Why does sneezing hurt so much?
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Dr Martin Scurr has been treating patients for more than 30 years and is one of the country's leading GPs. Here he answers your questions...
I have a slightly strange symptom - from time to time when I cough or sneeze I get an intense pain in my groin - as if a muscle is going into spasm. I also have a dull ache in that area most of the time. My GP couldn't find anything, so do you have any idea what it might be?
Sally Brooks, by e-mail
Dr Scurr says... This symptom is not as unusual as you might think. I believe your pain could be due to a hernia - when part of the intestine slips through a weakness in the abdominal wall.
Most commonly this occurs in the inguinal canal - essentially a tube that runs from the abdominal muscle to the groin, forming the crease. There are two inguinal canals, one running down the right side, one on the left. they are only about 4cm long (less than 2in) - in men they convey the spermatic cord (which carries sperm cells up from the testes to the prostate and then the penis); in women, it's the 'round' ligament, which is part of the system for supporting the uterus.
A weakness in the abdominal muscle can be something you are born with or you develop with age, obesity or even as a result of injury. A hernia occurs when increased pressure in the abdomen causes a section of the bowel or other tissue to protrude through this weakness. This pressure can be caused by coughing, sneezing, laughing, heavy lifting or, somewhat bizarrely, playing a wind instrument. And, as a result, leads to the pain you describe.
Inguinal (groin) hernias are common, affecting more than 100,000 Britons every year, particularly men. The hernia is usually only obvious when standing up, or coughing or straining. The bulge tends to disappear when the 'spilled' abdominal contents aren't under pressure, such as when lying down.
A doctor can usually diagnose this type of hernia by placing a finger over the site and asking you to cough. Doing this will enable them to feel a localised pressure or bulge; but an ultrasound scan is better proof, as the early hernia can actually be seen, trying to push its way through.
Hernias are treated by surgical repair, usually under general anaesthetic, with full recovery expected after four weeks or so. Modern surgical techniques minimise the recurrence rate, though this does occasionally occur as the repair is only as good as the muscles the surgeon is dealing with.
If I'm wrong and a hernia is not the cause, a second possibility is something known as Gilmore's Groin - described by eminent contemporary surgeon, Jerry Gilmore.
This is a tear of the adductor muscles, which are found at the top of the inner thigh. It is occasionally called a sportsman's hernia due to its prevalence among footballers, though it is strictly not a hernia: symptoms include pain on coughing or sneezing, and groin pain triggered by running, twisting, or turning.
Most importantly you don't have to be a sports enthusiast to get this - it could be caused by an awkward moment with a vacuum cleaner. This should be treated conservatively with strengthening exercises for the pelvic muscles. This is best conducted under the care of a physiotherapist, but if this fails then a surgical procedure is necessary to repair the torn muscle, followed by a six-week period of rest.
Either way, I recommend you discuss the symptom with your GP again; an investigation by ultrasound scan might be recommended, and if this fails to reveal an early hernia then ask for a referral to a specialist surgeon or sports injury physician.
I have a quarter-inch spot just below my lower lip, which has been diagnosed as a Campbell de Morgan spot. Unfortunately it bleeds for no apparent reason - in bed while asleep or walking down the road - and my GP has said nothing can be done. Shaving in the vicinity of the spot is impossible. The only advice has been to use a special type of liquid skin plaster at night to prevent the spot bleeding on the bed linen. Is there really nothing that can be done?
James Smith, Chatham, Kent
Dr Scurr says... How frustrating! I don't believe that you have been given the best option with regards to managing this skin lesion. I believe the spot should be removed.
Campbell de Morgan spots are harmless, cherry-red lesions that occur on the skin in middle age, and don't blanch on pressure. The cause is unknown but they consist of a knot of dilated capillaries and microscopic veins creating a tiny bulge on the surface of the skin. Typically, they occur on the trunk and extremities, so one just below your lower lip is rather unusual, though I do see them occasionally on the face. What we can say for sure is that we all get them, and the older you are the more you acquire.
As they are harmless, painless, and never get bigger than about 8mm in diameter, there really is no need to remove these spots. The only time this might be warranted would be for cosmetic reasons, which is, perhaps, why the NHS does not feel a responsibility here.
Write to Dr Scurr
To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email drmartin@dailymail.co.uk - including contact details.
Dr Scurr cannot enter into personal correspondence. His replies cannot apply to individual cases and should be taken in a general context. Always consult your own GP with any health worries.
But I suggest that the reason the spot on your face keeps bleeding is that it's been traumatised by shaving and now the mere stretch of a smile, or brush of a bedsheet is enough to catch it. For this reason you definitely have a non-cosmetic reason for removal, and I've no doubt that a dermatologist or a plastic surgeon would agree. The process itself is simple. First, a tiny quantity of local anaesthetic is injected into the skin beneath the spot, then it is either cut away or destroyed by cautery (hot wire burning).
Another method is using a hyfrecator - a low-powered device that emits high-frequency electrical pulses through a small probe touched on to the spot. This coagulates the capillaries and destroys the tissue. The residual mark would lead to a small pink patch within days and fade to be almost invisible in a few months. I'd ask your doctor to refer you to the local dermatology department so as to be relieved of this troublesome lesion.
By the way... My fear is GPs will take the money and run
So what are patients to make of the massive shake-up of the NHS announced last week? The biggest change is the scrapping of Primary Care Trusts over the next three years, handing over the responsibility for purchasing investigations and treatment to GPs.
GPs are now going to be the ones with the cheque book. At last we will be able to get rid of the nonsense and wasteful bureaucracy of the internal market - where hospitals had to fight to get contracts from PCTs (the massive bureaucracy to govern it all meant that the presumed savings were mopped up in administrative expenses).
This is good news for patients as GPs are better placed than bureaucrats in judging your needs, making choices about what treatment is needed - we can say goodbye to the days of decisions being forced upon your doctor, when availability of care was often restricted by the demands of a target-driven culture. My worry, however, is that public confidence in GPs - what they do and can achieve for them - is not great at present.
Blame the 2004 contract and the way most GPs chose to opt out of 24-hour care, abandoning their patients to the mercies of NHS Direct. Furthermore, the precious concept of continuity of care has faded - so often patients complain they can never see the GP of their choice.
These concerns, and this lack of confidence, need to be redressed. But how this will be achieved in the new era remains to be seen. However, I fear this might not be GPs' priority.
It does not surprise me that the Chairman of the Council of the British Medical Association - the nearest thing the doctors have to a trade union - says the new plans have filled the doctors with a mixture of feelings - consternation, dread, even anger.
But whatever happens, GPs need to work with the government and not against, as they are being handed a great opportunity - to save money, to re-establish the pre-eminence of the NHS in the world, and to restore the confidence of all patients by improving their experience of healthcare, whether it's an acute emergency, the daily management of minor illness, the long-term care of the chronically ill, or end-of-life care at home.
Along with good communication between doctors and patients, confidence of the public in their GPs is one of the most important ingredients of the health service - and once the family doctors hold the budget to pay for secondary care that confidence will swing one way or the other. I hope it goes well.
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