Direct vs. Indirect Inguinal Hernia: What Are the Differences?

An inguinal hernia, which occurs when organs push through weak areas of the abdominal muscles, can be direct or indirect.

The difference between indirect and direct inguinal hernias is in the anatomical location. Direct hernias protrude through the posterior (back) wall of the inguinal canal (passages that run down the lower abdomen on either side of the groin). Indirect hernias protrude through the inguinal ring (at the end of the inguinal canal).

Indirect hernias are often congenital (meaning present at birth), whereas direct hernias are due to heavy lifting or straining.

This article will discuss the symptoms, causes, diagnosis, and treatment of indirect and direct hernias.

Symptoms of Direct and Indirect Hernias

Indirect and direct inguinal hernias are similar in that they both present as bulges in the groin area. They also are both caused by organs pushing through the inguinal canal. However, indirect and direct hernias occur in different locations.

Direct hernias protrude through the back wall of the inguinal canal, while indirect hernias protrude through the inguinal ring.

The symptoms of indirect and direct hernias are similar. They include:

• A bulge in the groin area
• A bulge in the scrotum
• Pain or burning in or around the groin

When You Notice Symptoms

Symptoms may only be noticeable or be worse when coughing or straining. They improve when you rest or lie down.

Causes of Direct and Indirect Hernias

Although the symptoms of indirect and direct inguinal hernias are similar, the underlying causes are different.

Indirect Inguinal Hernias

Indirect inguinal hernias are often present at birth. They are more common in babies with testicles. These hernias occur when one or both of the inguinal canals do not close during fetal development.

This failure to fully close can result in organs in the abdomen being pushed outward. Certain genes may increase the risk of developing inguinal hernias.

While most indirect inguinal hernias are congenital, they don’t always show up in infancy or even childhood. Therefore, an adult may be diagnosed with an indirect inguinal hernia that wasn’t present at birth but appears later in life. This might occur due to an acquired weakness of the inguinal ring.

Direct Inguinal Hernias

Direct inguinal hernias occur along the back wall of the inguinal canal. They are the result of a weakened inguinal canal wall that happens as a person ages. They often are caused by straining or lifting something heavy.

Like indirect hernias, direct hernias are also more common in people with testicles. In fact, 27% of people with testicles will develop an inguinal hernia in their lifetime, while only 3% of people with ovaries will. Those over 40 are most at risk of developing this type of hernia.

Risk Factors

Certain people are more at risk of developing direct inguinal hernias. Risk factors include:

• Connective tissue disorders (tissues that support or protect the body's other tissues and organs)
• Chronic cough
• Chronic constipation
• Doing heavy lifting
• Regularly standing or walking for long periods
• A family history of inguinal hernias

Other Causes of an Abdominal Lump

Not all lumps in the abdomen are caused by hernias. Other possible causes include:

• Hematoma (collection of blood under the skin after injury)
• Lipoma (collection of fatty tissue under the skin)
• Swollen lymph nodes
• Tumor of the skin or muscles
  

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Diagnosing Inguinal Hernias

Doctors diagnose indirect and direct inguinal hernias through a physical exam and sometimes through radiological tests. Your doctor will begin by taking a medical history.

A physical exam involves visually observing the area and palpating (touching and pressing) to try to feel for a hernia. You will be asked to stand for the exam since the hernia may be more prominent when standing.

For those with testicles, your doctor will ask you to cough while they examine your scrotum. This will allow the doctor to feel the hernia move in and out.

If your doctor needs further confirmation, they may order certain tests. Tests used for diagnosing hernias include:

• Ultrasound
• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI) scan

Treatment for Inguinal Hernias

Inguinal hernias do not heal on their own and can grow larger over time. That’s why surgical repair is the only treatment for inguinal hernias. Worldwide, more than 20 million people undergo surgery for groin hernias every year.

Watchful Waiting

For adults who do not have significant symptoms, a doctor may use watchful waiting, which is closely monitoring but not giving treatment. However, it’s important to note that watchful waiting is not an alternative to surgery but rather a delay in receiving surgical repair.

Of those who delay surgery, 70% will require surgery within five years.

Indirect and direct inguinal hernia surgery involves two steps:

1. Moving the herniated tissue back into place
2. Repairing the weak area where the hernia occurred (in indirect cases, this involves closing the inguinal canal)

The type of surgery your doctor recommends depends on your age and overall health. Common surgical procedures are:

• Open surgery: Your surgeon will make an incision in your lower abdomen (groin) to locate and repair the hernia. The surgeon may use stitches and a piece of mesh for extra support when closing the hernia defect.
• Laparoscopic surgery: This is done by making several tiny holes in the abdomen. Your doctor will then insert special tools that will allow the surgeon to see the hernia from the inside of our abdomen and repair it. Mesh may also be used during this surgery to repair the hernia defect.

Both types of surgery are usually done under general anesthesia. The open approach can sometimes be done under local anesthesia. The procedure is performed by a surgeon that specializes in hernia repairs. Hernia surgery is usually outpatient, meaning that you will be able to go home the same day.

Strangulated Hernia

Inguinal hernias are usually not a cause for alarm. However, a strangulated hernia, in which blood flow to trapped tissue is cut off, can lead to life-threatening complications. The World Society of Emergency Surgery (WSES) recommends immediate emergency surgical hernia repair when strangulation is suspected.

Preventing Inguinal Hernias

Since indirect inguinal hernias are often congenital, it is not possible to prevent them. However, there are some steps you can take to lower your risk of developing a direct inguinal hernia, including:

• Be careful when lifting heavy things.
• Don’t strain when having a bowel movement.
• Treat constipation (difficulty moving your bowels).
• Treat a persistent cough.
• Get treatment if you must strain to urinate.
• Maintain a weight that is healthy for you.

Summary

Direct inguinal hernias occur through the posterior (back) wall of the inguinal canal, while indirect hernias protrude through the inguinal ring. Indirect inguinal hernias are often congenital, which means they are sometimes, though not always, diagnosed at birth.

Both types of inguinal hernias are more common in people with testicles. The chief symptom is a bulge in the groin or scrotum, and there may be associated pain. Diagnosis is by physical examination and may be confirmed with imaging. Then, surgery is needed to correct the problem.

Frequently Asked Questions

Indirect inguinal hernias in babies are congenital. This means that during fetal development, something did not develop completely. In this case, the inguinal canal, which runs on either side of the abdomen to the groin, did not close. When that happens, part of the internal abdominal organs pushes through that canal, causing a bulge in the groin area.

Inguinal hernias are quite common. In fact, 27% of people with testicles and 3% of people with ovaries will develop an inguinal hernia in their lifetime.

Indirect inguinal hernias are more common in babies with testicles. That's because testicles begin developing inside the abdomen and must travel down through the inguinal canal to reach the scrotum. When this canal doesn't close before birth, a hernia can develop. Direct inguinal hernias are also more common in people with testicles. That's because they have a wider inguinal canal than those with ovaries. As a result, over time, the canal is more likely to stretch out and become weak.

No. Inguinal hernias do not go away on their own. Therefore, surgery is the only solution for indirect and direct inguinal hernias.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

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By Kathi Valeii
Valeii is a Michigan-based freelance writer with a bachelor's degree in communication from Purdue Global.

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