Benign prostatic hyperplasia (BPH) is one of the common urological diseases in men. Its incidence increases with age. It manifests itself primarily with urinary complaints in men over the age of 50. Complaints such as frequent urination at night, dripping, intermittent and forced urination are the most common complaints. In men over the age of 45-50, inguinal hernia is mostly due to prostate enlargement. If elderly patients have an inguinal hernia, investigations for the prostate should also be performed. In this article, I will explain the relationship between BPH and hernia, its causes and treatment methods.

What does inguinal hernia/groin hernia mean?

Inguinal hernia or inguinal hernia is a condition in which the intestines enter and form a pouch as a result of the weakening of the abdominal wall muscles. It is mostly seen in men over the age of 40.

Risk factors involved in the formation of inguinal hernia:

• Chronic lung disease and cough
• Heavy lifting
• Heavy exercises
• Excessive weight

Hernias can sometimes be seen after abdominal surgeries. These are called “incisional hernia”. Due to the surgeries, the abdominal walls become weak and the intestines herniate there. In patients who have open surgery due to prostate cancer or BPH, a hernia may develop from the surgery site. Hernias may develop at the trocar sites in patients undergoing laparoscopic or robotic surgery.

How does BPH cause an inguinal hernia?

Prostate lobes enlarge in patients with benign prostatic hyperplasia (BPH). These prostate adenomas, which surround the urethra, compress the urethra over time, narrowing the urinary tract and making urine flow difficult. Patients with prostate have to strain to urinate due to the pressure of the prostate on the urethra. Since the abdominal muscles weaken with age, long-term strain and strain cause the intestines to gather towards the weakened parts, causing a hernia. These herniations often occur from the inguinal canal to the scrotum.

The inguinal canal is the place through which the testicular vessels and the seminal canal pass. In hernias that occur here, the intestines descend into the bag (scrotum) containing the testicle. A hernia can sometimes grow too large and become dangerous. Normally, the hernia disappears in the supine position and with examination. In some cases, the intestines that enter the hernia sac do not return to the abdomen and if the intestine lasts for a long time, the nutrition of the intestines may deteriorate and lead to gangrene, in which case urgent intervention is required.

Problems such as bladder neck stenosis and urethral stenosis may also cause inguinal hernia as they cause difficulty in urination if they last for a long time. Since there will be pressure on the urethra in prostate cancer patients, hernia formation may also occur in these patients.

In a study conducted in Taiwan involving 22,310 BPH patients, approximately 5% of the patients had a 10-year follow-up. It was reported that 84 of them developed an inguinal hernia. Hernia development was found to be 2.53% in people without prostate complaints. This study shows that BPH is an important risk factor for the development of inguinal hernia in male patients.

Another study showed that the development of hernia in prostate patients was related to the degree of complaints. Here, the development of hernia was found to be higher in those with many complaints (high IPSS, International Prostate Symptom Score).

It has been reported that approximately 12-25% of patients who underwent radical prostatectomy surgery due to prostate cancer later developed an inguinal hernia.

Can prostate and hernia surgery be performed at the same time?

BPH surgery and hernia surgery can be performed in the same session. This is also related to the general condition of the patient. Both surgeries can take a long time. If performing two surgeries together does not pose a problem for the patient in terms of anesthesia, both surgeries can be performed in the same session. If prostate surgery took a long time, patients are elderly, and prolonged surgery may cause problems, hernia surgery should be postponed to a later period.

Patients who underwent HOLEP surgery due to BPH also underwent open hernia surgery, and these patients did not need to stay in the hospital for a longer period of time, and no complications developed.

If a patient with an enlarged prostate also has a hernia, which surgery should be performed first?

If a patient has both a prostate and an inguinal hernia and requires surgery, prostate surgery must be performed first. Because hernia occurs in these patients largely due to prostate enlargement. If a hernia surgery is performed before, the patient will need to strain to urinate due to the prostate, and as a result, the hernia will recur.

Other risk factors that cause hernia recurrence after hernia surgery should also be taken into consideration. These conditions require treatment. Otherwise, the possibility of recurrence is high.

By what methods is prostate and hernia surgery performed?

Nowadays, BPH surgery is mostly performed endoscopically (closed method). The most commonly used closed method is TUR – plasmakinetic and laser prostate surgery (HOLEP). We perform HOLEP surgery on our BPH patients who require surgery.

Hernia surgery is performed by open surgery or laparoscopic method. If prostate surgery was performed by open method, open hernia surgery is also performed in the same session. Generally, hernia surgery is performed by laparoscopic method. In those who have had closed prostate surgery (HOLEP, TUR-P), hernia surgery is also performed endoscopically. If the patient has previously had an open surgery in the lower abdomen, it becomes difficult to perform endoscopic hernia surgery because there will be adhesions in the abdomen in such cases. In such cases, hernia repair with open surgery is more appropriate.

When does prostate enlargement require surgery?

Not every BPH patient necessarily requires surgery. For patients who do not have many complaints, we first recommend medical treatment, that is, medication. If drug therapy is ineffective, surgery is required.

Patients with BPH (benign prostatic hyperplasia) require surgery in the following cases:

• If there is no improvement with drug treatment
• If there is an inguinal hernia
• If you have bladder stones
• If there is diverticulum in the bladder
• If there is hydronephrosis in the kidneys (kidney functions are impaired)
• If their complaints are too many
• If there is urinary retention (inability to urinate)
• If there is bleeding due to prostate enlargement
• If there is recurrent urinary tract infection
• If there is excess urine left in the bladder after urinating (150 cc and above)

If there is a hernia along with BPH, should the hernia be treated?

Not every case of hernia necessarily needs to be treated. If the hernia is in the early stages and the patient does not have many complaints, there is usually no need for treatment. Surgical treatment is required for hernias that are large and cause discomfort to the patient. It is appropriate for these patients to be evaluated by a general surgery specialist. Along with hernia treatment, risk factors (obesity, chronic cough, etc.) must also be treated.

Does PSA increase in patients with hernia?

PSA (prostate specific antigen) is a molecule made by prostate tissue. It increases in serum in prostate cancer and prostate infections (prostatitis). There is no direct relationship between hernia and PSA. Its high level in hernia patients is not related to the hernia, but directly to prostate disease. Normally PSA values ​​should be 0-4 ng/ml. Above this, it should be investigated for prostate cancer and prostatitis.

In summary: Prostate enlargement and inguinal hernia may coexist. The reason for this is the pressure on the urethra (urinary canal) as a result of prostate enlargement. As a result of the pressure of the enlarged prostate on the urethra, these patients need to strain and strain to urinate. As a result of the weakening of the abdominal walls in older men, hernia formation is observed in BPH patients. The more urinary complaints (IPSS) in prostate patients, the more common the development of hernia. A hernia may also develop after open, laparoscopic and robotic surgeries for prostate cancer or BPH. These are called post-operative or incisional hernias. Prostate surgery and hernia surgery can be performed in the same session. If the surgery will take longer, hernia surgery is performed at a later stage. In a patient with BPH and hernia, prostate surgery must be performed first. If hernia surgery is performed first, the risk of recurrence is high. There is no direct relationship between PSA elevation and inguinal hernia.

Literature

Some literature on the association of prostate enlargement and hernia is given below. Main articles referenced in the preparation of this article:

• Lower urinary tract symptoms-Benign prostatic hyperplasia may increase the risk of subsequent inguinal hernia in a Taiwanese population: A nationwide population-Based cohort study. .PLoS One. 2020 Jun 8;15(6):e0234329.
• Correlation between the presence of inguinal hernia and the intensity of lower urinary tract symptoms. Acta Cir Bras. 2011;26 Suppl 2:125-8.
• [Combined inguinal hernia repair and transurethral resection of the prostate (TURP) for benign prostatic hypertrophy]. J Chir (Paris). 2009 Dec;146(6):549-52. 2009 Dec;146(6):549-52.
• Perioperative Outcomes of Inguinal Hernioplasty along with Holmium Laser Enucleation of the Prostate (HoLEP). I.Urol J. 2023 May 21;20(3):187-190.
• Simultaneous treatment of benign prostatic hypertrophy and inguinal hernia: an old procedure revisited. Dakar Med. 1999;44(2):219-21.
• Inseparable interaction of the prostate and inguinal hernia. International Journal of Urology. Volume 25, Issue 7 p. 644-648. 2018.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY