The Prevalence of Inguinal Hernia Among Athletes in Saudi Arabia: A Cross-Sectional Study

Introduction An inguinal hernia is the most common type of hernia. It might manifest as a groin bulge, lump, or enlarged scrotum. Swelling may be uncomfortable and painful and even cause intestinal obstruction. This study aimed to measure the prevalence of inguinal hernia among athletes in Saudi Arabia. Subject and methods This is a cross-sectional study conducted among Saudi Arabian athletes. A self-administered questionnaire was distributed among athletes using an online survey through different Saudi Olympic Training and Fitness Centers throughout the kingdom. The questionnaire includes sociodemographic characteristics (i.e. age, gender, etc.), risk factors, and complications of inguinal hernia. Results Of the 594 athletes, 55.6% were females and 57.6% were aged between 18 and 24 years. The most common type of sport was running (31%). The most common risk factor for inguinal hernia was previous abdominal surgery (57.5%). The prevalence of inguinal hernia among Saudi athletes was 12.3%. Being older in age and being male were the independent significant predictors associated with increased risk for inguinal hernia, whereas weightlifting was the independent significant factor of decreased risk for inguinal hernia. Conclusion The prevalence of inguinal hernia among athletes was 12.3%. Older male athletes were most likely at a greater risk to suffer from inguinal hernia as compared to the rest of the athletes. Further research is needed to extract more data about the prevalence of inguinal hernia among Saudi Arabian athletes and determine its risk factors.


Introduction
The most common type of hernia is an inguinal hernia. It might manifest as a groin bulge, lump, or enlarged scrotum. Swelling may be uncomfortable and painful, and even cause intestinal obstruction [1]. The lump usually bulges while lifting anything and goes away when lying down. An inguinal hernia often develops near the top of the inner thigh when fatty tissue or a portion of the bowel, such as the intestine, pushes through into the groin, and it enters a region known as the inguinal canal by pushing through a weak area in the surrounding muscle wall.
Inguinal hernia repair is one of the most commonly performed surgery worldwide [2]. It affects 220 million individuals and is one of the most prevalent surgical procedures globally. Most inguinal hernia cases are seen in men [3]. Risk factors include straining on the toilet while constipating or pulling large weights, as these actions create pressure on the abdomen and can cause inguinal hernias to emerge abruptly.
Inguinal hernia problems cause approximately 40,000 fatalities annually and a loss of 3,500,000 years of life due to incapacity [4]. An inguinal hernia may result in obstruction in which a portion of the intestine gets stuck in the inguinal canal and cause pain in the groin, nausea, and vomiting. Additionally, it can cause strangulation. During a case of strangulation, a portion of the intestine gets caught, cutting off its blood supply; this situation necessitates immediate emergency surgery to free the trapped tissue and re-establish its blood supply so that it does not perish.
However, an inguinal hernia might develop from a sports hernia [5]. A sports hernia, also known as athletic pubalgia, is a disorder characterized by persistent supra-inguinal groin discomfort brought by activity that is connected to a developing direct inguinal wall bulge whenever the abdominal muscles contract strongly.
Since these disorders are relatively frequent among athletes, excessive physical activity is considered the etiological cause. A more significant risk exists among athletes with a history of groin injuries, older athletes, players who take off time from competition, and athletes who specialize in sports that use only a portion of their muscles [6]. Inguinal hernia is a common source of pain in athletes [7].
Our study aims to fill the knowledge gaps regarding the prevalence and possible risk factors for hernias among athletes in Saudi Arabia.

Materials And Methods
This cross-sectional study was performed among athletes diagnosed with inguinal hernias in Saudi Arabia. All Saudi male and female athletes above the age of 18 who had been diagnosed with inguinal hernia were included in the study. On the other hand, non-Saudis, non-athletes, and individuals under 18 were not included in this research. The participants were randomly selected from athletes diagnosed with an inguinal hernia by physicians in Saudi Arabia between September 25 and November 25, 2022. The sample size was determined using the Raosoft sample size calculator (Raosoft Inc., Seattle, Washington, United States), and a total of 385 athletes were required to achieve a 95% confidence interval with a 5% margin of error.

Data collection tools and method
We used a self-structured Arabic questionnaire consisting of three sections, including an informed consent page with all the information about the study. The first section of the questionnaire was for sociodemographic information, the second section was for the past medical history of the participants, including a list of risk factors for developing an inguinal hernia, and the last section was for detailed information about the hernia.
Our questionnaire was drafted in English and then translated into Arabic by two independent experts. One was outside the medical field and the second was in the medical field. The questionnaire was validated first by expert evaluation. Content validity and face validity were established by the expert's evaluation. Then a pilot study was done that included 38 responses. We evaluated the internal consistency using Cronbach's α coefficient. A coefficient of 0.7 and above was indicative of good internal consistency.
The questionnaire was distributed online using Google Forms (Google LLC, Menlo Park, California, United States) and sent to the Saudi Olympic Training Centers around the kingdom, in addition to fitness centers. All participants were informed that no indentification would be necessary and that the data would be kept secure with only authorized access.

Ethical considerations
The Internal Review Board for Ethics in Research on Living Creatures at Imam Muhammad bin Saud Islamic University, Riyadh, Saudi Arabia approved the study (Approval number: 323/2022)

Statistical analysis
Descriptive statistics were summarized as numbers and percentages for all categorical variables. The prevalence of inguinal hernia was compared with the sociodemographic characteristics of the athletes by using the Chi-square test. Significant results were then gathered and tested in a multivariate regression model to determine the independent significant factors associated with inguinal hernia where the odds ratio, as well as 95% confidence interval, were also reported. A P-value of 0.05 was considered statistically significant. All data analyses were performed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States).

Results
A total of 594 athletes were involved; 57.6% were aged between 18 and 24 years with more than half (55.6%) being females. Table 1 presents the sociodemographic characteristics of the athletes. Approximately 43.8% were living in the western region. The most common type of sport associated with the athletes was running (31%), followed by weightlifting (29.8%) with 38.2% practicing the sport for one to two hours per week. The prevalence of inguinal hernia among the study participants was 12.3% ( Figure 1).

FIGURE 1: Prevalence of inguinal hernia among athletes
The characteristics of the athletes with inguinal hernia (n=73) are given in Table 2

TABLE 2: Risk factors and complications of inguinal hernia among athletes (n=73)
We used the Chi-square test to measure the influence of inguinal hernia in terms of sociodemographic variables ( Table 3). It was observed that the prevalence of inguinal hernia was significantly more common among the older age group (p<0.001), the male gender (p<0.001), and those who do boxing (p<0.001).

Factor
Inguinal Hernia P-value § Yes N (%) (n=73) No N (%) (n=521)  In a multivariate regression model ( Table 4), it was found that the older age group and male gender were the independent significant factors associated with an increased risk of inguinal hernia while weightlifting was the sole independent significant predictor of a decreased risk of inguinal hernia. This further suggests that compared to the younger age group, the risk of having an inguinal hernia was likely to increase among older athletes by at least 3.46 times (adjusted OR (AOR) 3.

Discussion
This study investigated the prevalence of inguinal hernia among Saudi Arabian athletes. The prevalence of inguinal hernia among athletes was 12.3%. This prevalence is consistent with the report of Ohene-Yeboah et al. [8]. The prevalence of untreated inguinal hernia among adult men in Ghana was 10.8% while in a study by Williamson et al. [9], 14 % of patients reported a single strenuous event (SSE) concomitant with the onset of hernia. Of them, only 5% reporting a hernia associated with SSE met published criteria for the association of the hernia with SSE, representing less than 1% of all patients treated for inguinal hernia in a one-year period at a single center. However, in the Arar region, among patients with an abdominal hernia (11.7%), the prevalence of inguinal hernia cases was 27.3%, and other detected cases were para-umbilical hernia (33.9%) and umbilical hernia (20.8%) [10]. In Brazil, the presence of an inguinal hernia was detected in 20.9% of patients [11], which was higher than our report. More investigation is required to ascertain the prevalence range of inguinal hernia among individuals who are engaged in strenuous activities.
The risk of inguinal hernia was more associated with the older age group (age ≥25 years). This result has also been proven across the literature wherein increasing age is correlated with an increased risk for inguinal hernia [8,[12][13][14]. Khalaf also documented that even though most of the patients were aged more than 40 years, their BMI was estimated to be in the normal range and most of the patients had chosen hernia repair. where 12% developed postoperative complications [14]. In our study, although the majority were in the normal BMI range, however, this did not reach a statistical significance (p=0.441).
Likewise, in our multivariate regression estimates, male athletes were predicted to have an approximately three times higher risk of inguinal hernia than female athletes. This mirrored the studies conducted by AhmedAlenazi et al. [10] and Iqbal et al. [15]. Both studies reported that the prevalence of hernia-related disease was higher in males than in females. In Sierra Leone, reports indicated that the major burden for the male population in Sierra Leone was groin masses [16]. Hence, citing problems with the cost, the author concluded that improving access to surgical care for adult patients with hernias and early intervention for children are needed to address the burden of disease and prevent complications or limitations of daily activity.
Despite a positive association between inguinal hernia among gender and age, in terms of the type of sports, our results suggest that compared to athletes who played other sports (i.e. swimming, basketball, and volleyball), the risk of inguinal hernia among athletes who were engaged in weightlifting was significantly less likely. However, a greater effect was seen in athletes who played football even though the effect of football on inguinal hernia in the adjusted model did not reach statistical significance (p=0.536). Thus, this result is subjected to further investigation to determine the true effect of the type of sports in relation to inguinal hernia. In Nigeria [17], research revealed that the significant predictors of inguinal hernia were strenuous work activities and a positive history of hernia. These findings were also shown in our results. Accordingly, we established that family history (42.5%), previous abdominal surgery (57.5%), history of abdominal trauma (41.1%), chronic cough (43.8%), chronic constipation (47.9%), and smoking (45.2%) were risk factors for inguinal hernia in athletes. Respondents living in the Al-jouf region seem to have a better awareness of the risk factors for developing a hernia [18]. Based on the reports, the subjects knew that heavy lifting (89.5%), pregnancy (88.5%), previous surgery (86%), constipation (81%), asthma (59%), enlarged prostate (41%), and smoking (40%) were all risk factors for a hernia, and their overall knowledge regarding hernia risk factors was either very good (38%) or good (36%).
Conversely, among athletes with inguinal hernia, the prevalence of those who suffered complications due to inguinal hernia was 43.8% and that of those who complained of pain during sports was 54.8%. Hence, 61.6% of them underwent surgical intervention for the management of the disease. This is almost consistent with the study of AhmedAlenazi et al. in which 20.2% experienced complications [10]. Approximately 47.5% of patients underwent surgical procedures while others preferred conservative treatment instead (47%). In Brazil, patients' treatment duration ranged from one month to 12 months; however, the rates of patients who came back to play sports were relatively higher at 95.2% [11]. These numbers concurred with the study done in Italy [19]. The study documented that the duration to return to full sports activity was approximately one month (94.4%) and at 9 months, 98.5% of the patients were active. On 13 years of follow-up, the study reported a recurrence rate of 2.5%.

Limitation
There is a potential for recall bias in our survey as the data were collected through self-reported questionnaire.

Conclusions
The prevalence of inguinal hernia among athletes was 12.3%. Older male athletes were most likely at a greater risk to suffer from inguinal hernia as compared to the rest of the athletes. The initiatives of government Olympic centers are imperative to monitor those athletes who were at greater risk for developing hernias. This may help in early detection and treatment; thereby reducing the prevalence and worst-case scenario of this condition. Further research is needed to extract more data about the prevalence of inguinal hernia among Saudi Arabian athletes and determine its risk factors.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Internal Review Board for Ethics in Research on Living Creatures at Imam Muhammad bin Saud Islamic University, Riyadh, Kingdom of Saudi Arabia issued approval 323/2022. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.