Hernias and Yoga

by Baxter

At the Yoga Alliance Leadership Conference this past weekend in Palm Springs, CA, I was presenting a session to and for yoga teachers. (By the way, the gathering was a great example of the positive benefits of “community” that Nina wrote about yesterday in her post What Really Helps Foster Healthy Aging!) It was entitled “Expecting the Unexpected,” and we discussed all the interesting injuries and maladies that yoga students bring to class, and how to work positively with whatever shows up for us. One of the topics I placed on the list of concerns was “inguinal hernia.”  The teachers present wanted more information—just the week before, a student had come to class with a recent discovery of just such a problem and wanted to do some yoga, if it would be safe to do so—so I’m addressing it here on the blog.

Just so happens about 10 years ago, the day after a fabulous week-long yoga retreat I had attended in Mexico, I glanced down while showering and noticed a small bulge in my left groin crease. Having cared for others with such bulges in the past, I knew immediately that I had an inguinal hernia. You might be asking me, what is up with “inguinal”? Isn’t a hernia a hernia? I’ll get to the specifics of this kind of hernia in a moment, but the word “hernia” as in “herniated” refers to one structure bulging or pushing into another space into which is usually does not go. There are hiatal hernias, involving the stomach sack and the diaphragm (another topic we will get to before too long!), umbilical hernias, where abdominal stuff pushes out through the navel area, and herniated discs, where the discs between the spinal bones pushes out into the spinal canal toward the spinal nerves.

In the case of an inguinal hernia, the abdominal contents, such a loop of small intestine, are able to push down through a weakness in the abdominal wall that leads to the inguinal canal. This canal is located just beneath the fold of tissue in the groin area. In men, it leads down towards the scrotal sack, which is why the doctor examines men by placing an exam finger from the scrotum up into the inguinal canal and has the patient cough. An increase in abdominal pressure, such as during a cough, while laughing or lifting, can push some abdominal stuff into the canal, where it is likely to bump against a waiting digit of the doc. In my case, there was a small bulge already visible that would increase in size a bit with any of the above maneuvers. Inguinal hernias are more common in men.  Women can have similar hernias in the groin area, but often have a femoral hernia, just below the groin crease.

Any activity or medical problem that increases pressure on the abdominal wall tissue and muscles may lead to a hernia, including:

• chronic constipation, straining to have bowel movements
• chronic cough
• cystic fibrosis
• enlarged prostate, straining to urinate
• extra weight
• fluid in the abdomen (ascites)
• heavy lifting
• peritoneal dialysis
• poor nutrition
• smoking
• overexertion
• un-descended testicles

When I first discovered the bulge, it was not causing me any symptoms. It might have gone on like that or it could have led to some achy soreness, too. It might have been manageable if I changed habits, avoiding increases in abdominal pressure via less lifting and such. But I knew I wanted to have a normal activity level, if not an increased one involving lots on interesting yoga poses, as well as the ability to have a carefree guffaw whenever I wanted. So I chose to have a surgical repair. The most serious potential problem with an untreated inguinal hernia is if a loop of bowel enters the canal, gets twisted and has its blood supply cut off. If the bowel segment begins to die, it can be a life-threatening emergency. I figured an elective surgery, while my life was not being threatened imminently, was a better way to go. The non-surgical approach is usually to avoid lifting or increased abdominal pressure and to wear a special belt called a truss, that puts external pressure over the groin area.

Most people who develop a hernia are born with the weakness in the area. In some of those people, they never have any overt evidence of the problem, and so may never get a full on hernia. But once it shows up, it is unlikely to spontaneously go away. The bulge can disappear when things are quiet, but it is likely to come back after a coughing jag, some yard work or even a moderate yoga practice. Gravity plays into it too, so if you are standing and engaging the abdominals without any specific modifications, you could aggravate a hernia. Even bearing down to urinate or defecate could worsen the bulge.

So for most healthy yogis who would like to maintain a typical yoga asana practice, I’d suggest you discuss surgical repair of your inguinal hernia with your doctor. And although the procedure is relatively safe, for those who are surgery averse, there was a study in 2006 looking at men with hernias but no pain. Half got surgery, the other half took a wait and see approach. The groups, when compared five years later, had about the same complaints of pain in both groups. This does not apply to other scenarios of inguinal hernia, but you may have other options. 

In my case, my right inguinal canal was actually more open than my left, so I had both sides sealed off with some surgical mesh, designed to prevent unwanted bowel loops from heading down stream. Things have held well for ten years now. If there is some time between diagnosis of inguinal hernia and your scheduled repair, yoga modifications could be of some help in preventing a bulge from getting bigger. Inverted poses, such as elevated legs up the wall, with a bolster under the pelvis and chair shoulder stand, if approached with abdominal softness, could use gravity to your advantage. When you are inverted, the bowel loops will be pulled away from the inguinal canal. 

Another possibility would be to cautiously learn the lower two bandhas: Mula Bandha, the pelvic floor lift, and Uddiyana Bandha, the flying upward lock. Usually engaged during an exhalation, contracting the pelvic floor muscle upward and drawing the lower abdominal muscles inward and upward could act as a protective action when engaging the abdominals is necessary to perform a task or an asana. You would also want to use caution in forward bends, as bringing the belly close to the thighs will almost certainly put downward pressure toward the inguinal canal.

Once your hernia is repaired, a return to your yoga practice should be guided by your level of soreness and pain, which will hopefully recede as you advance your poses gradually. Core strengthening utilizing the bandhas, should help support overall healing and could have a preventive benefit to minimize the risk of a recurrent hernia. I was able to gradually resume my full asana practice gradually of a two-month period, and I no longer even experience the soreness I felt right after the operation.

If you decide to go the non-surgical route, there was a recent study conducted in India looking at asana for treatment of inguinal hernia. They found it effective in some ways.  The following are the poses they used. I do not suggest you do these without consulting an experienced yoga teacher to make sure your technique does not aggravate your condition!  Here we go:

“Vajrasana, Ustrasana, Paschimottanasana, Pawanmuktasana, Utthanpadasana, Matsyasana and Sarvangasana were selected based on its effects to compress inguinal canal, strengthen the abdominal muscles and to reduce the intra-abdominal pressure, because weakness or flabbiness of abdominal muscles and elevated intra-abdominal pressure may be the causes for the hernia in non-congenital subjects included in this study.” 

To learn more, see the International Journal of Yoga. It seems that like a lot of health issues, the approach to treating this common condition is gradually changing. So do some research, talk to friends, talk to your doctor, and come up with a plan that works best for you.