American Journal of Epidemiology Vol. 146, No.

9
Copyright © 1997 by The Johns Hopkins University School of Hygiene and Public Health Printed in U.S.A.
All rights reserved

Risk Factors for Inguinal Hernia in Women: A Case-Control Study

Mike S. L. Liem,1 Yolanda van der Graaf,2 Reinder C. Zwart,1 Ingrid Geurts,1 and
Theo J. M. V. van Vroonhoven1 on behalf of the Coala Trial Group3

Potential risk factors for inguinal hernia in women were investigated and the relative importance of these
factors was quantified. In women, symptomatic but nonpalpable hernias often remain undiagnosed. However,
knowledge on this subject only concerns hernia and operation characteristics, which have been obtained by
review of case series. Virtually nothing is known about risk factors for inguinal hernia. The authors performed
a hospital-based case-control study of 89 female patients with an incident inguinal hernia and 176 age-
matched female controls. Activity since birth with two validated questionnaires was measured and smoking
habits, medical and operation history, Quetelet index (kg/m2), and history of pregnancies and deliveries were
recorded. Response for cases was 81 % and for controls 73%. Total physical activity was not associated with
inguinal hernia (univariate odds ratio (OR) = 0.8, 95% confidence interval (Cl) 0.6-1.1), but high present sports

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activities was associated with less inguinal hernia (multivariate OR = 0.2, 95% Cl 0.1-0.7). Obesity (Quetelet
index >30) was also protective for inguinal hernia (OR = 0.2, 95% Cl 0.04-1.0). Independent risk factors were
positive family history (OR = 4.3, 95% Cl 1.9-9.7) and obstipation (OR = 2.5, 95% Cl 1.0-6.7). In particular,
smoking, appendectomy, other abdominal operations, and multiple deliveries were not associated with
inguinal hernia in females. The protective effect of present sports activity may be explained by optimizing the
resistance of the abdominal musculature protecting the relatively small inguinal weak spot in the female. The
individual predisposition for inguinal hernia may be quantified by these risk factors, and, with this in mind, the
authors advise that further evaluation might be needed for the patient with unexplained inguinal pain. Am J
Epidemiol 1997;146:721-6.

family characteristics; hernia, inguinal; obesity; physical fitness; sports; women's health

Inguinal hernia in females, although not as common
as in males, still results in an appreciable number of
operations yearly. For instance, in the Netherlands in
1994, there were approximately 3,500 operations for
inguinal hernia in females out of a total of 33,000
operations (1). Reports of case series of female ingui-
nal hernia, and that have been mostly uncontrolled and
retrospective, have emphasized the different, but fa-
vorable, stronger inguinal anatomy in females (2-4).
Received for publication January 13, 1997, and accepted for
publication June 26, 1997.
Abbreviations: Cl, confidence interval; OR, odds ratio.
1
Department of General Surgery, University Hospital Utrecht,
Utrecht, The Netherlands.
2
Department of Epidemiology & Public Health, University of
Utrecht, Utrecht, The Netherlands.
3
The members of the Coala Trial Group are as follows: W. S.
Meijer, St. Clara Hospital, and R. U. Boelhouwer, Ikazia Hospital,
Rotterdam; G. J. Clevers, Diakonessenhuis, and Y. van der Graaf,
M. S. L. Liem, A. J. P. Schrijvers, and Th. J. M. V. van Vroonhoven,
University Hospital, Utrecht; J. P. Vente, Hofpoort Hospital, Woer-
den; and L. P. S. Stassen, C. J. van Steensel,* and W. F. Weidema,*
Reinier de Graaf Gasthuis, Delft, The Netherlands. (*Presently at the
Ikazia Hospital, Rotterdam, The Netherlands.)
Reprint requests to Dr. M. S. L Liem, Department of General
Surgery, G04.228, University Hospital, P.O. Box 85.500, 3508 GA
Utrecht, The Netherlands.
Indeed, this explains the lower incidence in females,
but it does not explain why some females do acquire
an inguinal hernia.
Inguinal hernias can either be congenital or ac-
quired. In predominantly male populations, the risk
factors that have been found to be associated with
inguinal hernia are muscle deficiency (previous appen-
dectomy or other abdominal operations), physical
stress, intra-abdominal pressure (obstipation and pros-
tatism), smoking, aging, pelvic fractures and trauma,
connective tissue disease, and systemic illnesses (5-10).
In females, obesity, pregnancy, and operative pro-
cedures have been shown to be risk factors that com-
monly contribute to the formation of inguinal hernia
(11). However, to our knowledge, all of these risk
factors have never been quantified. Therefore, to study
these alleged risk factors, we performed a hospital-
based case-control study with incident female cases in
six hospitals in the Netherlands.
MATERIALS AND METHODS
Cases and controls
The trial-bureau of a large multicenter prospective
randomized trial comparing laparoscopic and conven-

721
722 Liem et al.
tional inguinal hernia repair collected and registered
all incident female cases of inguinal hernia in the six
participating hospitals between January 1994 and
November 1995. These hospitals were representative
of the different hospital types in the Netherlands in
order to enhance generalizability (12).
An inguinal hernia was diagnosed by two experi-
enced physicians and was defined as a clinically de-
tectable swelling in the groin or a clearly palpable
defect of the abdominal wall in the groin. For all cases,
an operation report was obtained to confirm diagnosis
to exclude uncertainty. Inclusion criteria for cases
were written informed consent and age between 20
and 80 years. Patients who were mentally incompetent
or unable to speak and understand Dutch were ex-
cluded.
Controls were selected from females who visited the
outpatient surgical clinic for excision of common be-
nign tumors of the skin unlikely to confound a com-
parative analysis, such as sebaceous and epidermal
cysts, fibromas, seborrheic warts, cutis pendulas, and
lipomas. Each of these women had a minor, elective
operation carried out as an outpatient. Individuals who
have had an inguinal hernia in the past were excluded.
Two controls were matched to one case for hospital,
age (within 5 years), and time of surgical intervention
(in the same month). Controls also needed to give
informed consent, and they were excluded if they were
mentally incompetent or were unable to speak Dutch.
Identified cases and controls were approached by
mail by the surgical attendants at least 6 weeks after
the operation, when they were completely recovered.
The purpose of the study was explained in writing and
the women were asked for their cooperation in filling
out a questionnaire. Individuals who did not respond
were sent a reminder after an interval of 6 weeks.
Variables
All variables were collected after informed consent
of the individual by both hospital record and question-
naire, which could be returned by prepaid mail.
In all participants, we recorded age, height, weight,
and socioeconomic status by both education and part-
ner education. Smoking history and habits were re-
corded with a questionnaire used by Rookus and van
Leeuwen (13). History of operations (particularly ab-
dominal operations) and medical history, including
pregnancies, miscarriages, deliveries, and number of
children, were also recorded. We specifically asked for
obstipation, defined as infrequent or difficult evacua-
tion of feces with sufficient discomfort to seek medical
attention. Furthermore, we asked for obstructive pul-
monary and urinary tract disease, trauma of the ingui-
nal region or lower abdomen, fractures of the pelvis,
connective tissue disease, and family history for in-
guinal hernia, including gender and relation with the
family member.
Lifetime physical activity was estimated with two
validated questionnaires with the questions written in
Dutch (14, 15). Physical activity was measured with
the Baecke questionnaire (14, 16). This questionnaire
estimates recent, present activity in three categories:
work, sports activity, and leisure time. Additional
leisure-time activity questions were added, and the
entire questionnaire recently underwent a validation
(16). For each category, high activity was represented
by the maximum score of 5, and low activity by the
minimum score of 1. A total activity index was cal-
culated by adding the three separate scores (16). Work
activity in the past was estimated with four categories
(i.e., sedentary, standing, labor, heavy labor) using
examples for both activity level and job type (17).
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Furthermore, time of exposure of both present and past
work activity was recorded. Sports and leisure-time
activity in the past was also measured (18). For both
categories, high activity was represented by the max-
imum score of 12, and low activity by the minimum
score of 3.
All participants were again contacted by phone and
interviewed by an experienced interviewer to check
the validity of the answers and to obtain missing
answers. The duration of the telephone call was mea-
sured in minutes. In addition, the subject's knowledge
of the hypotheses of this study was questioned and an
evaluation was made of whether this knowledge had
any influence on recall of exposure (19).
Statistical analysis
All analyses were planned beforehand because risk
factors under investigation were reported to be asso-
ciated with inguinal hernia. Past work, sports, and
leisure-time activities were analyzed separately. Age
was separated into four age groups (20-34, 35-49,
50-64, and 65-80 years) and Quetelet index (kg/m2)
into three categories (<25, >25 to <30, and >30).
Odds ratios with 95 percent confidence intervals were
used to estimate the relative risks for cases compared
with controls. Initial analyses were done with Stu-
dent's f-test for continuous, normally distributed data
or with the Mann-Whitney U-test if not normally
distributed. If a significant difference was found in a
continuous variable (for instance, an index for activi-
ty), the variable was divided into four groups by
quartiles and used for further analyses. Unmatched,
unadjusted odds ratios and their corresponding 95
percent confidence intervals were calculated with the
use of SPSS for Windows 6.0 (SPSS, Inc., Chicago,
Illinois), and, if a significant association was found,
Am J Epidemiol Vol. 146, No. 9, 1997
 Risk factors for Inguinal Hernia in Women 723

matched, unadjusted odds ratios were calculated. A p TABLE 1. Percentage distributions of selected baseline
value of <0.05 was considered statistically significant, characteristics and mean height and weight of cases
and controls in a hospital-based case-control study of
and all p values were calculated two-sided. inguinal hernia in women, the Netherlands, January 1994
Significant univariate correlates found with matched to November 1995
(i.e., conditional) logistic regression were entered into
Cases Controls
a multivariate conditional logistic regression analysis Characteristic (n = 72) (n=125)
to correct for the simultaneous effects of covariates Age category (years) (%)
(EGRET version 1.02.07, 1995, Statistics and Epide- <35 9.7 9.7
miology Research Corp. and Cytel Software Corp., >35-:50 33.3 32.0
Seattle, Washington). In addition, other variables >50-<65 23.6 30.4
>65 33.3 28.0
whose univariate test had a p value of <0.25, or Height in cm (SD*) 167(7) 166 (6)
variables which were of alleged biologic importance, Weight in kg (SD) 67(11) 69(11)
were also included in the model. For model building, Education (%)
we applied backward stepwise elimination of variables None 1.4 1.6
Elementary 40.3 52.8
(20). Adjusted odds ratios with their 95 percent con- Secondary 54.2 42.4
fidence intervals were derived from the estimated re- University 4.2 3.2
gression coefficients. Marital status (%)
No partner 20.8 14.4

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RESULTS
After exclusion of patients who did not fulfil the
inclusion criteria, 89 eligible cases were identified as
well as 176 controls who met the matching criteria.
For two of the cases, only one matched control could
be identified. Questionnaires were sent to all the se-
lected cases and controls, but only 72 cases (81 per-
cent) and 129 controls (73 percent) returned the ques-
tionnaires. From these 129 controls, 106 could be
matched to a respondent case, creating 34 case-control
triplets and 38 case-control pairs. Nineteen of 23 re-
maining controls could be matched to cases who only
had one control, if we only matched for age and
operation date. In this way, we obtained 53 case-
control triplets and 19 case-control pairs, leaving four
unmatched controls. The characteristics of the 72
cases and 125 controls are shown in table 1.
Fifty-five cases underwent surgery for a primary
hernia (76 percent); 17 patients had undergone a pre-
vious hernia repair in the past (i.e., had a recurrent
hernia), 14 with a first recurrent hernia (19), two a
second recurrent hernia, and one a third recurrent
hernia. In three out of 72 operations (4 percent), a
bilateral repair was done. The remaining operations
were performed for an inguinal hernia on the left side
in 36 cases (50 percent), and in 33 cases for a hernia
on the right side (46 percent). There were 30 direct
hernias and 39 indirect hernias; in two cases, this was
unclear and a femoral hernia was also suspected. One
case did not have her hernia repaired, so we were
unable to confirm the hernia type. Sixteen cases had
undergone a previous appendectomy, but in only four
cases was this associated with a right inguinal hernia
and in only two cases was it associated with a bilateral
inguinal hernia.
Partner 79.2 85.6
Education of partner (%)
None 0 0.8
Elementary 37.5 45.6
Secondary 30.7 30.4
University 11.1 8.8
* SD, standard deviation.
All individuals included in our analysis were con-
tacted by telephone, and the duration of the telephone
call was similar between cases and controls. The tele-
phone interview did not show different responses on
questions compared with the written answers, but
more cases than controls reported high activity than
controls (54 percent vs. 32 percent), which might
indicate a relation between high activity and inguinal
hernia.
Activities in the past and present activity during
work were not associated with inguinal hernia, and the
latter association remained absent if duration of this
work was taken into consideration. Activity and body
mass index in the control group compared well with
those of another study of women representative for the
general Dutch population (16). No relation with ingui-
nal hernia was found for any type of abdominal oper-
ations or for pregnancy. Present sports activity and
climbing stairs were associated with decreased risk of
having an inguinal hernia. Other factors associated
with inguinal hernia were positive family history for
inguinal hernia and obstipation (table 2). Thus, four
possible risk factors were identified. Furthermore, we
added variables which were shown by univariate test
to have a p value of <0.25, i.e., obstructive urinary
tract disease, umbilical hernia operation, pelvic frac-
tures, Quetelet index, and present total activity index
(table 2). Finally, education and education of the part-
ner were included as possible confounders in a multi-

Am J Epidemiol Vol. 146, No. 9, 1997

724 Liem et al.

TABLE 2. Potential risk factors in cases and controls in a hospital-based case-control study of
inguinal hernia in women, the Netherlands, January 1994 to November 1995

Risk Median (interquartile range)

P
factor Cases Controls value*

Present activity
Present work activity index 2.9 (2.6-3.2) 2.9(2.6-3.1) 0.6 (NSt)
Duration present work (years) 26 (17-43) 30(12-43) 1.0 (NS)
Duration x present work activity 86.9 (43.6-118. 1) 86.6 (36.3-123.5) 1.0 (NS)
Present sports activity index 2.0(1.8-2.5) 2.3(1.8-2.8) 0.02
Present leisure-time activity index 2.9 (2.7-3.3) 3.0 (2.6-3.3) 1.0 (NS)
Present total index (work + sports + leisure
time) 8.0 (7.2-8.5) 8.1 (7.3-9.0) 0.15 (NS)
Climbing stairs/day (no.) 7(3-11) 10(5-12) 0.03
Past activity
Past work activity index 1(0-3) 2(0-3) 0.9 (NS)
Duration past work (years) 5(0-11) 6 (0-10) 0.5 (NS)
Duration x past work activity 6 (0-24) 12(0-25) 0.4 (NS)
Past sports activity index 6(4-8) 6(4-8) 0.5 (NS)
Past leisure-time activity index 8(6-9) 8(6-9) 0.8 (NS)
23.9 (22.0-25.8) 24.8 (22.8-27.6)

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Quetelet index (kg/m*) 0.06 (NS)
Children (no.) 2(1-3) 2(1-3) 0.5 (NS)
Smoking (pack-years) 1.4(0-12.0) 2.5 (0-9.8) 0.6 (NS)

% yes Crude
Risk
95% Clt
factor Cases Controls ratio*
Miscarriage 0 1 0.9 0.4-1.7
Children 81 82 0.9 0.4-1.9
Twins 3 3 0.9 0.2-4.8
Inguinal hernia in family 44 19 3.4 1.8-6.4
Positive female family member 13 2 8.8 1.8-41.9
Smoking 25 26 0.9 0.5-1.8
COPD 6 5 1.2 0.3-4.3
Urinary tract obstruction 7 3 2.3 0.6-8.7
Obstipation 31 18 2.0 1.0-3.8
Trauma 1 2 0.6 0.1-5.6
Pelvic fracture 3 1 3.5 0.3-39.8
Abdominal operations (%) 44 53 0.7 0.4-1.3
Umbilical hernia (%) 4 1 5.4 0.6-52.8
Cicatrical hernia (%) 3 2 1.8 0.2-12.7
Appendectomy (%) 22 22 1.0 0.5-2.1
Cholecystectomy (%) 6 10 0.5 0.2-1.6
Bowel operation for carcinoma (%) 6 6 0.9 0.2-3.0
* p values and odds ratios were calculated by unmatched analyses.
t NS, not significant; Cl, confidence interval; COPD, chronic obstructive pulmonary disease.

variate conditional model. The remaining factors were
Quetelet index, obstipation, present habitual sports
activity index, and family history of inguinal hernia,
and these variables provided the most stable model
(table 3). Adjusted odds ratios controlling for simul-
taneous effects are shown. A high level of present
habitual sports activity was protective for inguinal
hernia compared with a low level. For instance, fe-
males with a positive family history and high habitual
sports activity may not have an increased risk for
inguinal hernia.
DISCUSSION
This case-control study has studied all potential risk
factors as reported in the literature. The only risk
factors that were found to be independently associated
with inguinal hernia in females were present habitual
sports activity, Quetelet index, defecation pattern, and
family history of inguinal hernia.
These findings are in contrast to the main risk factor
that has been suspected to be associated with inguinal
hernia, namely heavy physical exercise. The stronger
inguinal anatomy in females, as shown by a number of
authors (2, 3, 11), may explain this lack of association.
Heavy physical exercise has been the subject of many
statements and studies in the literature (21, 22). Some
studies have classified occupations into categories for
activity level (21, 23), thereby also assuming similar
standard activity for people with the same occupation.
For instance, all office clerks perform sedentary work.

Am J Epidemiol Vol. 146, No. 9, 1997

 Risk factors for Inguinal Hernia in Women 725

TABLE 3. Adjusted odds ratios for inguinal hernia in women the absence of sports activities coincided with obesity
by major risk factors in a hospital-based case-control study, in the females of this report (11) and this may explain
the Netherlands, January 1994 to November 1995 the opposite finding. In addition, hernias may not be so
Risk
Adjusted easy to diagnose in obese females. Other factors such
odds 95% Clt
(actor
ratio* as pregnancies and abdominal operations were also
No inguinal hernia in family 1-0*
suspected to be risk factors but did not show any
Inguinal hernia in family 4.3 1.9-9.7 relation. Ponka (11) observed the presence of these
factors more frequently in females with inguinal her-
Present sports activity index nia in his uncontrolled case series but did not provide
score
<1.75 1.0*
a statistical analysis.
1.75-2.0 0.8 0.3-1.9 Individual predisposition to inguinal hernia has been
2.0-2.75 0.4 0.1-1.0 claimed in the past mostly on the basis of the various
>2.75 0.2 0.1-0.7 anatomy found in dissection studies (8, 24, 25), but
Quetelet index (kg/rtf)
<25 1.0*
this individual predisposition has not been quantified.
>25, <30 0.7 0.3-1.5 A positive family history may point toward a relatively
>30 0.2 0.04-1.0 weak anatomy and may form the basis for this predis-
position. Spangen (2) and Herrington (4) pointed out
No obstipation 1.0*
that many symptomatic but nonpalpable hernias in

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Obstipation 2.5 1.0-6.7
* Odds ratios were adjusted for all other variables shown in the
table.
t Cl, confidence interval.
* Reference category.
Additionally, these clerks may perform different exer-
cise during leisure-time or sports activities. In this
study, we have thoroughly measured all activities
since birth by using validated questionnaires that es-
timated physical activity during work, sports, and lei-
sure time. Physical activity should also be measured in
this fashion in males to reevaluate this risk factor.
However, some support for chronic increased intra-
abdominal pressure as an etiologic factor for inguinal
hernia may be provided by the association between
obstipation and hernia. This was an independent factor
but did not reach statistical significance.
High habitual sports activity appeared to be protec-
tive for inguinal hernia compared with low habitual
sports activity. An explanation may be the favorable
anatomy in females (2). In females, there is a smaller
musculo-pectineal orifice of Fruchaud, i.e., the weak
spot in the groin where all hernias may occur, and the
abdominal musculature surrounding this weak spot
may be maintained in good shape with controlled
strenuous activity. Muscular stress of the abdominal
musculature may not be so high during work or leisure
time, and this may be a reason for the absence of a
relation between the index of present activity during
work and leisure time with inguinal hernia.
Obesity has been suggested to be a risk factor (11),
but subcutaneous fat is unlikely to influence the
strength of the abdominal wall. Indeed, our study
certainly did not provide evidence that obesity in-
creases risk. On the contrary, obese females appeared
to have some protection for inguinal hernia. Perhaps
females are seldom diagnosed. Moreover, failure to
consider occult inguinal hernia in females with lower
abdominal pain may lead to unnecessary laparotomy
(4). In view of this, the presence of a positive family
history might alert the general practitioner and referral
to a surgeon might be necessary for further evaluation
with ultrasound or diagnostic laparoscopy (26, 27).
There are several problems in case-control studies
which should be addressed and which might affect the
validity of its conclusions. Our cases and controls
were drawn from the same population, and their refer-
ral patterns were similar. Both had undergone minor
surgery, and the cases were referred to closely located
general hospitals in the absence of specialized hernia
centers in the Netherlands. Some potential controls
might have been operated upon by the general practi-
tioner himself, but this is unlikely to be associated
with the exposures under investigation, because not
being referred merely reflects the interest of and com-
petence of the general practitioner. Another issue
might be bias and misclassification, but cases and
controls were not aware of all hypotheses, and the
questionnaires had been validated. Increased activity
was assumed to be associated with inguinal hernia
(24). Recall bias would have resulted in cases overes-
timating their sports activities: cases were more likely
to believe that activity caused hernias when in fact
activity was protective. That could have led to an
underestimation of the protective effect. Also, recall
bias might have played a role in reporting family
history. However, this potential bias may have been
obviated in part by checking the answers of controls
for family history of inguinal hernia by telephone
interview. Cases who gave up activity because of
discomfort of the hernia could have led to an under-
estimation of exposure in cases, and this might explain

Am J Epidemiol Vol. 146, No. 9, 1997

726 Liem et al.
an apparent protective effect of sports activities. How-
ever, all cases with knowledge on this risk factor
stated that they had not changed their sports activity
pattern because of the hernia, and it is unlikely that
this bias could be the sole explanation because most
patients see a physician very soon after discomfort that
limits their activity, and many patients with inguinal
hernia have no discomfort or pain at all (4).
Finally, we examined obesity and socioeconomic
status by both patient and partner education for con-
founding, but this did not change the odds ratios
significantly. In addition, matching for age was suc-
cessful. The last concern may be absence of statistical
power. However, based on available data, we assumed
a standard deviation of 1.1 on the total activity index
score (16), and we calculated that with our sample size
a difference of 0.66 between the mean total activity
score of cases and controls with a two-sided signifi-
cance level of 0.05 and power of 95 percent could
have been detected (28).
In conclusion, our data indicate that high sports
activity and obesity are protective for inguinal hernia
and that positive family history and obstipation are
risk factors for inguinal hernia in females. Particularly
in patients with unexplained lower abdominal pain, the
presence of these factors should prompt the physician
to consider the diagnosis of inguinal hernia.
ACKNOWLEDGMENTS
The authors express their thanks to all administrative
personnel in the department of surgery and department of
records of the participating hospitals for their assistance in
data assessment for this study. They also wish to thank their
colleagues in the Department of Epidemiology, University
Hospital, Utrecht, and in particular Dr. Margreet A. Pols,
Marion Kallewaard, and Dr. Petra H. M. Peeters for useful
discussions on this subject.
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