Why are men being refused surgery for their hernias?
When Shamus Burns found a lump in his groin on holiday last year, he was naturally alarmed.
But after seeing a GP on his return home, the 43-year-old Huddersfield University lecturer was reassured to learn it was just a small hernia.
It was probably caused by lifting heavy flagstones when he was renovating the family home.
‘The doctor explained that it was essentially a weakness in the muscle, allowing my intestines to push through, creating a little bulge under the skin,’ says Shamus, who lives in Halifax with his wife Helena, 37, and two young children.
Hernias – either in the groin or abdomen – are very common, with around a quarter of men affected (compared with just 3 per cent of women).
Indeed, hernia repair is one of the most commonly performed operations in the UK, with more than 100,000 carried out each year.
While hernias can be symptom free, many men suffer severe discomfort and pain.
And, although rare, there is a risk of an untreated hernia becoming ‘strangulated’, where the intestine becomes so firmly wedged in the abdominal muscle that its blood supply is cut off, which can be life threatening.
Although he was told this was highly unlikely in his case, Shamus was offered surgery to repair the hernia.
However, many thousands of men will no longer have this option, due to a radical – and controversial – shift in the approach to hernia treatment.
Instead of routinely operating, consultants in six regional health authorities are adopting a policy of ‘watchful waiting’. This means patients are advised to return to their GP only if they have symptoms (typically pain) or the hernia grows.
The change is in the wake of recent American research that showed monitoring patients, instead of them having immediate elective surgery, did not raise the risk of a strangulated hernia.
Supporters of watchful waiting also point to the fact that in up to 20 per cent of cases, the hernia recurs where surgery is carried out.
Furthermore, there can be debilitating side-effects. A study at the University of Aberdeen found that around a third of patients reported chronic pain after their hernia operation.
The problem of post-operative hernia pain is so ubiquitous that it has earned an official label: Post Herniorrhaphy Pain Syndrome (PHPS) – ranging from tenderness at the site of the surgery to chronic debilitating pain and back ache.
Some men also have difficulty passing urine and/or erectile dysfunction.
The man who was instrumental in the NHS move towards watchful waiting is Professor Jonathan Meakins, a former Nuffield Professor of Surgery at Oxford. He himself has lived with two hernias – ‘one on the right, one on the left, had them for 20 years, both symptom-free’ – that he’s never had treated or repaired.
As he explains: ‘Having been a surgeon for many years, I know the operation does not always go well. Personally, I’m not interested in exchanging a painless state for a 15 to 20 per cent chance of ongoing post-operative pain.’
Four years ago, the Department of Health asked Professor Meakins to write a list of criteria for hernia surgery.
He concluded that repair should be offered only when the hernia is painful and growing; where the patient has a history of complications; where the patient’s job is dependent on the repair, or if the patient demands it.
Watch and wait: Shamus Burns turned down a chance for hernia repair
In fact, as Professor Meakins points out, the latter rarely occurs. ‘You’d be amazed at how often, if you tell the patient that they don’t need this surgery, they’d be out of your door – fast.’
He believes repair is only necessary for younger men who play a lot of sport, have an active job, or feel, due to discomfort or embarrassment, that their hernia is affecting their love lives.
‘It is likely a 25-year-old will need it fixing at some point so you may as well get on with it, but a 75-year-old with no symptoms who is not very active and takes care of themselves, well, that would have to be a judgment call and we’d probably leave it alone.’
But the shift to watchful waiting has angered some who believe hernia repair is being dropped simply to save money. Hernia surgery costs the NHS up to £100million a year.
Professor Meakins agrees that saving money was ‘almost certainly’ the original motive for the move away from surgery.
‘There was a long list of men with hernias, and so it was inevitable that someone would ask, do they all need instant repairs?’
But that, he suggests, is not a bad thing. ‘It was the right place to look for cost cutting; the managers in the primary care trusts were asking the right question.’
Mark Woods would vehemently disagree. For the 44-year-old supermarket worker from Tonbridge, Kent, the policy of watchful waiting has been painful and – in his view – unnecessary.
He first developed a hernia in 2005, and underwent surgery to repair it. Then, late last year, he began to experience swelling in his groin again – another hernia was developing. This time he’s being treated with watchful waiting.
Mark says the pain has been so bad that he’s had to take eight weeks off work. ‘It made my employer very unhappy. Since then my consultant has told me he wants to see if it enlarges before he arranges an operation.
‘The decision to wait is threatening my ability to do my job, which involves heavy lifting, but all I’ve been offered are painkilling injections. I know the operation carries a risk, but I’m still desperate to have it so I can get back to normal. I want my life back,’ he says.
The fact is, most hernias are painful and should be treated, says one of the world’s leading hernia experts.
‘Around 70 per cent of inguinal hernias (in the groin) will cause symptoms such as pain and discomfort, and for that reason the patient will actually request repair,’ says Patrick O’Dwyer, Professor of Surgery at Glasgow University and President of the British Hernia Society.
‘Thirty per cent have little in the way of symptoms at presentation other than a lump; however, over time, most of these will become painful or increase in size. For this reason, we also recommend repair for patients with minor symptoms as long as they are medically fit for a local anaesthetic’
As it happens, hernia patient Shamus Burns turned down the chance to have his hernia repaired.
He has spent most of his career in medical research, and says: ‘As a scientist, I read all the original research papers on watchful waiting and they were excellent. While there was no benefit in the majority of cases from operating, the risks of post-operative pain were relatively high.
‘Why would I risk possible chronic pain, and all the other risks of hospital stays such as MRSA, over a condition that I am happy to live with. Yes, I feel occasional throbs of pain, but as we age, who doesn’t?
‘I now wear a flat support that looks much like a weight belt, but around the groin area. This keeps the hernia pushed back in place, behind the abdominal muscles, while the muscle wall has a chance to heal itself.
‘I’m trying to promote that by exercising and keeping my weight down. If it were to become strangulated, I am sure emergency treatment would be successful.
‘But if other men are in pain and want surgery, of course they should have it.’