Article first published on The Straits Times
SINGAPORE – In 2023, Mr Joshua See saw a doctor after he experienced some pain in his left testicle. There was also a small bulge on the right side of his pelvic area.
A physical examination with a urologist showed that he had an inguinal hernia, also known as a groin hernia.
A hernia is a condition in which part of an organ protrudes through a cavity wall, such as the intestine bulging through a weak part of the abdominal wall. It is caused by a combination of muscle weakness and strain.
“It caused me anxiety and stress knowing that my intestines were sticking out. I had never undergone surgery, and the thought of going under the knife was quite scary,” says the 35-year-old.
Mr See is the founder and chief executive of a preventive care company and has a fiancee.
He decided to give himself three months to try to heal naturally.
He sought a physiotherapist’s help to strengthen the muscles in his abdominal area, and wore a hernia belt. The belt applies gentle pressure to the hernia, which can help reduce discomfort and prevent the protrusion from worsening.
Ironically, it caused him more discomfort.
He then consulted Dr Ganesh Ramalingam, medical director and specialist in general surgery at G&L Surgical Clinic, located at Mount Elizabeth Novena Hospital. An ultrasound scan showed that Mr See had inguinal hernia on the left and right sides of his groin.
He underwent hernia repair surgery in April 2023.
The procedure repairs the weakened muscle or tissue, and pushes the protruding organ or fatty tissue back into place to prevent discomfort and complications.
Overuse of abdominal muscles
Heavy weightlifting and exercising over many years could have caused Mr See’s hernia, says Dr Ganesh.
Mr See has been active since his teenage years, playing basketball competitively in secondary school and starting weight training when he was 13.
Before he developed a hernia, he was working out almost every day, running and doing high-intensity interval training.
He also did weight training three times a week, carrying 85kg to 100kg while doing exercises such as bench presses, squats and shoulder presses.
Overuse of the muscles in the abdominal area over a long period of time can cause them to be strained, and lead to weakening of the tissues, causing a hernia, says Dr Ganesh.
As a person ages, the body’s ability to repair tissues and muscles after exertion also diminishes.
“The natural repair processes that heal small tears in muscles become less effective, which can increase the likelihood of a hernia developing,” he notes.
This can happen with professional athletes, including soccer players and bodybuilders, says Dr Ganesh.
According to a study published in the Brazilian Journal of Orthopaedics in 2016, hernias impact as many as 20.9 per cent of athletes, with weightlifting being one of the most common sports leading to hernias.
Dr Chok Aik Yong is the medical director at Aelius Surgical Centre at Mount Elizabeth Hospital in Orchard. He says exercises that put extra emphasis on the hips, abdominal muscles and groin, such as deadlifts and squats, can repeatedly strain and add compounding stress to the abdominal muscles, potentially resulting in an inguinal hernia.
Heavy weightlifting and strenuous physical exertion, he adds, often involve the contraction of major muscle groups including the rectus abdominis (commonly referred to as abs), oblique muscles (at both flanks) and diaphragm.
This results in increased pressure within the abdominal cavity.
“Like your blood pressure, intra-abdominal pressure must stay within normal range to avoid problems. When you lift weights or engage in physical activity, the intra-abdominal pressure rises, with pressure further increasing when lifting from a squatting position. The downward pressure effect can be further exacerbated with gravity, contributing to the development of inguinal and other hernias,” says Dr Chok.
Sudden increase in physical activity causes risk
A hernia can also develop in people who suddenly step up their level of physical activity or heavy lifting after a period of being sedentary. This abrupt change can strain the muscles and tissues, creating a weak spot through which internal organs or tissues may protrude, says Dr Ganesh.
In March, Mr Lorenzo Lim, 28, started exercising after being largely sedentary for four years.
“In the past, I could lift 130kg quite easily. This time, I started off with lighter weights, but felt they were too light. So I decided to lift heavier at 110kg and I felt it was okay. But when I kept lifting, I started to feel a pain in my groin,” says Mr Lim, who works as a freelancer in the events and marketing industry.
He saw Dr Brian Anthony Tian, a consultant at Singapore General Hospital’s (SGH) General Surgery department, in May. A check-up showed that Mr Lim had an inguinal hernia and required an operation.
Mr Lim, who has a girlfriend, has stopped exercising in the meantime. He plans to go for hernia repair surgery in August or September. He will also hire a personal trainer for guidance when he resumes exercise.
Groin hernia is most common
There are several types of hernia, but inguinal hernia is the most common type, say doctors.
Globally, as high as 25 to 30 per cent of men can develop hernias in their lifetime, says Dr Tian. While it is a lot rarer in women, groin hernia is still the most common type in women, he adds.
According to the 2019 Global Burden of Disease Study, in that year, 86 per cent of the cases of inguinal, femoral, and abdominal hernias were males (11.24 million) and 14 per cent were females (1.79 million).
There are two different types of inguinal hernias – indirect and direct hernias.
Direct hernias form in an area of weakness at the groin. “This weakness develops as one ages, on a background of regular straining,” says Dr Tian.
Indirect hernias have a different origin or cause.
He says: “In male babies, the testicles form within the abdomen and move through the inguinal (groin) canal into the scrotum. The inguinal canal typically closes soon after birth. In cases where this canal doesn’t close properly, it will manifest as a hernia when internal organs slide out through this canal.”
This same process occurs in females. However, without the presence of testicles, this canal generally closes up.
Besides heavy weightlifting and sudden intense exercise, prolonged coughing or straining during bowel movements and while urinating can also increase pressure within the abdomen, and contribute to the development of a hernia, say doctors.
People with inguinal hernias often have a noticeable bulge in the groin region, especially when standing, coughing or straining. It is often accompanied by aching or discomfort at the site of the bulge. They might also experience pain or pressure in the groin, exacerbated by bending over, coughing or lifting.
In severe cases, Dr Chok says there may be pain and swelling around the testicles as intestines descend into the scrotum.
While small inguinal hernias may not cause symptoms, these may enlarge over time, leading to more symptoms as weakened muscle walls give way and tissues protrude.
If left untreated, patients may be at risk of a strangulated hernia, which can result in infection and even death, says Dr Chok.
The symptoms of a strangulated inguinal hernia include severe pain and redness in the affected region, fever, rapid heart rate, nausea and vomiting.
Surgery can be performed to repair a hernia, like in Mr See’s case, and prevent complications from occurring.
“This involves returning the abdominal contents to the abdominal cavity and reinforcing the weakened area of the abdominal wall. This is usually done with an insertion of a mesh over the weakened area,” says Dr Tian.
The mesh causes the body to form strong scar tissue in the region it is placed and strengthen the abdominal wall, he explains. The procedure may be performed in open or keyhole surgery.
Two months after Mr See’s hernia surgery, he hired a personal trainer and gradually resumed exercise.
“It is important to seek professional medical advice quickly if you think you might have a hernia. I hope the awareness of the condition can be raised, so it leads to early discovery and proper treatment, and so people can resume their daily activities faster,” says Mr See.
Reducing risk of hernia while exercising
It is important to avoid working out with very heavy weights. While the definition of this varies significantly based on an individual’s strength, experience and body weight, there are general guidelines, says Dr Chok.
If you are unable to maintain proper form or hold the weight in one position without losing control, the weight is likely too heavy.
During a repetition, Dr Chok suggests pausing the movement to see if you can keep the weight steady for a few seconds. If you struggle to control the weight at any point, consider reducing it until you find a manageable option.
You can also consider the use of supports and appropriate exercise gear during workouts. For instance, if you do weighted squats or deadlifts, use a weightlifting belt, advises Dr Chok. “This can provide added support to the abdominal and lower back muscles, and help prevent injury.”
If you are increasing the weight you are lifting, Dr Chok says a good indicator is if you can complete two or three sets of 10 to 12 repetitions, and the last few repetitions feel significantly easier. “This suggests that your muscles have adapted, and it is time to add more weight to continue progressing,” he adds.
Dr Chok shares four tips to reduce the risk of hernia developing as a result of exercise.
1. Strengthen your abs
Although strengthening your entire core cannot guarantee a hernia will not occur, it is important as a preventive move and to maintain overall well-being. Recommended exercises include planks and bicycle crunches.
2. Practise proper lifting techniques
When lifting heavy objects, use your legs instead of your back, and avoid sudden, jerky movements that might strain your abdomen.
3. Use a weightlifting belt for support
If you do weighted squats or deadlifts, use a weightlifting belt. This can provide added support to the abdominal and lower back muscles, and help prevent injuries.
4. Warm up with lighter weights
It is important that you increase weights gradually during your workout, even if you have been weightlifting for years. Start with a few warm-up sets using lighter weights, then gradually increase the weight while reducing the number of repetitions.
