BPH/PVR and Hernias
Created 12Sep2023, Last edited 23Dec2023
Case Studies:
May 2008 Patient's right Inguinal Hernia repaired by mesh
July 2011** 1st Urinary Tract Infection (UTI). Eight days in hospital. Tests reveal a) blockage due to Benign Prostatic Hyperplasia (BPH), b) High Post Void Residual (PVR) only discovered due to the UTI and possibly existed for three years before.
Aug 2021** 2nd UTI costing 4 days in hospital plus several tests and NHS staffing time.
Jan 2023** Left Inguinal Hernia occurs. BPH blockage has still not been removed. Cost to NHS for mesh repair.
Had the Urological blockage been discovered and dealt with shortly after May 2008 and well before July 2021 all three above ** starred events, costing the NHS, may not have happened.
A urological blockage problem and a hernia can often co-exist (NOTE 1) raising two interesting possibilities, both saving NHS money:
a) NOTE 2 Combine urology surgery, to relieve pressure, followed by Hernia mesh repair, in a single operation.
b) NOTE 3 Use a hernia to reveal unsuspected urological problems allowing early intervention
Above shows the position of an Inguinal Hernia. The Femoral or Scrotal Hernia is lower down. With the UK NHS in 2011 it was no problem to get referred to a hospital specialist for a Inguinal mesh repair but in 2022 it proved much more difficult despite the risk of a strangulated Hernia. Also had urological problems been sorted quickly hernias possibly might not have resulted.
NOTE 1 "urological blockage problem and a hernia can often co-exist"
Elevated residual urine has a relation to prostatic obstruction, although not a strong one.
https://www.sciencedirect.com/topics/nursing-and-health-professions/postvoid-residual-urine-volume
Inguinal Hernia. Often presented together with Benign ...Inguinal hernia is commonly found in men over 40 who have been also diagnosed with benign prostatic hyperplasia (BPH). Due to the enlargement of prostate gland, it causes the strain during urination and increases an abdominal pressure.
https://www.bangkokhospital.com/en/content/inguinal-hernia-often-presented-together-with-benign-prostatic-hyperplasia
The Clinical Study: Impact of Benign Prostate Hyperplasia on the Inguinal Hernia Formation
It was concluded that voiding difficulty caused by Benign Prostate Hyperplasia is a significant reason for elderly male patients to develop into inguinal hernia.
https://www.sciencepublishinggroup.com/article/10.11648.j.ijbecs.20180403.11
NOTE 2 "Combine urology surgery to relieve pressure with Hernia mesh repair in a single session"
...combining mesh hernioplasty and HoLEP "is a better option because of low wound infection and hernia recurrence rates. Combining these two also saves the patient of having to undergo another hospital admission and surgery, besides the significant NHS cost savings"
https://pubmed.ncbi.nlm.nih.gov/15198155/
Inguinal hernia is a common complication of benign prostatic hyperplasia. It occurs in 15% to 25% of cases. The treatment the cause of abdominal hypertension and in particular prostatic obstruction should be considered before or at the same time as hernia treatment to avoid recurrence.
https://www.researchgate.net/publication/38067157_Combined_inguinal_hernia_repair_and_transurethral_resection_of_the_prostate_TURP_for_benign_prostatic_hypertrophy
NOTE 3 "Use a hernia to reveal unsuspected urological problems"
The Clinical Study: Impact of Benign Prostate Hyperplasia on the Inguinal Hernia Formation
It was concluded that voiding difficulty caused by Benign Prostate Hyperplasia is a significant reason for elderly male patients to develop into inguinal hernia.
It is important to have routine prostate examinations required for elderly male patients with the diagnosis of inguinal hernia.
A patient presenting with a hernia needs tests (e.g. a simple PVR test) to reveal possible unknown urological problems. Questioning the patient is not too helpful/reliable.
Post Void Residual (PVR) measurement
Measurement of the PVR determines the quantity of urine remaining in the bladder shortly after a voluntary void; this measurement can be readily obtained using a ultrasound scanner or by directly measuring the urine volume via a one time use urinary catheter.
http://medical-dictionary.thefreedictionary.com/diuresishttp://en.wikipedia.org/wiki/Diuresis
Diuresis: Discharge of urine, especially in unusually large amounts.*
Alivizatos et al (2004) reported that scans were not accurate after an increased water load had caused a diuresis.
http://onlinelibrary.wiley.com/doi/10.1111/j.1442-2042.2004.00951.x/abstract
PVR urine Volume after increased water load diuresis (PVR1) differed from that recorded after normal bladder filling and voiding at first desire (PVR2), with the PVR1 being larger than the later PVR2 in every patient. Measurement of postvoid residual volume in a relaxed patient, who voids at first desire, represents everyday life and should be the correct method of testing. Gerasimos Alivizatos 22Dec2004.
Residual urine volumes in an individual patient at different times can vary widely.
https://www.sciencedirect.com/topics/nursing-and-health-professions/postvoid-residual-urine-volume
Further notes
PDF report above finding is: Multiple diverticulae with trabeculated blader
Goog: multiple diverticula with trabeculated bladder
"Most cases of bladder diverticulum result from increased intravesical pressure and occur in men older than 50 years of age who have urinary outflow obstruction due to Benign Prostatic Hyperplasia (BPH)"
https://www.sciencedirect.com/topics/medicine-and-dentistry/bladder-diverticulum
Google: can increased intravesical pressure cause hernia
"Long-standing increase of the intravesical pressure resulting from urinary bladder outlet obstruction (BOO) can cause both secondary bladder diverticula and groin hernias."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9724892/
PDF mentions I take ISC for BOO
"Inguinal hernias are also known as groin hernias"
https://www.coventryrugbygpgateway.nhs.uk/pages/hernia-inguinal-hernia-in-adults/
https://www.aomrc.org.uk/ebi/checker/repair-of-minimally-symptomatic-inguinal-hernia/
Similar criteria
https://www.bangkokhospital.com/en/content/incarcerated-hernia
Watch out! Do not leave hernias untreated
Risk factor: Benign Prostatic Hyperplasia (BPH) etc
https://www.nghs.com/2021/03/24/when-should-i-consult-a-doctor-about-getting-hernia-surgery
Hernias do not heal on their own and they will almost always require surgery. Delaying hernia surgery will allow the hernia to grow and muscles will likely become weaker. This will make surgery and recovery more difficult.
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About 80% of patients with inguinal hernia develop enough symptoms over 10 years that they end up needing surgery.
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https://gps.northcentrallondon.icb.nhs.uk/pathways/hernia-clinical-pathway
Good flow chart
At bottom 'Male patient with reducible inguinal hernia'
Is patient symptomatic? Presents with visible (yes) or easily palpable (Literal meaning of palpably is "in a way that can be felt or palpated") swelling in the groin, often with discomfort during strenuous exercise or heavy lifting.
Yes
If patient ok about surgery then Routine Referral
https://www.nghs.com/2021/04/12/can-i-exercise-when-i-have-a-hernia
Hernias cannot heal on their own. While surgery may not be necessary right away, the only way to permanently remedy your hernia is to have it repaired surgically.
Early intervention will prevent your symptoms from getting worse and will make your recovery from hernia surgery easier. This means you’ll be able to get back to the activities you enjoy quicker and with less pain.
https://bestpractice.bmj.com/topics/en-us/723
What is symptomatic inguinal hernia?
Summary. An inguinal hernia occurs when abdominal or pelvic contents protrude through a dilated internal ring or attenuated inguinal floor in the inguinal canal. Presents with visible or easily palpable swelling in the groin, often with discomfort during strenuous exercise or heavy lifting.29 Jun 2022
https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547
Inguinal hernia signs and symptoms include: A bulge in the area on either side of your pubic bone, which becomes more obvious when you're upright, especially if you cough or strain. A burning or aching sensation at the bulge. Pain or discomfort in your groin, especially when bending over, coughing or lifting.
There is good evidence that asymptomatic and mildly symptomatic hernias can be safely managed through a watchful waiting approach, and therefore surgical repair of hernias that are not causing any significant impact on daily activities is not usually funded. (Gloucester NHS)
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If you aren't able to push the hernia back in, the contents of the hernia can be trapped (incarcerated) in the abdominal wall. An incarcerated hernia can become strangulated, which cuts off the blood flow to the tissue that's trapped.
An incarcerated hernia occurs when herniated tissue becomes trapped in the weak point in the abdominal wall and cannot easily be moved back into place.
Risk of strangulation is higher (2.8% to 4.5%) among patients presenting for emergency repair of incarcerated hernias.
https://www.mdedge.com/familymedicine/article/62947/what-risk-bowel-strangulation-adult-untreated-inguinal-hernia
The risk of bowel strangulation is estimated to be small—less than 1% per year.
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https://cks.nice.org.uk/topics/scrotal-pain-swelling/management/inguinal-hernia/
"Offer routine referral to general surgery to consider surgical management if the hernia is symptomatic but reducible"
Below was referenced by NICE...
https://patient.info/digestive-health/hernia-leaflet
In some areas, NHS funding for hernia repair is not automatically given and your GP or surgeon may need to apply for this.
How are hernias repaired?
A small operation is recommended. Wearing a support (truss) was a method used in the past but is now not recommended.
Below was also referenced by NICE...
https://www.britishherniasociety.org/groin-hernia-and-you/
There is sometimes, but not always, some discomfort– but it is not excruciating pain.
"hernias will not go away without surgical repair"
"majority of hernias will gradually become bigger and more uncomfortable with time, no matter how careful you are. Wearing a special device called a truss (support) to stop the lump coming out of the hole was used in the past, but is now thought to have no or limited benefit and are also fairly uncomfortable"
https://www.uhbristol.nhs.uk/patients-and-visitors/your-hospitals/bristol-royal-infirmary/what-we-do/ogteam/conditions,-tests-and-treatments/hernias/inguinal-hernia/
watchful waiting (that is, not operating but keeping an eye on a hernia), is safe for inguinal hernias with no or minimal symptoms. They did also say that most men with no or minimal symptoms from a hernia will go on to develop symptoms at some point, and then require surgery. Therefore, the decision of whether or not to have an operation to repair a hernia that is causing no or only minimal symptoms is something that individuals need to decide for themselves.
Men with symptoms from an inguinal hernia should have it repaired, providing they are fit for the operation.
A mesh-based repair was recommended for patients with inguinal hernias.
https://bnssg.icb.nhs.uk/directory/hernia-repair-in-adults/
Bristol, North Somerset Integrated Care Board (ICB)
Hernia Repair in Adults is not routinely funded by the CCG and is subject to this restricted policy. see Hernia-Repar.pdf
Hernia-Repar.pdf
Referral to Secondary Care and subsequent treatment may be provided where patients meet criteria below:
2. Difficulty in reducing the hernia
OR
3. A risk of strangulation
Following types of hernia should be referred to Secondary Care due to the
increased risk of incarceration / strangulation without the need to secure funding authorisation from the ICB:
5. Inguinal-scrotal hernia in a male patient (Inguinal-scrotal Hernias are hernias which have passed into the scrotum. These types of hernias have a higher risk of strangulation.)
“minimally symptomatic hernia” - an inguinal hernia with complaints that do not interfere with normal daily activities.
mesh fixation
Around 98% of inguinal hernias are found in men because of the vulnerability of the male anatomy to the formation of hernias in this area of the body.
Inguinal hernias can occasionally be life‐threatening if the bowel within the peritoneal sac strangulates or becomes obstructed, or both.
Performed either by open surgery or by a minimal access key‐hole (laparoscopic) approach.
Such repairs can be performed via total extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) methods. In TAPP the surgeon enters the peritoneal cavity and places a mesh through a peritoneal incision. TEP is different in that the peritoneal cavity is not entered, but the mesh is positioned at the same place; behind the muscles of the abdominal wall and in front if the peritoneum.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6485597/
laparoscopic (keyhole) surgery
youtube inguinal TAPP hernia mesh repair
Inguinal Hernia Repair TAPP and TEP techniques.
In TAPP the surgeon goes into the peritoneal cavity and places a mesh through a peritoneal incision over possible hernia sites.
TEP is different in that the peritoneal cavity is not entered and mesh is used to seal the hernia from outside the peritoneum (the thin membrane covering the organs in the abdomen).
Remember: tEp External to peritoneal cavity
Inguinal Hernia TAPP or TEP repair?
TAPP procedure is easier to learn and perform; however there are many possible advantages to using the TEP approach. There is less chance of visceral damage (injuries to all internal organs) because the abdominal cavity is not entered.
Transabdominal pre‐peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8845481/