need to do is check for a hernia.” I had him drop his shorts and checked for a hernia and had him cough. I told him that everything was normal and he could get dressed. I started to fill out his sports physical form and he asked me, “Hey doc, why did I have to cough?”

 

I stopped and thought for a second and then said, “That’s a great question.”

 

I took out a piece of paper and drew the anatomy of the scrotum and the abdomen and described what a hernia was and how it occurs. I will share with you what I told him.
 

Early in the development of a male fetus, the testes are located in the abdomen.

 

There is a tube-like structure called the inguinal canal that connects the abdomen with the scrotum. In most male fetuses, the testicles migrate down into the scrotum via the inguinal canal. This occurs by 6 months of gestation in most males…usually between 25 and 35 weeks of gestation. If the inguinal canal does NOT close, there is a persistent opening that connects the abdomen with the scrotum. An inguinal hernia is when a portion of the intestine or its supporting tissue (the omentum) moves into the scrotum.

 

This will cause a bulge in the scrotum and in most cases it can move back and forth and doesn’t cause any real problems.

 

But with increased straining and increased intra-abdominal pressure, it can get bigger and bigger over time and what can happen is that the portion of intestine that has herniated into the scrotum can get trapped in the scrotum and the blood supply to this segment of the intestine can be compromised and cut off. This is known as an incarcerated or strangulated hernia and would require immediate surgery to try to save that portion of intestine.
 

So when we examine for a hernia, we feel up into the scrotum where the inguinal canal would be, then we have the patient cough and feel for any “bulge” or intestine that may be pushed down into the scrotum.

 

When the patient coughs, the intra-abdominal pressure is increased and a hernia should be felt. For athletes who have a potential hernia, it is obvious how intense training and weight lifting would exacerbate a hernia. When I finished my explanation, my patient (in true high school demeanor) nodded, and said, “…Cool…thanks doc.” What struck me was that his father was listening intensely and said, “You know, I’ve had alot of these exams in my lifetime, and I never really knew that, thanks.”
 

One article from the Mayo Clinic reported that as many as 25% of all males will have an inguinal hernia during there lifetime.

 

There are actually two types of inguinal hernias. An indirect inguinal hernia happens when the intestine “herniates” through the inguinal canal that has not closed, into the scrotum. This occurs in around 2% of all male infants, It is 30 times more likely to occur in premature infants. It is possible that the inguinal canal doesn’t completely close or is partially open and if so, the hernia may not “develop” until much later in life.

 

The second type is the is the direct inguinal hernia whereby there is a weakness of the supporting structures (abdominal muscles) near the opening of the inguinal canal.

 

Over time with increased straining and increased intra-abdominal pressure, these structures give way and the intestine can protrude through the wall of the inguinal canal into the groin. These typically do not go directly into the scrotum.