Sex-Based Differences in Management of Asymptomatic Reducible Inguinal Hernia in Patients Over 60
Yes, there is a clinically significant difference: female patients with inguinal hernias—particularly femoral hernias which are more common in women—face substantially higher complication rates and should proceed to elective repair more urgently than male patients, while watchful waiting remains a reasonable option for minimally symptomatic male patients over 60.
Key Sex-Based Differences
Female Patients: Higher Risk Profile
Female patients have a significantly higher postoperative complication rate (38.5%) compared to male patients (6.4%, p<0.001) when undergoing inguinal hernia repair 1
Femoral hernias are significantly more frequent in females, and these carry a substantially higher risk of intestinal resection due to strangulation and necrosis compared to other hernia types (p<0.005 and p<0.001, respectively) 2
The higher complication rate in females appears related to both the anatomical type of hernia (femoral vs inguinal) and potentially delayed presentation leading to emergency surgery [1, 2
Male Patients: Lower Risk, Watchful Waiting Viable
Inguinal hernias are significantly more frequent in males, and these have lower rates of strangulation compared to femoral hernias 2
In men with minimally symptomatic inguinal hernias, watchful waiting is a reasonable and safe strategy, though 68% will eventually require surgery with longer follow-up (median 3.2 years, maximum 11.5 years) 3
Men older than 65 years crossed over to surgical repair at a higher rate (79%) compared to younger men (62%), suggesting symptoms progress more in older males 3
Only 3 patients required emergency operation during watchful waiting, with no mortality, demonstrating the safety of this approach in selected male patients 3
Clinical Decision Algorithm
For Female Patients Over 60 with Reducible Inguinal/Femoral Hernia:
Recommend elective repair under local anesthesia to avoid the 22.6% complication rate associated with emergency surgery (versus 6.1% for elective surgery, p<0.001) 1
Do not offer watchful waiting given the higher risk of femoral hernia strangulation and the 38.5% complication rate in females [1, 2
For Male Patients Over 60 with Minimally Symptomatic Inguinal Hernia:
Watchful waiting is acceptable if the patient is truly minimally symptomatic, understanding that 68-79% will eventually require surgery 3
Counsel patients that pain is the most common reason for eventual crossover to surgery (54.1% of cases) 3
If elective repair is chosen, perform under local anesthesia when possible, as this is associated with the lowest complication rate and no cardiovascular complications or deaths in geriatric patients 4
Critical Risk Factors Regardless of Sex
Emergency surgery carries significantly higher complication rates (22.6% vs 6.1% elective, p<0.001) and should be avoided through timely elective repair 1
Advanced age ≥65 years, high ASA score (III-IV), concomitant diseases, and time from symptom onset significantly influence morbidity and mortality 2
General anesthesia is a risk factor for morbidity; local anesthesia should be used whenever possible in geriatric patients [2, 4
Common Pitfalls to Avoid
Do not apply the watchful waiting data from male patients to female patients—the evidence base for watchful waiting comes exclusively from studies of men, and females have demonstrated significantly higher complication rates [1, 3
Do not delay elective repair in females with groin hernias, as femoral hernias have the highest rate of strangulation requiring bowel resection 2
Do not use general or spinal anesthesia routinely in patients over 70—all cardiovascular complications and deaths in one geriatric series occurred with these modalities rather than local anesthesia 4