Today I found out why doctors have men “turn their heads and cough” during a physical.

Pretty much all guys have been there at some point or another. The doctor asks you to drop your drawers. They slap on their latex gloves, grab your junk, and ask you to turn your head and cough. One imagines this can’t exactly be the highlight of the doctor’s day, probably ranking up there with the lovely process involved in probing prostates for potential problems. So what exactly are they looking for when they ask you to turn your head and cough? In a word: hernias.

More specifically, they are checking for something called an inguinal (inner groin) hernia, which accounts for about 70%-80% of all hernia cases and is surprisingly common in men and not nearly so much in women (lifetime risk of 27% for men vs. just 3% for women, due to the much smaller opening in women’s superficial inguinal ring than men’s). In fact, inguinal hernia surgery is one of the most common surgeries performed on kids and teenagers. Inguinal hernias happen when certain soft tissue, particularly lower intestines, starts to come through the lower abdominal wall through a small hole or tear in the wall.

So how does grabbing a guy’s balls help the doctor’s check for this? It turns out, they aren’t actually grabbing your balls, as is often eluded to in many a comedic skit. What they are doing is poking their fingers up around the inguinal canal, above the testicles. The inguinal canal runs down about where your leg and torso meet and is also the canal the spermatic cord passes through, attached to the testicles. For women, ligaments pass through this canal to help hold the uterus in place. For both sexes, the ilioinguinal nerve also passes through the inguinal canal.

The inguinal canal has some common weak spots, so doctors are feeling around these weak spots and particularly looking to see if they can feel a bulge or other indications that something is poking through that shouldn’t be, often falling into the scrotum. Besides something in a guy’s scrotum that shouldn’t be, a slight bulge might also be visible around where the upper thigh meets the groin. If either of these things happens, congratulations, you have an inguinal hernia.

As to why the doctor will then have you stand and turn your head and cough, the first part is because the hernia may well disappear when you lay down, with the tissue receding back into your abdominal cavity. The second “turn your head” part is simply for sanitary reasons; it’s bad enough the doctors are having to get eye level with and grab around your scrotum, but they don’t want to also be coughed on (some doctors also may ask you to cover your mouth in addition to or instead of turning your head). As to why they ask you to cough, this creates internal pressure in your abdomen. So if some of your intestines or other soft tissue is protruding through your abdominal wall into your scrotum or if there is an opening that tissue may exploit momentarily when pressure is added, coughing will help the doctor observe these things.

Once found, it used to be common for doctors to immediately recommend that the inguinal hernia be fixed via surgery, in order to avoid potentially life threatening complications, such as if the intestines become strangled, cutting off blood supply and potentially resulting in gangrenous tissue or an infection. However, this has very recently started to change to more of a “let’s keep a close eye on it” approach for many minimal cases, such as very small bulges that don’t cause pain and are “reducible” in that the tissue can be pushed back into the abdomen when pressure is applied or when the person lays down (so here the tissue isn’t being “incarcerated” or “obstructed” and chance of strangulation is minimal).

This recent switch from recommending surgery for everyone who has this to the “keep a close eye on it” approach is because there is only about .2% chance of the inguinal hernia becoming trapped, while 10%-12% of people who have this particularly hernia surgery end up having post-surgery “herniorraphy pain syndrome”, also known as “inguinodynia”, which is basically just chronic groin pain that lasts more than a few months after the surgery was performed. So if the hernia isn’t already causing pain or isn’t too severe in its size, the doctor may well simply recommend a treatment plan, which won’t actually fix it, but will help manage it.

If you liked this article and the Bonus Facts below, you might also like:

Bonus Facts:

Common contributing factors to hernias are: obesity, straining (often from lifting heavy objects; making sure to breathe while you’re straining will help avoid excessive pressure in your abdomen), diarrhea, constipation, pregnancy, sudden weight gain, continual coughing, and a poor diet (particularly lack of fiber). So, as in so many things in life, eat lots of fruits, vegetables, and whole grains, and take steps not to be fat (not just eating less calories, but exercising too) and your quality of life will likely improve dramatically throughout your lifetime to go along with the lesser risk of complications due to a hernia. Also, don’t smoke. Among many other things that are bad for your body about smoking, smoking can cause persistent coughing, which causes extra strain in your abdomen.

Hernias also commonly pop up in abdominal areas where you’ve had surgery, called “incisional hernias”. These are the second most common type of hernia after inguinal. The third most common are femoral (outer groin, most common in women, particularly pregnant or obese women), umbilical (belly button, most common in babies or women who are pregnant, obese, or have given birth to several children), and hiatal (upper stomach, with the tissue(s) protruding through the diaphragm where the esophagus passes through, which can often feel like heartburn, chest pain, or just indigestion).

For teens particularly, doctors may take advantage of the fact that they have their hands near your balls, to do a quick check of your testicles to make sure there aren’t any signs of testicular cancer or other abnormalities. Testicular cancer is the second most common cancer that teenage boys get, so it’s good to check. (Although, it only occurs in about .0003% of teenage boys, so it’s not exactly common, but better safe than dead.) So when checking for these things, they really are grabbing your balls, unlike when they’re checking for a hernia.

Surprisingly, hernias tend to be much more common in babies than in adults. A particularly common one for a newborn is a umbilical hernia, which can cause a bulge around the baby’s belly button. This bulge will be larger when they are straining, such as when they cry. These types of hernias don’t always need fixed though. Often doctors will recommend a “wait and see” approach for umbilical hernias. If they last past a year or so, then surgery is usually recommended.

Most teenagers who get hernias have had the weakness or hole in their abdominal tissue that lets something poke through since birth. It just sometimes takes a bit of time for your internal tissues to exploit this weakness, given the right set of circumstances.

The word “hernia”, originally popping up spelled “hirnia” in the 14th century, comes from the Latin “hernia” meaning “protruded viscus” or “protruding organ”. This is probably from the Proto-Indo-European *ghere, meaning “gut, entrail”.

Expand for References