The Canadian Hernia Society reports that 27 per cent of all men – more than one in four – can expect an “inguinal” hernia in their lifetime.Inside Creative House/iStockPhoto / Getty Images
Richard Littlemore is a Vancouver-based journalist, consultant, speechwriter and author.
It started, as so many things do, with a stirring in the loins. But not a good stirring. On the contrary, I was lying on the couch, battling a case of COVID-19 and – to use a vernacular phrase that I had previously thought to be metaphorical – I was coughing my guts out.
I knew right away what had happened, an awareness rooted in my reading of history rather than health care. Specifically, I was thinking about the voyageurs, the near-superhuman fur-trade workers who, at the turn of the 19th century, would paddle their canoes from Prince George to Thunder Bay and back in the course of a short summer. On portages, these sinewy men would heft beaver pelts or trade goods bundled into 90-pound “pieces” – this being judged a convenient weight for a man to carry – two at a time! Not surprisingly, the top three killers of voyageurs have commonly been reported as drowning, infections and strangulated hernias. That last one occurred when, under the weight of these heavy loads, a voyageur’s abdominal wall would give way, allowing a bit of bowel to squeeze through, pinch and become septic. Death was not especially quick, and it was fantastically ugly.
With that in mind, when I started to feel the ache and the pinch – in a place where a man doesn’t want to feel either of those sensations – I was alert to the probable cause and distraught about the possible consequences. It took 10 days to see my doctor and another week to get an ultrasound, conducted by a pleasant woman and her trainee, both of whom – mercifully – focused more on the video monitor than on the personal space they were probing with the ultrasound paddle. They confirmed the diagnosis: my innards were heading outward.
Apparently, I should have seen it coming. The Canadian Hernia Society reports that 27 per cent of all men – more than one in four – can expect an “inguinal” hernia in their lifetime. (Women get them too, but in much smaller numbers.) Hernia repair is the third most common surgery in Canada – more than 50,000 are performed every year. But as the general surgeon and hernia specialist Dr. Tracy Scott said in an interview after my procedure: “Men don’t tend to talk about anything that they think should be embarrassing.”
That might require a clarifier. An inguinal hernia is not something that a man might “think” is embarrassing; it is embarrassing. Because, despite the muscle-ripping image of the overburdened voyageur, the most common hernia doesn’t break through in a presentable place. Rather, under pressure, the abdominal contents look for the easiest point of exit, which turns out to be the inguinal canal – the pipeline that carries the plumbing for one testicle or the other. So when your intestines start breaking out like some kind of malevolent alien, the bulge emerges in that tender and usually private place. It’s inconvenient. And it hurts.
The good news, in the early stages, is that you can push the monster back into its lair, restoring some sense of normalcy and comfort – but only until you cough or sneeze or push, until you try to lift something or, at some point, even just stand up. Imagine, then, standing alone, hand in your pants, trying to poke the herniated handful back where it belongs, when the elevator doors open. It’s surprising how frequently you’re caught by an older male who says, “Ah, hernia? I had mine fixed last year.” More often, you find a woman, wary and offended, leaping to all kinds of wrong conclusions. So yes, Dr. Scott: it is embarrassing.
That, however, doesn’t make a hernia repair urgent, at least not within Canada’s oversubscribed health care system. Rather, the best hernia surgeons in the country are maddeningly philosophical about the condition and the wait times for surgery. Dr. Scott, who works out of St. Paul’s Hospital in Vancouver and does as many as 200 hernia surgeries a year – including most of the really complicated ones – said that a normal inguinal hernia is a “quality of life issue. It’s not life-limiting.” Absent the need to be lifting trade goods in and out of a canoe, there is little chance a hernia will become strangled or “incarcerated,” and require an emergency repair. Dr. Scott said that most people are safe to wait – a view that is supported by a considerable body of peer-reviewed research on the acceptability of what is called “watchful waiting.”
Dr. Hari Ondiveeran, the president of the Canadian Hernia Association and a general surgeon in Saint John confirmed that, unlike joint replacements or cataracts, there are no guidelines for appropriate wait times for hernia surgery anywhere in the country. But Dr. Ondiveeran also said he thought that was appropriate. As a general surgeon, his skills are in demand for every issue that occurs between the breastbone and the pubis, so if he is prioritizing between, say, a bowel cancer operation or a hernia repair, the hernia waits.
Surgical delays grew even longer during the worst part of the pandemic. Even aside from people’s reticence to go to the doctor, hospitals also cancelled elective surgeries, so hernia surgeons across the country built up a backlog. And COVID itself probably made things worse. Both Dr. Scott and Dr. Ondiveeran said that while no one has yet done the research, it makes sense to expect a COVID-related increase in hernia cases. “The intra-abdominal pressure rises even more when you cough than when you lift something heavy,” Dr. Ondiveeran said, so if you have any predisposition – or if you already have a small hernia that is asymptomatic – a COVID-induced coughing fit could trigger a larger problem.
That appears to have been my situation. In addition to being a plumbing conduit for nerves, blood vessels and the vas deferens that transports sperm from the testicle, the inguinal canal is also the route that the testicles themselves follow when they descend from the abdomen into the scrotum in the first year of a baby’s life. In as many as 25 per cent of cases, the opening doesn’t close up completely after the testes have passed through, leaving an increased chance of symptomatic herniation later in life. Dr. Scott confirmed that mine was such a “congenital” hernia, so it scans that the COVID coughing took me to the next level.
On the wait list issue, even without leaving the country, people who live in Ontario – and deep-pocketed residents from farther afield – have a potential queue-jumping opportunity at the Shouldice Hospital in Toronto. It’s a private facility that has been providing hernia care since the Canadian medical innovator Dr. Earle Shouldice opened his first small clinic in 1945, leveraging his own, globally recognized surgical technique.
Pre-Shouldice, the history of hernia treatment was a bit gruesome and not particularly successful. No one wants to remember the Renaissance-era efforts to burn hernia bulges off with a hot poker. Things started getting better in the 1880s, when an Italian physician named Dr. Edoardo Bassini developed a life-changing procedure, which Dr. Shouldice refined in the 1940s. Newer innovations now incorporate a surgical mesh to strengthen a hernia repair; Dr. Ondiveeran likened it to using rebar to strengthen concrete. But even today – three-quarters of a century later – “Shouldice” is the favoured technique for the small percentage of patients who might be allergic or otherwise reactive to polyester or polypropylene inserts. Shouldice chief executive John Hughes said in an e-mail correspondence that his surgeons perform 20 per cent of the roughly 32,000 hernia repairs funded by the Ontario government every year – so 6,400 annually. The hospital’s also advertises broadly, drawing patients from outside the province, or the country; for example, Rand Paul, the libertarian Republican Senator from Kentucky, took some flack in 2019 for coming to Canada for his surgery – even though he was quick to point out that his was an all-private transaction.
No matter where you go for surgery, you’ll have to be patient; even at Shouldice, wait times are 70 to 80 days, and they can be much longer in the public system. Dr. Scott said she tries to keep waits to less than a year: six months before the first consultation and six months again for the surgery. But she is flexible in cases where the symptoms are serious – or the sufferer is noisy. She handled my case in under 90 days, and my hernia was pretty minor, especially compared with the giant, down-to-your-knees examples you can see if you are bold enough to Google images for “large hernia.” Though I recommend you don’t; it’s very unsettling.
That comes back to Dr. Scott’s point about men not wanting to acknowledge or – heaven forfend! – share details of any threatening health event, much less one erupting below the beltline. Most men of a certain age (say, over 11), are hesitant to admit weakness. In the words of Dr. John Oliffe, Canada Research Chair in Men’s Health Promotion at the University of British Columbia’s school of nursing: “Within the normative frame of masculinity, guys tend not to self-disclose.” Dr. Oliffe said the research confirms the tendency for men to want to project strength, to be seen as self-reliant and stoic.
Men are also raised to be problem-solvers, a good intention that doesn’t map well onto a highly complex health care system. So if someone starts talking about a squirm-inducing medical condition, the conversation itself becomes discomfiting. Guys don’t want to talk about problems for which they can’t suggest a solution. That’s a problem for men’s health, Dr. Oliffe said. In a clogged health care environment, “You’ve got to be resilient. You often have to tell your story more than once.”
As well, he said, it would be helpful if more men could find “peer support”: Someone who doesn’t flinch with whom to have those hard conversations. In addition to generating a likely spike in herniations, “COVID taught us all the value of connection.” It would be good for us all if we started making use of that revelation.