SPINE Manual of Groin Pain 2016 PDF

Brian P. Jacob David C.
Chen
Bruce Ramshaw Shirin Towfigh
Editors
The SAGES Manual

of Groin Pain
123
The SAGES Manual
of Groin Pain
The SAGES Manual
of Groin Pain
Brian P. Jacob, MD, FACS

Mount Sinai School of Medicine, NY, USA
David C. Chen, MD
Lichtenstein Amid Hernia Clinic at UCLA,
Santa Monica, CA, USA
Bruce Ramshaw, MD, FACS

Transformative Care Institute, Daytona Beach, FL, USA
Shirin Towfigh, MD, FACS

Beverly Hills Hernia Center, Beverly Hills, CA, USA
Editors
Editors
Brian P. Jacob, MD, FACS David C. Chen, MD
Associate Clinical Professor Associate Professor of Clinical
of Surgery, Icahn School Surgery
of Medicine at Mount Sinai Clinical Director,
Partner, Laparoscopic Surgical Lichtenstein Amid Hernia Clinic,
Center of New York Department of Surgery,
Regional Medical Director David Geffen School of Medicine
New York, NY, USA at UCLA
Co-Director, Advanced Hernia Shirin Towfigh, MD, FACS
Solutions at Transformative Care President, Beverly Hills Hernia
Institute Center
Chief Medical Officer, Beverly Hills, CA, USA
Surgical Momentum
Chairman, the Bruce Kennedy
General Surgery Residency
Program at Halifax Health
Associate Clinical Professor,
Florida State University
Daytona Beach, FL, USA
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10.1007/978-3-319-21587-7
ISBN 978-3-319-21586-0 ISBN 978-3-319-21587-7 (eBook)

DOI 10.1007/978-3-319-21587-7
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Foreword
Inguinal hernia repair is one of the most common operations done by

general surgeons in practice today. In the early 1990s, the surgical
approach to inguinal hernias underwent a major transformation from
primary sutured tissue repairs to the widespread use of tension-free
mesh repairs using both open and laparoscopic techniques. The primary
reason for this shift was twofold: (1) there was an unacceptably high
recurrence rate with primary tissue repairs, and (2) the tension-free
approach allowed an earlier return to full and unrestricted activity.
However, this move toward mesh-based repairs has come with a price
that is, a higher rate of chronic or lingering groin pain
post-herniorrhaphy.
The SAGES Manual of Groin Pain provides a comprehensive look at
all aspects of groin pain that might be encountered by a surgeon in prac-
tice. The book is organized into sections according to primary or second-
ary groin pain with chapters on definitions, the various etiologies, and
the approach to diagnosis and management across the spectrum of dis-
orders. It is important to note that not all groin pain is due to a hernia or
occurs post-hernia repair. Of particular interest to the reader in this
regard will be the section on athletic pubalgia or the so-called sports
hernia, which has gained increasing attention in the sports and general
surgery community in recent years and which continues to confound
clinicians who are asked to see these individuals.
The book also takes on several contemporary areas of debate in the
prevention of groin pain post-hernia repair, including the role of biologic
mesh, technical tips and tricks to minimize postoperative pain, and the
role of prophylactic neurectomy. It concludes with a unique section of
case reports that cover the gamut of difficult groin pain scenarios likely
to be encountered as well as patient perspectives on these topics.
Like The SAGES Manual of Hernia Repair that preceded it, The
SAGES Manual of Groin Pain fills an important need in contemporary
v
vi Foreword
hernia practice that will be a valued reference for any surgeon who man-
ages these patients. Drs. Jacob, Chen, Ramshaw, and Towfigh are to be
commended for bringing this work together into one compendium that
should become a mainstay of any hernia surgeons library.
St. Louis, MO, USA L. Michael Brunt, MD

Contents
Part I Primary Groin Pain
1 Introduction to Primary and Secondary Groin Pain:

What Is Inguinodynia? ............................................................ 3
Brian P. Jacob, David C. Chen, Bruce Ramshaw,
and Shirin Towfigh
2 Groin Pain: A Neurologic and Musculoskeletal
Anatomic Review.................................................................... 9
Irmina Anna Gawlas and Warwick J. Peacock
3 Complex Regional Pain Syndrome Types I and II ................. 17
Payam Vahedifar and Evish Kamrava
4 Chief Complaint of Groin Pain: How to Take
and Document a Specific Groin Pain History, Exam,
and What Studies to Order ..................................................... 27
Jacob A. Greenberg
5 Groin Pain: An Overview of the Broad
Differential Diagnosis ............................................................. 41
Charles Ma and Archana Ramaswamy
6 Groin Pain Etiology: The Inguinal Hernia,
the Occult Inguinal Hernia, and the Lipoma .......................... 49
Ibrahim M. Daoud and Katherine Dunn
7 Groin Pain Etiology: Athletic Pubalgia Evaluation
and Management ..................................................................... 59
Gregory J. Mancini
8 Groin Pain Etiology: Hip-Referred Groin Pain ...................... 73
Joshua C. Campbell and Guy D. Paiement
9 Groin Pain Etiology: Spine and Back Causes ........................ 103
Charles H. Li, Victor W. Chang, Irene Wu,
and Daniel C. Lu
vii
viii Contents
10 Groin Pain Etiology: Spermatic Cord

and Testicular Causes.............................................................. 111
Juzar Jamnagerwalla and Howard H. Kim
11 Groin Pain Etiology: Pudendal Neuralgia .............................. 137
Michael Hibner and Catherine Coyne
12 Chronic Pelvic Pain in Women ............................................... 153
M. Jonathon Solnik and Matthew Thomas Siedhoff
13 Imaging for Evaluation of Groin Pain .................................... 173
Joseph M. Miller, Shane D. Smith, David N. Ishimitsu,
and Rola Saouaf
14 Perioperative Pain Management: Multi-modalities
to Prevent Postoperative Chronic Pain ................................... 193
Brian J. Dunkin
Part II Secondary Groin Pain
15 Chronic Groin Pain Following Anterior Hernia Surgery ....... 211

Jennifer S. Schwartz, David S. Strosberg,
and David B. Renton
16 Chronic Groin Pain Following Posterior Hernia Surgery ...... 221
Edward L. Felix
17 The Orthopedic Perspective on Groin Pain:
The Native and Prosthetic Hip................................................ 233
Calin Stefan Moucha
18 Algorithmic Approach to the Workup and Management
of Chronic Postoperative Inguinal Pain .................................. 245
Johan F.M. Lange Jr.
19 Radiologic Evaluation for Postoperative Groin Pain.............. 257
Joseph M. Miller, David N. Ishimitsu, and Rola Saouaf
20 Management of Groin Pain: Interventional
and Pharmacologic Approaches ............................................. 267
Anuj Malhotra
21 Dermatome Mapping: Preoperative and Postoperative
Assessment.............................................................................. 277
Rigoberto lvarez
Contents ix
22 Management of Inguinal Hernia Recurrences

(When Pain Is the Primary Symptom).................................... 293
Keri A. Seymour and Jin S. Yoo
23 Mesh Removal for Chronic Pain: A Review
of Laparoscopic and Open Techniques ................................... 301
Lisa A. Cunningham and Bruce Ramshaw
24 Open Triple Neurectomy ........................................................ 319
Ian T. MacQueen, David C. Chen, and Parviz K. Amid
25 Laparoscopic Triple Neurectomy ........................................... 333
Stephanie A. Kingman, Parviz K. Amid,
and David C. Chen
26 Chronic Orchialgia: Workup and Management ...................... 343
Jamin V. Brahmbhatt, Ahmet Gudeloglu,
and Sijo J. Parekattil
Part III Current Debates
27 The Role of Bioactive Prosthetic Material

for the Treatment of Sports Hernias ....................................... 365
David S. Edelman
28 Prevention of Pain: Optimizing the Open Primary
Inguinal Hernia Repair Technique .......................................... 375
Giampiero Campanelli, Marta Cavalli, Piero Bruni,
Andrea Morlacchi, and Gianni Maria Pavoni
29 Prevention of Pain: Optimizing the Laparoscopic
TEP and TAPP Techniques ..................................................... 389
Jorge Daes Daccarett
30 Prophylactic Neurectomy Versus Pragmatic Neurectomy...... 397
Ryan Berg and Matthew I. Goldblatt
31 Triple Neurectomy Versus Selective Neurectomy .................. 405
Wolfgang M.J. Reinpold and Alexander D. Schroeder
32 Chronic Groin Pain: Mesh or No Mesh.................................. 417
Nathaniel F. Stoikes, David Webb, and Guy R. Voeller
x Contents
Part IV Case Reports and Patients Perspectives
33 Foreign Body Reaction, Fibromyalgia,

and Autoimmune Disorders .................................................... 429
Shirin Towfigh
34 Patient with Groin Pain After an Athletic Event .................... 435
Kent W. Kercher
35 Chronic Post-inguinal Herniorrhaphy Pain:
A Patients Perspective ........................................................... 447
David C. Chen and Brian P. Jacob
36 Sports Hernia with Adductor Tendonitis ................................ 453
Fredrick J. Brody and Jeffrey Harr
37 Patient with Groin Pain After a Plug and Patch
Hernia Repair .......................................................................... 463
Christopher G. DuCoin and Garth R. Jacobsen
38 Patient with Groin Pain After Open Inguinal
Hernia Repair with Mesh ........................................................ 467
Jeffrey A. Blatnik and Ajita S. Prabhu
39 Patient with Groin Pain After a Lichtenstein
Hernia Repair .......................................................................... 473
Shirin Towfigh
40 Patient with Groin Pain After Tissue Repair,
Anterior Approach .................................................................. 479
Shirin Towfigh
41 Right Inguinal Hernia with Osteitis Pubis:
A Case Report of Osteitis Pubis and Ipsilateral
Inguinal Hernia ....................................................................... 483
Naif A. Al-Enazi and Brian P. Jacob
42 Patient with Chronic Pelvic Pain ............................................ 491
Shirin Towfigh
43 Thoracolumbar Syndrome ...................................................... 495
James A. Rydlewicz and Dean J. Mikami
44 Patient with Referred Hip Pain ............................................... 501
Shirin Towfigh
Contents xi
45 Value-Based Clinical Quality Improvement

for Chronic Groin Pain After Inguinal Hernia Repair............ 505
Bruce Ramshaw
46 Patient Care Manager Perspective on Chronic
Groin Pain After Hernia Repair .............................................. 515
Brandie Forman and Bruce Ramshaw
47 Workers Compensation: An Occupational
Perspective on Groin Pain, Including Psychosocial
Variables, Causality, and Return to Work ............................... 523
Joseph S. Pachman and Brian P. Jacob
Index ............................................................................................... 531

Editors and Contributors
Editors
Brian P. Jacob, MD, FACS
Icahn School of Medicine at Mount Sinai, New York, NY, USA
Laparoscopic Surgical Center of New York, New York, NY, USA
David C. Chen, MD
Clinical Surgery, Lichtenstein Amid Hernia Clinic, Santa Monica, CA, USA
Department of Surgery, David Geffen School of Medicine at UCLA,
Advanced Hernia Solutions at Transformative Care Institute, Daytona
Beach, FL, USA
Surgical Momentum, Daytona Beach, FL, USA
The Bruce Kennedy General Surgery Residency Program at Halifax
Health, Daytona Beach, FL, USA
Florida State University, Daytona Beach, FL, USA
Shirin Towfigh, MD, FACS
Beverly Hills Hernia Center, Beverly Hills, CA, USA
Contributors
Naif A. Al-Enazi, MD, MBA
Clinical Fellow of Laparoscopic and Bariatric Surgery, Mount Sinai
Medical Center, New York, NY, USA
Rigoberto lvarez, MD
Hernia Surgery, Proben Centro Especializado en Biocontencin,
Guadalajara, Jalisco, Mexico
Parviz K. Amid, MD, FACS
Clinical Surgery, Lichtenstein Amid Hernia Clinic, Santa Monica,
CA, USA
xiii
xiv Editors and Contributors
Jeffrey A. Blatnik, MD
Minimally Invasive Surgery and Abdominal Wall Reconstruction,
Department of Surgery, University Hospitals Case Medical Center,
Cleveland, OH, USA
Grazia Bombini, MD
General and Day Surgery Unit, Center of Research and High
Specialization for the Pathologies of Abdominal Wall and Surgical
Treatment and Repair of Abdominal Hernia, Istituto Clinico
SantAmbrogio, Milan, Italy
Jamin V. Brahmbhatt, MD
The PUR Clinic, Personalized Urology and Robotics, Clermont, FL, USA
Department of Urology, South Lake Hospital in Partnership with
Orlando Health, Clermont, FL, USA
Frederick J. Brody, MD, MBA
Department of Surgery, George Washington University Medical Center,
Washington, DC, USA
Piero Bruni, MD
Giampiero Campanelli, MD
University of Insubria di Varese, Milan, Italy
Joshua C. Campbell, MD
Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
Marta Cavalli, MD
University of Catania, Milan, Italy
Editors and Contributors xv
Victor W. Chang, MD
Department of Neurology and Neurosurgery, Henry Ford Hospital,
Detroit, MI, USA
Catherine Coyne, BA
University of Arizona College of Medicine, Phoenix, AZ, USA
Lisa A. Cunningham, MD
General Surgery Resident, PGY2, Daytona Beach, FL, USA
Department of General Surgery, Halifax Health Medical Center,
Daytona Beach, FL, USA
Jorge Daes Daccarett, MD, FACS
Minimally Invasive Surgery, Clinica Bautista, Barranquilla, Atlntico,
Columbia
Ibrahim M. Daoud, MD, FACS
Management Information System, St. Francis Hospital and Medical
Center, Hartford, CT, USA
University of Connecticut School of Medicine, Hartford, CT, USA
Valentina De Berardinis, MD
Resident in General Surgery, University of Insubria di Varese, Milan,
Italy
General and Day Surgery Unit, Center of Research and High Specialization
for the Pathologies of Abdominal Wall and Surgical Treatment and
Repair of Abdominal Hernia, Istituto Clinico SantAmbrogio, Milan,
Italy
Christopher G. DuCoin, MD, MPH
Division of Minimally Invasive Surgery, Minimally Invasive and
Advanced Gastrointestinal Surgery, La Jolla, CA, USA
Department of Surgery, University of California San Diego, La Jolla,
CA, USA
Brian J. Dunkin, MD, FACS
Clinical Surgery, Weil Cornell College of Medicine, New York, NY,
USA
Methodist Institute for Technology, Innovation, and Education, Houston
Methodist Hospital, Houston, TX, USA
Katherine Dunn, MD
Department of Surgery, Whidden Memorial Hospital, Cambridge Health
Alliance, Boston, MA, USA
xvi Editors and Contributors
David S. Edelman, MD, FACS

The Gallbladder and Laparoscopic Surgery Center of Miami, Miami,
FL, USA
Department of SurgeryDoctors Hospital, Coral Gables, Miami, FL, USA
Edward L. Felix, MD, FACS
Department of Surgery, Marian Regional Medical Center, Santa Maria,
CA, USA
Brandie Forman
Advanced Hernia Solutions, Transformative Care Institute, Daytona
Beach, FL, USA
Irmina Anna Gawlas, MD
Department of Surgery, David Geffen School of Medicine at UCLA, Los
Angeles, CA, USA
Matthew I. Goldblatt, MD, FACS
Department of Surgery, Medical College of Wisconsin, Milwaukee, WI,
USA
Jacob A. Greenberg, MD, EdM, FACS
Department of Surgery, University of Wisconsin, Madison, WI, USA
Ahmet Gudeloglu, MD
Memorial Ankara Hospital, Ankara, Turkey
Jeffrey Harr, MD
Department of Surgery, George Washington University Medical Center,
Washington, DC, USA
Michael Hibner, MD, PhD, FACOG, FACS
Division of Surgery and Pelvic Pain, Department of Obstetrics and
Gynecology, St. Josephs Hospital and Medical Center, Phoenix, AZ, USA
Creighton University School of Medicine, Omaha, NE, USA
University of Arizona College of Medicine, Phoenix, AZ, USA
David N. Ishimitsu, MD
Department of Radiology, VA West Los Angeles Medical Center, Los
Angeles, CA, USA
Garth R. Jacobsen, MD, FACS
Center for the Future of Surgery, San Diego, CA, USA
UCSD Hernia Center, San Diego, CA, USA
Department of Surgery, University of California at San Diego, San
Diego, CA, USA
Editors and Contributors xvii
Juzar Jamnagerwalla, MD
Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA,
USA
Evish Kamrava, MD
Nuvo Spine and Sports Institute and Ortho Regenerative Center, Encino,
CA, USA
Kent W. Kercher, MD, FACS
Department of General Surgery, Carolinas Medical Center, Charlotte,
NC, USA
Howard H. Kim, MD
Male Reproductive Medicine and Microsurgery, Los Angeles, CA, USA
Department of SurgeryCedars-Sinai Medical Center, Los Angeles,
CA, USA
Stephanie A. Kingman, MD
Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
Johan F.M. Lange Jr., MD
Department of Surgery, The University Medical Center Groningen,
Groningen, The Netherlands
Charles H. Li, BS
Department of Neurosurgery, David Geffen School of Medicine at
UCLA, Los Angeles, CA, USA
Daniel Lu, MD, PhD
Department of Neurosurgery, David Geffen School of Medicine at
UCLA, Los Angeles, CA, USA
Charles Ma, MD
Department of Surgery, University of Minnesota, Minneapolis, MN, USA
Ian T. MacQueen, MD
Los Angeles, CA, USA
Anuj Malhotra, MD
Pain Management Division, Department of Anesthesiology, Icahn
School of Medicine at Mount Sinai, New York, NY, USA
xviii Editors and Contributors
Gregory J. Mancini, MD, FACS

Department of Surgery, University of Tennessee, Knoxville, TN, USA
Dean J. Mikami, MD, FACS
Dept of Gastrointestinal Surgery, Center for Minimally Invasive Surgery,
Columbus, OH, USA
The Ohio State University Wexner Medical Center, Columbus, OH, USA
Joseph M. Miller, MD, MS
S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical
Center, Los Angeles, CA, USA
Calin Stefan Moucha, MD
Division of Adult Reconstruction & Joint Replacement,
Leni and Peter W. May Department of Orthopaedic Surgery, Icahn
School of Medicine at Mount Sinai, New York, NY, USA
Joseph S. Pachman, MD, PhD, MPH
Adjunct Faculty, University of Connecticut, Storrs, CT, USA
Guy D. Paiement, MD
Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA,
USA
Sijo J. Parekattil, MD
The PUR Clinic, Personalized Urology and Robotics, Clermont, FL,
USA
Department of Urology, South Lake Hospital in Partnership with
Orlando Health, Clermont, FL, USA
Warwick J. Peacock, MD, FRCS
David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Ajita S. Prabhu, MD
Department of Surgery, Case Comprehensive Hernia Center, University
Hospitals Case Medical Center, Cleveland, OH, USA
Archana Ramaswamy, MD, FACS, FRCSC
Department of Surgery, Minneapolis VA Health Care System, University
of Minnesota, Minneapolis, MN, USA
Wolfgang M.J. Reinpold, MD
Department of Surgery and Hernia Center, Gross Sand Hospital
Hamburg, Teaching Hospital of the University of Hamburg, Hamburg,
Germany
Editors and Contributors xix
David B. Renton, MD, MSPH, FACS

Division of General and Gastrointestinal Surgery, Department of Surgery,
The Ohio State University Wexner Medical Center, Columbus, OH, USA
James A. Rydlewicz, MD
Department of General Surgery, Aurora Medical Center in Grafton,
Grafton, WI, USA
Rola Saouaf, MD
Body MRI and Congenital Cardiac MRI Program, S. Mark Taper
Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles,
CA, USA
Alexander D. Schroeder, MD
Department of Surgery and Hernia Center, Gross Sand Hospital
Hamburg, Teaching Hospital of the University of Hamburg, Hamburg,
Germany
Jennifer S. Schwartz, MD
Division of General and Gastrointestinal Surgery, Department of
Surgery, The Ohio State University Wexner Medical Center, Columbus,
OH, USA
Keri A. Seymour, DO
Department of Surgery, Division of Metabolic and Weight Loss Surgery,
Duke University, Durham, NC, USA
Matthew Thomas Siedhoff, MD, MSCR
Department of Obstetrics and Gynecology, Division of Advanced
Laparoscopy and Pelvic Pain, University of North Carolina at Chapel
Hill, Chapel Hill, NC, USA
Shane D. Smith, MD
Columbus Radiology, Columbus, OH, USA
M. Jonathon Solnik, MD, FACS
Department of Obstetrics and Gynecology, Division of Urogynecology
and Center for Minimally Invasive Gynecologic Surgery, Cedars-Sinai
Medical Center, Los Angeles, CA, USA
Nathaniel F. Stoikes, MD, FACS
Department of Surgery, University of Tennessee Health Science Center,
Memphis, TN, USA
xx Editors and Contributors
David S. Strosberg, MD
Department of Surgery, The Ohio State University Wexner Medical
Center, Columbus, OH, USA
Payam Vahedifar, MD
Physical Medicine and Rehabilitation and Pain, Nuvo Spine and Sports
Institute and Ortho Regenerative Center, Encino, CA, USA
Guy R. Voeller, MD, FACS
Department of Surgery, University of Tennessee Health Science Center,
Memphis, TN, USA
David L. Webb, MD, FACS
Division of Minimally Invasive Surgery, Department of Surgery,
University of Tennessee Health Science Center, Memphis, TN, USA
Jin S. Yoo, MD, FACS
Division of Metabolic and Weight Loss Surgery, Duke University,
Durham, NC, USA
Part I
Primary Groin Pain
1. Introduction to Primary
and Secondary Groin Pain:
What Is Inguinodynia?
Brian P. Jacob, David C. Chen, Bruce Ramshaw,

and Shirin Towfigh
If dedicated inguinodynologists already existed and were easily

accessed by patients with groin pain, we would have much less of a need
for this type of manual. However, as of today, inguinodynology is not
yet a specialty, nor do specific inguinodynologists readily exist. In fact,
patients with groin pain and chronic groin pain either primarily existing
or secondarily existing following a hip or hernia surgical procedure are
often lost, mainly because they have no place or physician to turn to with
this chief complaint. The Internet is filled with an equal number of
myths and facts and is often not helpful with finding patients a specialist.
With such an extensive differential diagnosis, the optimal treating physi-
cian may be a pain specialist, a physical therapist, a psychologist, a
radiologist, a gastroenterologist, a general surgeon, an orthopedic sur-
geon, a urologist, a neurosurgeon, a neurologist, a rehabilitation special-
ist, a chiropractor, an acupuncturist, a gynecologist, or even a plastic
surgeon. The differential diagnosis for groin pain crosses into 15 differ-
ent specialties, so no wonder patients are lost.
Inguinodynia is the technical term for groin pain, and chronic groin
pain is a complex topic. In an attempt to organize this complex disease
entity, we set out to gather chapters that covered the entire differential
diagnosis of a patient with groin pain. In doing so, we quickly realized
that patients could be divided into two broad categories: primary groin
pain, or groin pain not related to a prior surgery (this would include pain
after sports, a sprain, or overuse during work), and secondary groin
pain, or groin pain that began after a surgical procedure (including her-
nia repairs and orthopedic surgeries). Our chapters are thus divided up
Springer International Publishing Switzerland 2016 3

B.P. Jacob et al. (eds.), The SAGES Manual of Groin Pain,
DOI 10.1007/978-3-319-21587-7_1
4 B.P. Jacob et al.
as such. That being said, complex systems science tells us that there will
not be a single pathway to work up and cure each groin pain patient, and
that each patient should expect an individualized outcome.
If a reader takes away only one message from this entire manual, it
is that the single most important initial steps in helping a patient with
groin pain, even if they also present with a hernia bulge, is to take a full
and detailed pain history that focuses on that pain complaint and
includes information on the patients back, hip, groin, pubis, and legs.
Never assume that the pain is from the hernia alone. A full and detailed
groin pain exam should then follow, which would include documenting
any obvious hernias.
Document, document, and document some more. The specific his-
tory and exam will often help dictate which approach is optimal for each
patient. For primary groin pain, starting your approach with the patients
backevidence for entities that cause groin pain like sacroiliac joint
dysfunction, thoracolumbar syndrome, and degenerative disc disease
should be sought. The hip pathologies causing groin pain should then be
discussed, and include intra- and extra-articular diseases, with femoral
acetabular impingement (FAI) and acetabular labral tears being among
the more common intra-articular etiologies causing groin pain. Extra-
articular hip causes are extensive and include iliopsoas bursitis, trochan-
teric bursitis, snapping hip syndrome, pelvic stress fractures, obturator
nerve (and other nerve) entrapment syndromes, and lumbar radiculopa-
thies. The pubic bone itself can be to blame with either osteitis pubis or
pubic rami stress fractures. In addition, each muscle and tendon that
inserts on the pubis can have a tendonopathy, tendonitis, a sprain, or an
avulsion injury. Finally, the muscles and tendons of the buttock and leg
that insert on the pubic bone can also be sprained or torn, causing groin
pain. An adductor sprain is the most common etiology of the leg tendons
to blame. The concept of a sports hernia, now accepted as a misnomer,
is really just a weak transversalis fascia bulging through a widened inter-
nal ring, and is a diagnosis of exclusion when all other disruption inju-
ries have been excluded by exam and MRI.
Nerve compression or entrapments may be to blame and should be
considered in the differential. These nerves, which can be compressed or
entrapped, include the T12 nerve, the iliohypogastric, the ilioinguinal,
the genitofemoral, the lateral femoral cutaneous, the pudendal, and the
obturator nerves. True inguinal hernias and difficult-to-palpate occult
hernias are included in the broad differential. To add complexity, there
is an additional long list of GI, GU, and GYN etiologies for groin pain
should the history and exam suggest these. Some etiologies in this list
1. Introduction to Primary and Secondary Groin Pain 5
include chronic relapsing appendicitis or diverticulitis, IBD, adhesions,

orchitis, prostatitis, and in women, round ligament pain, endometrioma,
and endometriosisto name a few.
When it comes to discussing secondary groin pain, a few definitions
are helpful. Nociceptive pain is caused by activation of nociceptors by
nociceptive molecules due to tissue injury or inflammatory reaction.
These signals are then transmitted to the brain via A-delta and C-fibers.
Neuropathic pain is caused by direct nerve injury due to direct contact
of nerves with mesh and/or nerve entrapment by sutures, staples, tacks,
folded mesh, or meshoma. For complex pain histories lasting for more
than 6 months, or years, where no real etiology can be found, a referral
to a pain specialist and/or a neurologist or neurosurgeon can sometimes
be helpful in differentiating between chronic regional pain syndromes
type 1 and 2, and can provide useful information for surgeon and
patient alike.
Neuropathic pain complaints following hernia surgery can be subdi-
vided into either a chronic regional pain syndrome type 1 or type 2,
depending on (a) when the pain began after surgery: after a time lag
(type 1) or immediately (type 2), (b) whether or not the pain follows a
specific nerve distribution: no (type 1) or yes (type 2), and, finally, (c)
whether the pain is alleviated with local anesthetic blocks: no response
(type 1) or immediate but temporary response (type 2). It is believed that
neurectomy or removal of noxious material has a better chance of
resolving pain if type 2 exists while type 1 carries a worse prognosis.
Patients with type 1 often need referral to physicians specializing in cop-
ing mechanisms and alternative therapeutic remedies. Nonetheless, it is
very important to ascertain whether the pain began before or after the
hernia repair, and if after the repair, how long after the repair.
Generally (and more practically), pain after an inguinal hernia repair
is caused by (a) the material inserted (mesh, tacks, or sutures), (b) an
inadequately reduced hernia, or (c) a missed lipoma or hernia.
Unfortunately, many recurrent hernias are actually just inadequately dis-
sected hernia fields the first time. The pain resulting from inserted mesh,
fixation tacks, technique, or sutures can be caused by direct irritation
from the material or by adjacent nerve damage. In an open repair, the
nerves that may be involved include the iliohypogastric, ilioinguinal,
and the genital branch of the genital femoral nerve. In a laparoscopic
repair, those at risk are the lateral femoral cutaneous nerve, the entire
genital femoral nerve and its distal branches, andif tackingthe ilio-
inguinal and iliohypogastric nerves. A careful history and physical
should be able to identify the affected nerve.
6 B.P. Jacob et al.
The history and workup for secondary groin pain are equally important.
An operative report should be obtained and reviewed, and a CT scan
and/or a MRI performed. Attention should be directed toward looking
for surgical material and recurrences on the CT, and nerve pathology as
well as musculoskeletal damage on the MRI. It is important to remem-
ber that hip pathologies such as osteoarthrosis, labral tears, and femoral-
acetabular impingement syndromes present as groin pain near the
internal ring over 70 % of the time, and can be the etiology even if a
patient has had hernia repair in the past.
Office-based local nerve blocks can be used for diagnostic purposes,
paying careful attention to the nerve that is blocked, whether or not
immediate relief is obtained, and when after the block the pain returns.
Pain that responds immediately to a local block and remains alleviated
for a short time tends to respond better to neurectomy or foreign body
removal than does pain that is not decreased immediately. Neurectomy
should be used as a last resort, as even a triple neurectomy carries a
10 % failure rate in terms of mitigating the pain.
The choice of operation, if needed for secondary groin pain, will
depend on the previous surgery, as well as the patients response to local
and regional nerve blocks, which can be performed for diagnostic pur-
poses, as indicated above. Open surgical procedures can be very useful
in treating many of the primary groin pain etiologies that are neuro-
muscular-skeletal in origin. Tendonotomies, hernia repairs, neurolysis,
fascial strengthening and reappoximation, and neurectomies are just
some techniques employed during open surgeries, but the list is exten-
sive. On the other hand, the minimally invasive (laparoscopic or robotic)
transabdominal preperitoneal (TAPP) approach is very useful as a diag-
nostic, and possibly therapeutic, tool for patients presenting with groin
pain either primarily or after hernia repairs. However, patients should be
warned that all of these operations carry significant risk of side effects
or injury to vessels, nerves, and surrounding viscera, and these risks
must be weighed against the significance of the patients pain complaint
before embarking on remedial surgery. Patients should be educated that
there is a chance the surgery will not resolve their pain, but can still
contribute greatly to the workup, with the goal being an eventual diag-
nosis and resolution.
If performing a TAPP for groin pain, the surgeon should mark the
patients pain spot with a marker before the surgery. During the TAPP
procedure, potential pain-inducing tacks and mesh can be removed,
adhesions can be identified and lysed, viscera can be examined, and the
1. Introduction to Primary and Secondary Groin Pain 7
femoral, direct, and indirect spaces can be carefully examined for

missed, new, or recurrent hernias.
Neurectomy and laparoscopic neurectomy are emerging once again
as a possible last resort surgery that, if performed by an experienced
surgeon, can be life-improving for sure. That being said, if a surgeon is
not familiar with revisional hernia surgery or neurectomy, the patient
should be referred elsewhere.
In conclusion, inguinodynia, or groin pain, can be acute onset or
chronic in nature. Patients suffering from either deserve to have easier
access to find a physician specializing in groin pain, and we hope a
manual like this one will at least inspire more surgeons to master the
anatomy, differential diagnosis, history and physical exam, workup, and
nonoperative and operative techniques involved with inguinodynia that
are required to assist some of these patients. While a groin pain team
will always be required to fully treat inguinodynia patients, for a general
surgeon, sometimes just being able to facilitate the diagnosis and
workup can be as rewarding to these groin pain patients as would be an
entire surgery. For just that reason alone, every general surgeon should
read this manual.
2. Groin Pain: A Neurologic
and Musculoskeletal Anatomic Review
Irmina Anna Gawlas and Warwick J. Peacock
Boundaries of the Inguinal Canal

As shown in Fig. 2.1, the anterior wall of the inguinal canal is the
external oblique aponeurosis, reinforced laterally by the internal oblique
muscle [1]. The posterior wall is formed by the transversalis fascia later-
ally and the conjoint tendon medially. The inguinal and lacunar liga-
ments are the floor. The roof is formed by the fusion of the lowest fibers
of the transversus abdominus and internal oblique muscles, which
become the conjoint tendon, and insert onto the pubic crest.
Fascial Layers and the Inguinal Rings

In order to understand the course of the various structures that enter
and exit the inguinal canal, listed in Table 2.1, the fascial layers and their
openings must first be conceptualized. In the male, the internal ring is
an opening in the transversalis fascia through which the vas deferens
enters on its course from the pelvis. The vas meets the gonadal vessels
and the genital branch of the genitofemoral nerve as they approach from
an inferolateral direction and picks up the cremasteric artery as it
branches off the inferior epigastric artery. These comprise the cord
structures that are covered by the internal spermatic fascia, formed from
the connective tissue of the transversalis fascia. Fibers from the internal
oblique form a second covering of the cord, the cremaster muscle, and
cremasteric fascia. In the female, the internal ring transmits the round
ligament, which suspends the uterus anteriorly, and the genital branch of
the genitofemoral nerve. The cord structures that approach and pass

DOI 10.1007/978-3-319-21587-7_2
10 I.A. Gawlas and W.J. Peacock
Iliohypogastric
Ilioinguinal
Lateral cutaneous Genitofemoral
Genital branch
Femoral branch Interior epigastric vessels
Femoral nerve
Femoral artery External ring
Femoral vein
Spermatic cord
Fig. 2.1. Borders of the inguinal canal (from Wagner et al. [1], with kind
permission McGraw-Hill Education).
Table 2.1. Structures of the inguinal canal.

Vas deferens (or round ligament)
Artery to the vas
Gonadal artery
Cremasteric artery
Cremasteric vein
Gonadal vein (pampiniform plexus)
Genital branch of genitofemoral nerve
Ilioinguinal nerve
Sympathetic nerves
Lymphatics
Internal spermatic fascia
Cremasteric fascia and muscle
External spermatic fascia
2. Groin Pain: A Neurologic and Musculoskeletal 11
Epigastric vessels
Myopectineal
orifice
Iliopubic
tract
Iliopsoas muscle
Coopers ligament
Internal spermatic
Lacunar ligament vessels
External iliac a. and v.
Obturator vessels
Obturator n. Vas deferens
Fig. 2.2. Laparoscopic view of the internal ring (from Wagner et al. [1], with
kind permission McGraw-Hill Education).
through the internal ring are best appreciated from the laparoscopic
view, which is illustrated in Fig. 2.2 [1].
The external ring is a triangular opening in the aponeurosis of the
external oblique muscle. To form the external ring, the aponeurosis
splits into a lateral crus, which attaches to the pubic tubercle, and a
medial crus attached to the pubic crest. The two crura are held together
by intercrural fibers at the apex of the triangular opening. The ilioingui-
nal nerve and the cord structures destined for the scrotum (or the round
ligament into the labium majus in the female) pass through the external
ring where fibers from the external oblique continue downward to form
the third covering of the cord, the external spermatic fascia.
Some authors refer to a third ring which is deep and slightly lateral
to the internal ring, and is formed by an opening in the preperitoneal
fascia [2, 3]. This ring transmits the gonadal vessels and the vas from the
visceral space of the preperitoneum into the parietal space of the preperi-
toneum, where they are joined by the genital branch of the genitofemo-
ral nerve. These fascial planes and spaces, and the structures they
contain, are illustrated from an axial view in Fig. 2.3. Mesh placement
during laparoscopic repair should be in the visceral compartment;
Transversalis
fascia
Transversus Parietal peritoneum
abdominis muscle Vas deferens
Testicular artery
External oblique vein
muscle
Inferior epigastric
artery and vein
Internal oblique
muscle
Genital branch of Bladder

genitofemoral nerve
Cremasteric
artery/vein Rectus
muscle
Genital
branch
Ilioinguinal nerve
Fig. 2.3. Axial illustration of preperitoneal planes.
incorrect placement in the parietal preperitoneal space is a potential

cause of postoperative pain because the mesh may directly contact the
genital and/or femoral branches of the genitofemoral nerve and the lat-
eral femoral cutaneous nerve [1].
Anatomical Course and Innervation

of the Three Inguinal Nerves
The anterior ramus of L1, with perhaps a contribution from T12,
emerges lateral to the psoas muscle and crosses quadratus lumborum in
the retroperitoneum. The L1 nerve branches into the upper iliohypogas-
tric and lower ilioinguinal nerves. The iliohypogastric nerve pierces the
transversus abdominus muscle above the iliac crest, and then travels in
the neurovascular plane between the transversus abdominus and the
internal oblique muscles, to both of which it provides motor innervation.
It then pierces internal oblique at a variable point along the anterior
abdominal wall, eventually passing through external oblique about

2.5 cm superior to the external ring, providing sensory innervation to the
suprapubic skin [3].
The lower branch of the L1 nerve is the ilioinguinal nerve, which
similarly pierces the transversus abdominus muscle to travel in the
neurovascular plane and then passes through the internal oblique to enter
the inguinal canal, providing motor innervation to the lower fibers of
both muscles. It runs with the cord structures and exits the canal via the
external ring to provide sensory innervation to the overlying skin of the
upper medial thigh, anterior scrotum, and base of the penis (or labium
majus and mons pubis).
The genitofemoral nerve arises from L1 and L2 within the substance
of psoas major and then courses downward on its anterior surface. It
divides into a genital and a femoral branch. The genital branch travels
along the external iliac artery and then ascends to meet the vas deferens
at the internal ring. Entering the inguinal canal, it becomes part of the
spermatic cord lying on its inferior surface with a companion vein. In the
male, it passes into the scrotum via the external ring and provides motor
innervation to the cremaster muscle (and therefore is responsible for the
cremasteric reflex), and sensory innervation to a small part of the scro-
tum. In the female, it provides sensory innervation to the mons pubis.
The femoral branch passes deep to the inguinal ligament, lateral to the
femoral artery, supplying the skin of the upper anterior thigh immedi-
ately inferior to the ligament.
The sympathetic nerves of the spermatic cord originate in the T10-11
spinal cord segments and travel with the greater and lesser splanchnic
nerves to the pre-aortic plexus. These autonomic fibers then run with the
gonadal artery to the testis. The sympathetic efferent fibers are vasomo-
tor, and the afferent fibers conduct testicular pain, which is thus referred
to the umbilical region, innervated by the tenth intercostal nerve.
Anatomy of the Femoral Ring

Immediately posterior and inferior to the inguinal ligament is the
femoral ring. It is bounded posteriorly by the pectineal ligament, medi-
ally by the lacunar ligament, and laterally by the femoral vein.
Immediately below the inguinal ligament from lateral to medial lie the
femoral nerve, femoral artery and vein, both contained within the femo-
ral sheath, and most medially, the femoral canal with its contained fat
and lymphatic tissue.
Variations in Neuroanatomy and Intraoperative

Considerations
It is estimated that, during open repair, all three inguinal nerves can
be distinctly identified in 7090 % of patients [3]. The anatomy of the
iliohypogastric and ilioinguinal nerves is highly variable. The L1 nerve
trunks may divide into its two nerves early or late as it crosses quadratus
lumborum, or even may continue as one nerve as far as the anterior
abdominal wall before dividing. They are generally inversely propor-
tional in size.
Within the inguinal canal, the ilioinguinal nerve may be found within
the cremasteric sheath (as opposed to its usual position where it lies on
the anterior surface of the cord) [4]. Occasionally, it may not pass
through the external ring but may pierce the external oblique aponeuro-
sis more proximally [5].
During open repair, the genital branch of the genitofemoral nerve is
prone to injury as it enters the canal at the internal ring when the cord is
encircled with a Penrose drain while the floor of the inguinal ligament
is being exposed [6].
The iliohypogastric nerve may be injured in open repairs while
securing the superior edge of mesh to the aponeurosis of the transversus
and internal oblique muscles. During laparoscopy, it can also be injured
while the superior edge of the mesh is tacked into place, as this nerve
will not be seen where it runs in the neurovascular plane between the
transversus and internal oblique [6]. As they approach the internal ring,
the genital branch of the genitofemoral nerve will be inferior, and the
ilioinguinal nerve lateral, and both also may be inadvertently tacked dur-
ing laparoscopic repair.
Clearly, an awareness of the classic anatomy, as well as its possible
variations, is extremely important to avoid nerve damage.
References
1. Wagner JP, Brunicardi FC, Amid PK, Chen DC. Inguinal hernias. In: Brunicardi FC,
Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, editors.
Schwartzs principles of surgery. 10th ed. New York: McGraw Hill Medical; 2014.
p. 1495521. Ch. 37.
2. Mirilas P, Mentessidou A, Skandalakis JE. Secondary internal inguinal ring and associ-
ated surgical planes: surgical anatomy, embryology, applications. J Am Coll Surg.
2008;206(3):56170.
3. Amid PK, Hiatt JR. Surgical anatomy of the preperitoneal space. J Am Coll Surg.
2008;207(2):295. Author reply 2956.
4. Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, Di Miceli D,
Doglietto GB. International guidelines for prevention and management of post-opera-
tive chronic pain following inguinal hernia surgery. Hernia. 2011;15(3):23949.
5. Amid PK. Causes, prevention, and surgical treatment of postherniorrhaphy neuropathic
inguinodynia: triple neurectomy with proximal end implantation. Hernia. 2004;8(4):
3439.
6. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. Cause and prevention of posth-
erniorrhaphy neuralgia: a proposed protocol for treatment. Am J Surg. 1988;155(6):
78690.
3. Complex Regional Pain
Syndrome Types I and II
Payam Vahedifar and Evish Kamrava
Introduction
Chronic pain is described by the International Association for the
Study of Pain as pain lasting greater than 3 months. Some etiologies of
chronic groin pain are radicular in nature, such as from lumbar impinge-
ment of the L13 lumbar nerves, muscle strains and sports hernias, pain
from pubic structures and enthesopathy, osteoarthritis of the hip, and
labral tears of the hip. These pain problems are often treatable, and
despite their chronicity, follow an anatomical and pain pattern that is
consistent with the underlying injury.
Additionally, chronic groin pain has become a common problem
associated with hernia operations. Pain after inguinal hernia repair can
be classified as acute postoperative pain, hernia recurrence, nerve injury,
foreign body reaction, and injury due to surgical technique. In the past,
hernia repair had complication and recurrence rates of up to 67 %; how-
ever, newer techniques using mesh reinforcement with lighter-weight
mesh have shown reduction in post-procedure chronic pain. Despite
technical improvements, chronic groin pain continues to be a frequent
complaint after hernia repair, with incidence of at least 10 %. In the
majority of patients, pain can be the result of localized disruptions that
are directly the consequence of the operation, such as from the sutures,
clips, or scar tissue. It can also be due to entrapped nerves. Pain can also
be due to recurrence of the hernia. Revisional procedures and appro-
priate directed care can resolve the symptoms in a good proportion of
patients.
In some patients, however, pain continues or even intensifies
despite treatment and revision surgery and, in a subset of patients, may
have a faster course. These patients should be further evaluated for the

DOI 10.1007/978-3-319-21587-7_3
18 P. Vahedifar and E. Kamrava
possibility of complex regional pain syndrome (CRPS). In these

circumstances, patients may have pain that is clearly more severe than
expected based on their injury. The pain in this subgroup does not usu-
ally respond to typical treatments. The pain is often accompanied with
allodynia, with hyperesthesia, and with autonomic changes. This sub-
group of patients may have complex regional pain syndrome (CRPS).
Complex regional pain syndrome (CRPS) defines a range of painful
conditions following an insult, together with abnormal changes in auto-
nomic function. Pain in CRPS is disproportionate to any instigating
physical cause or injury. The goal of this chapter is to define CRPS and
to help identify the clinical presentations, treatments, and plausible
therapy as related to chronic groin pain.
Complex Regional Pain Syndrome

Type I and Type II
The terms CRPS type I and II have recently been used as a diagnos-
tic and descriptive tool for the previously known syndromes of reflex
sympathetic dystrophy and causalgia, respectively. This change in typol-
ogy occurred to help with diagnosis and to establish specific criteria for
the pain syndromes. The hallmarks of CRPS as defined by the International
Association for the Study of Pain (IASP) include the following: (a) spe-
cific injury or noxious stimuli, which may include surgery; (b) continued
pain that is disproportionate to the noxious stimuli or injury, including
allodynia and hyperalgesia; (c) changes in localized skin, including edema
and changes in blood flow and coloration of the skin; and (d) no specific
dermatomal or nerve pattern. This diagnosis is excluded by the existence
of other conditions that would otherwise account for the degree of pain
and dysfunction [1]. Furthermore, type I designation is used to describe
conditions that are not associated with nerve injury, whereas type II is
used to describe those that are associated with nerve injury.
CRPS classification can also be clustered into four distinct groups.
Group 1 has pain-processing abnormalities such as allodynia and hyper-
esthesia. Group 2 has skin color changes and vasomotor dysfunction.
Group 3 shows edema and pseudo-motor changes such as sweating and
piloerection. Group 4 has motor trophic signs such as localized atrophy,
spasticity, dystonia, and tremors [2].
Recently proposed clinical criteria for the diagnosis of CRPS
include painful conditions that are characterized by continuous pain
3. Complex Regional Pain Syndrome Types I and II 19
disproportionate to the degree of the usual course and symptoms of the

underlying injury. The pain is regional by definition, and it does not
follow a dermatomal or nerve pattern. The patient also must report at
least three of the following changes: (a) sensory hyperesthesia, (b) vaso-
motor changes such as temperature asymmetry, (c) skin color changes,
sudomotor changes, and edema such as sweating, piloerection, and
swelling, and (d) motor trophic changes such as decreased range of
motion, weakness, dystonia, tremors, and changes in hair, nail, and skin.
Physical findings on examination at the time of evaluation should con-
tain at least two of the following: (a) evidence of hyperalgesia, (b) evi-
dence of vasomotor changes, (c) evidence of edema, (d) sweating and
changes in sweating asymmetry, and (e) motor trophic changes that are
noted on examination. Furthermore, there should be no other diagnosis
that better explains the underlying conditions symptoms (Table 3.1) [3].
Clinical Management of CRPS

The most important factor in the management of CRPS is early
diagnosis and early treatment. CRPS can affect a person at any age but
has a peak onset at approximately 3750 years [4]. Treatment of CRPS
should be directed at restoring function and decreasing pain as soon as
possible. Therapeutic guidelines include the multidisciplinary approach
to treatment of pain, including physical therapy, medical intervention,
and behavioral and psychological interventions. These have been
proven most effective in the overall treatment of patients and their
return to function with effective decrease in pain. Stanton-Hicks et al.
reported specific guidelines in therapeutic intervention and algorithm
for functional improvement, with the use of physical therapy at a mea-
sured pace and time contingent, to alleviate symptoms in a timely man-
ner [5]. The following are essential to the treatment: the process of
desensitization of the involved area, mobilization of the area, electrical
stimulation if tolerated to reduce the pain secondary to myofascial
changes, and isometric strengthening. Furthermore, a range of motion,
stress loading, aerobic conditioning, and movement therapies, includ-
ing vocational and functional rehabilitation, have been proposed in
treatment algorithms for patients with CRPS. Adjunctive psychological
intervention has been used in parallel with physical therapy to manage
expectations, to improve motivation, and to use with behavioral, bio-
feedback, relaxation, imagery, and hypnosis techniques to help improve
overall outcome (Fig. 3.1) [6].
Table 3.1. Criteria for diagnosis of CRPS, per International Association for the
Study of Pain.
1. Continued pain that is disproportionate to the inciting event
2. No other diagnosis better explains the signs and symptoms
3. Signs and symptoms below
Symptom (complaint) Sign (physical exam)
At least 1 symptom in at At least 1 sign at the time of
least 3 of the following evaluation in at least 2 of the
categories following categories
Sensory Hyperesthesia Hyperalgesia to pin prick
Allodynia Allodynia to light touch
Allodynia to temperature
sensation
Allodynia to deep somatic
pressure
Allodynia to joint movement
Vasomotor Temperature asymmetry Temperature asymmetry
Skin color changes greater than 1 C
Skin color asymmetry Skin color changes
Skin color asymmetry
Sudomotor/ Edema Edema
edema Sweating changes Sweating changes
Sweating asymmetry Sweating asymmetry
Motor/trophic Decreased range of Decreased range of motion
motion Motor dysfunction such as
Motor dysfunction such weakness, tremor, dystonia
as weakness, tremor, Trophic changes such as
dystonia hair, nail, or skin changes
Trophic changes such as
hair, nail, or skin changes
Adapted from Harden et al. [3], with kind permission John Wiley & Sons
Pharmacologic Treatment
Oral pharmacological treatment of CRPS has shown beneficial treat-
ment with early-onset CRPS. The use of corticosteroids in early stages
of CRPS has proven effective in some patients. Kozin et al. demon-
strated that the pulsed use of steroids in patients with chronic regional
pain syndrome showed improvement in 6080 % of patients after
2 weeks [7]. Similarly, Christensen et al. confirmed decrease in pain in
the first 34 months [8]. Farah et al. have also shown effectiveness of
NSAIDS in some forms of CRPS in early stages of disease [9].
Fig. 3.1. Treatment algorithm for multimodality therapy of patients with CRPS.
Opioid use has not been studied in controlled trials for the treatment
of CRPS, although it is frequently used early in the treatment of CRPS.
Intravenous use of opioids has shown some response in patients with
neuropathic pain and may have a role in the treatment of severe CRPS
[10, 11]. Other oral medication treatments such as gabapentin, carba-
mazepine, valproic acid, phenytoin, and tricyclic antidepressants have
also shown beneficial effects in a subgroup of patients with CRPS
[1215].
Topical Medication
Topical medications have shown efficacy in the treatment of
neuropathic pain in those with diabetic and postherpetic neuralgia.
This treatment may be an intuitive approach in treating allodynia and
hyperalgesia at the affected area. Robbins et al. reported significant
efficacy in patients with CRPS using large doses of topical capsaicin [16].
Davis et al. studied the topical use of clonidine to relieve the localized
hyperalgesia in patients with sympathetically mediated pain, with favor-
able results [17]. Similarly, topical ketamine use as described by Finch
et al. has been effective in reducing symptoms of allodynia among
patients with CRPS [18].
Intravenous Medications
Several forms of intravenous medication have shown promise in the
treatment of CRPS. There are a number of controlled studies on bisphos-
phonate such as pamidronate, alendronate, and clodronate, all of which
have shown considerable improvement in pain with patients with
CRPS. Also, intravenous use of ketamine in the treatment of CRPS has
shown a significant reduction in allodynia [19, 20]. Other intravenous
medications such as lidocaine as demonstrated by Wallace et al to have
shown to help decrease pain in patients with CRPS types I and II [21].
Interventional Therapy
Interventional therapies have been used in conjunction with manual
and physical therapy as well as behavioral therapy in order to reduce
pain and increase the likelihood of positive outcomes. These treatments
should not be used in the absence of multimodality treatment and should
not be started if there is no improvement with physical therapy.
Interventional therapies are best used as an adjunctive treatment to
decrease pain and to allow faster improvement in symptoms. One such
therapy, sympathetic nerve blockade, has been historically used among
those with CRPS as a diagnostic and therapeutic intervention to allevi-
ate pain. Several studies have shown a reduction in sympathetically
mediated pain with this blockade [22]. These nerve blocks should be
continued as long as they provide improvement. If the effect of the
nerve blockade plateaus, other treatments should be considered.

Intrathecal use of morphine and baclofen has also been studied in the
treatment of CRPS [23].
Intravenous regional anesthesia refers to the use of clonidine and
lidocaine, as described by Reuben and Sklar. They showed complete
pain relief after 46 sessions of such treatment [24].
Spinal cord stimulation has been shown in a randomized control trial
to alleviate pain among patients with refractory CRPS [25]. Furthermore,
Harke et al. found improvement in pain among those who had previ-
ously responded well to sympathetic block, with reduction in their level
of pain. This was a prerequisite to spinal cord stimulation [26].
Peripheral nerve stimulation and peripheral field stimulation are also
viable options when conventional treatment protocols have not provided
adequate relief [27]. The use of ultrasound-guided intervention to help
directly visualize the affected nerve has allowed for the use of direct
visualization techniques, such as imaging, to implant peripheral elec-
trodes without need for surgical dissection. Others have used peripheral
field stimulation for localized extremity pain or regional pain rather than
directly stimulating the nerve [28]. Finally, the stimulation of the dorsal
root ganglion has also been considered [29]. This offers more specific
targeting of a regional area and may have value in treatment of refrac-
tory conditions.
Other more novel interventional techniques for treatment of CRPS
have promising outcomes but have not been studied extensively. One
such treatment is transcranial magnetic stimulation. In one study, contin-
ued stimulation of the motor cortex by TMS of the affected side showed
a decrease in pain as compared to sham stimulation [30].
Although interventional treatment has been a hallmark of decreasing
pain and improving symptoms, the use of these interventions has longer-
term success when used with conservative treatment including physical
and behavioral therapies (see Fig. 3.1).
Summary
The current diagnostic criteria for CRPS are delineated in Table 3.1.
However, it is important to understand that the vast majority of patients
who have chronic and/or acute pain that is disproportionate to the incit-
ing injury do not fulfill all the diagnostic criteria for CRPS. And yet, at
the same time, care must be taken to appropriately treat these patients
with a structured plan of early pharmacological therapy, interventional
therapy, and restorative therapy in order to avoid a full-blown case of

CRPS (see Fig. 3.1).
Interventional therapies, such as nerve blocks, should be initiated to
not only help in the diagnosis of the patients underlying condition but
also to help in the differential diagnosis of the underlying cause of their
pain. Using topical medications over the affected area that triggers the
pain, such as the area of the surgical scar after a hernia repair, should be
initiated early in the course of treatment. Also, appropriate use of opi-
oids should be considered.
Psychological factors should always be taken into consideration for
treatment of patients. Guided interventional techniques can help with
appropriate diagnosis and to help avoid overdiagnosis of CRPS, as may
be in the case of certain neuropathic pain, for example. Furthermore, as
CRPS is a disabling and devastating disease for both patients and their
loved ones, consideration of interventional and novel techniques to help
alleviate pain, such as transcranial magnetic stimulation, sympathec-
tomy, spinal cord stimulation and peripheral nerve stimulation, should
not be abandoned.
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syndromes and definitions of pain terms. Seattle, WA: IASP Press; 1994.
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regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently com-
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study. Pain. 2003;103(1-2):199207.
5. Stanton-Hicks M, Baron R, Boas R. Complex regional pain syndromes: guidelines for
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6. Mugge W, van der Helm FC, Schouten AC. Integration of sensory force feedback is
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I. Clinical and histological studies: evidence for bilaterality, response to corticoste-
roids and articular involvement. Am J Med. 1976;60(3):32131.
8. Christensen K, Jensen EM, Noer I. The reflex dystrophy syndrome response to treat-
ment with systemic corticosteroids. Acta Chir Scand. 1982;148(8):6535.
9. Farah BA. Ketorolac in reflex sympathetic dystrophy. Clin Neuropharmacol. 1993;

16(1):889.
10. Portenoy RK, Foley KM, Inturrisi CE. The nature of opioid responsiveness and its
implications for neuropathic pain: new hypotheses derived from studies of opioid
infusions. Pain. 1990;43(3):27386.
11. Rowbotham MC, Reisner-Keller LA, Fields HL. Both intravenous lidocaine and mor-
phine reduce the pain of postherpetic neuralgia. Neurology. 1991;41(7):10248.
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4. Chief Complaint of Groin Pain: How
to Take and Document a Specific Groin
Pain History, Exam, and What Studies
to Order
Jacob A. Greenberg
Editors Comment (BPJ)

The chief complaint of groin pain is serious. Surgeons who perform
inguinal hernia repairs should develop a thorough understanding of the
neuro and musculoskeletal anatomy of the inguinal region so that the his-
tory provided by a patient in pain can be expertly matched to a focused
pain physical exam. A patient with a complaint of groin pain and a simul-
taneous inguinal hernia should not automatically be told that the pain is
absolutely from the inguinal hernia until a thorough pain physical exam
has been performed and documented. Some patients with chronic pain
complaints after inguinal hernia repairs have undiagnosed sport injuries
that were misdiagnosed as an inguinal hernia, and this situation is abso-
lutely preventable by increasing awareness. Repairing a hernia in a
patient with a sports injury risks ongoing pain complaints, excessive office
visits and associated costs, and worst of all, an unsatisfied patient. This
thorough chapter clearly explains how to take and document a proper his-
tory and physical on a patient whose chief complaint is groin pain.
Introduction
When the patients chief complaint is pain in the groin, surgeons
need to have an established routine to proceed with a proper evaluation.
This routine is very different than if the complaint was for a simple

DOI 10.1007/978-3-319-21587-7_4
28 J.A. Greenberg
inguinal hernia. In fact, most hernias present as asymptomatic, or as a

bulge without accompanying pain, and so when the patient says they
have pain in the region of the groin, the physicians focus must shift. Do
not assume that the pain is simply because the patient has a hernia.
Groin pain is a common complaint seen in primary care clinics
throughout the world. In sports medicine clinics across the United
States, groin pain accounts for roughly 10 % of office visits [1]. While
groin pain is a common complaint among elite athletes, there are mul-
tiple causes of groin pain, including inguinal and femoral hernias that
affect a large percentage of nonathletes as well [2]. With a wide variety
of pathologies as potential causes of hip or groin pain, it is imperative
to begin all evaluations with a thorough history and physical exam. An
accurate history and physical accompanied by appropriate ancillary
imaging studies can help to determine the specific cause of groin pain
in the majority of patients. In this chapter, we will review the pertinent
initial workup for patients presenting with groin pain.
History
As with all other medical problems, the workup for patients with
groin pain should begin with a thorough and accurate history of the pres-
ent illness. The history should start with questions about the spine and
back, then the hip, and then the abdominal wall, groin, and accompany-
ing upper leg. This history will guide not only the physical exam maneu-
vers required for a thorough evaluation but will also lead to prompt
diagnosis and treatment through the ordering of appropriate diagnostic
tests and referrals if needed.
The pain should be characterized in terms of location, duration, sen-
sation, onset, severity, aggravating or alleviating factors, and pattern of
radiation. Additionally, in patients with chronic groin pain, these symp-
toms may change with time, and this should be elicited as part of the
history. Patients with inguinal hernias will frequently note a bulge in the
groin, while many other pathologies, such as hip sources of groin pain,
musculoskeletal strain, and sports hernias, may not be associated with a
bulge. Patients should be asked about pain with specific movements and
activities as this may help to further narrow the differential diagnosis.
Additionally, patients should be queried about the presence or absence
of mechanical symptoms with their gait as this points to the presence of
labral tears or loose bodies of the hip as the likely diagnoses [3, 4]. Table
4.1 shows many of the possible causes of groin pain.
4. Chief Complaint of Groin Pain 29
Table 4.1. Possible causes of groin pain.

Category Causes
Hernia Indirect inguinal hernia
Direct inguinal hernia
Femoral hernia
Hip joint injury Avulsion fracture
Stress fracture
Labral tear
Loose bodies
Degenerative joint disease
Femoroacetabular impingement
LeggCalvPerthes disease
Slipped capital femoral epiphysis
Osteonecrosis
Athletic injuries Sportsmans hernia (inguinal disruption)
Osteitis pubis
Adductor muscle strain
Genitourinary Ectopic pregnancy
Round ligament pain
Endometriosis
Ovarian cyst
Ovarian torsion
Varicoceles
Prostatitis
Orchialgia
Urinary tract infection
Gastrointestinal Appendicitis
Diverticulitis
Inflammatory bowel disease
Irritable bowel syndrome
Adhesions
Particular attention should be paid to the acuity of the injury. In ath-

letes, many acute groin injuries arise from strains of the adductor muscles
or hip flexors and will resolve with conservative measures [5]. Chronic
causes of groin pain are less likely to resolve and generally require more
definitive treatments [58]. Schilders and colleagues classified chronic
sources of groin pain in athletes into four separate categories: hip joint
injury, osteitis pubis, adductor dysfunction, and sports hernias [9].
Patients with hip joint injuries will commonly indicate their pain with the
C sign (Fig. 4.1), where the hand is cupped over the hip in the shape of
the letter C with the ipsilateral index finger positioned over the groin and
30 J.A. Greenberg
Fig. 4.1. In The C Sign, the hand is cupped over the hip in the shape of the
letter C with the ipsilateral index finger positioned over the groin and the thumb
located proximal to the greater trochanter.
the thumb located proximal to the greater trochanter [10]. Patients with
adductor injuries often complain of a pulling or tearing sensation in the
groin with activity, while those with osteitis pubis note tenderness over
the pubic symphysis. Patients with sports hernias typically complain of
pain that is unilateral and burning or sharp in nature. The pain may radi-
ate to a variety of locations, including the proximal thigh, lower back,
lower abdomen, and downward to the scrotum as well [11]. Patients are
generally able to sleep comfortably through the night, but upon awaken-
ing may experience extreme pain while attempting to get out of bed.
Sudden movements, especially rotational or forceful activities such as
sit-ups, cutting, and rapid acceleration or deceleration, will exacerbate
these symptoms [5], while periods of rest will often relieve them, only to
have them return upon resuming athletic activities [12].
Patients with inguinal hernias as their source of groin pain may expe-
rience a different set of symptomatology from those with sports hernias.
The pain or discomfort associated with the inguinal hernia tends to be
progressive over the course of the day and will be worse even in the
evenings. Certain positions that increase intra-abdominal pressure, such
as sitting, may exacerbate these symptoms, while lying supine may
relieve them and return the hernia contents to their intra-abdominal loca-
tion. Many patients will note increases in pain with forceful activities
such as sneezing, coughing, and bowel movements, and some will
reflexively hold their groin during these activities in order to mitigate

these symptoms. Unlike patients with sports hernias, those with inguinal
or femoral hernias will often notice a bulge and may associate their
symptoms with a change in its size. All patients should be asked about
any change in bowel or bladder habits to assess for any obstructive type
symptoms and should also be asked about any history of incarceration
of their hernias.
While traditional hernias, sports hernias, and other sport-related mus-
culoskeletal injuries comprise the majority of causes for groin pain,
there are many other congenital and acquired causes of groin pain that
should be factored into ones differential diagnosis. Congenital disorders
associated with osteonecrosis of the hip, including slipped capital femo-
ral epiphysis, congenital hip dysplasia, and LeggCalvPerthes dis-
ease, may all be a source of groin or hip pain in adulthood [13]. Other
causes of osteonecrosis such as chronic steroid use or alcohol abuse
should also be assessed. Many genitourinary conditions may present
with groin pain as well, and these should be discussed in detail, espe-
cially with sexually active women and women of childbearing age
where the differential diagnosis should include conditions such as pelvic
inflammatory disease, ectopic pregnancy, ovarian cysts, endometriosis,
ovarian torsion, and round ligament pain.
An accurate and thorough history is the key initial step in the workup
of all patients with groin pain. While the history alone may not confirm
the diagnosis, it will help determine which physical exam maneuvers
and ancillary studies will be most appropriate and helpful in determining
the cause of the patients complaints.
Physical Exam
The physical examination should begin with vital signs, including
accurate height and weight. Overweight and obese patients have a lower
incidence of inguinal hernia formation compared to normal weight indi-
viduals [14, 15]. Routine physical examination of the thorax and abdo-
men should be performed, but the majority of the physical exam should
be focused on the groin and the hip. The back, pelvis, groin, and upper
thigh should be completely exposed in order to facilitate a thorough
examination.
Examination should begin in the upright position with inspection.
Palpation of the spine and paraspinal muscles should be done. Unilateral
inguinal hernias will often be apparent as an asymmetric bulge in the
32 J.A. Greenberg
inguinal area that may or may not extend into the scrotum in males.
Most other pathologies will have no obvious findings on inspection
alone. Palpation of the groin should also begin in the upright or standing
position. Many inguinal hernias can be palpated simply by placing the
hand over the inguinal canal and reducing any hernia contents into their
intra-abdominal position. The patient is then asked to cough or to per-
form the Valsalva maneuver, and the hernia contents should slide past
ones fingers. If a hernia cannot be appreciated, the index finger can be
placed into the inguinal canal by invaginating the scrotum in male
patients. With a finger placed deep in the canal, hernias can again be
appreciated with Valsalva or cough. Additionally, the inguinal occlusion
test can be performed to determine if the hernia is direct or indirect [16].
With this maneuver, the hernia contents are reduced and manual pressure
is applied over the presumed site of the deep inguinal ring. The patient
then performs a Valsalva maneuver, and one can observe if the hernia
appears with continued compression (direct) or only after release of the
internal ring (indirect). While this maneuver may help to differentiate
the types of inguinal hernia, its accuracy is relatively low and is not
likely to alter the surgical intervention [17, 18]. If no hernia is appreci-
ated, then the groin is similarly examined with the patient lying supine.
If hernias still cannot be recognized, then ancillary imaging may be
necessary or an alternative diagnosis should be entertained.
Patients with sports injuries, often suspected by the patients history,
should undergo a sequential exam of the back, hip, and groin [19, 20].
For a general surgeon, the exams will in most cases be basic, but even a
basic exam will help direct referral or image ordering. The spine and
back should be palpated along the thoracic, lumbar, and sacral vertebrae.
The paraspinal muscles should also be palpated, and the rare entity of
thoracolumbar syndrome should be ruled out when this entity is sus-
pected. The hip should then be examined with some simple maneuvers
that examine hip rotation, extension, and flexion. The rest of the exam
should focus on the groin, where a firm understanding of the musculo-
skeletal anatomy will help greatly in figuring out the precise cause of the
athletic pubalgia. The rectus muscle insertion on the pubis should be
examined with palpation and a sit-up or crunch maneuver while palpat-
ing the conjoint tendon Fig. 4.2 [11]. Reproducible pain in this area
suggests rectus sheath or conjoined tendon pathology. The pubic tuber-
cle should be palpated and pain with direct pressure can suggest osteitis
pubis [21]. Finally, the leg muscles, specifically the adductors and
abductors, can be examined by asking the patient to adduct and abduct
against resistance and noting any reproducible symptoms [20]. The hip
Fig. 4.2. The examiner places pressure on both groins, while the patient actively sits
up. Pain indicates a possible inguinal disruption injury.
flexors (iliopsoas and rectus femoris) can also be tested at this point with
leg flexion against resistance. If all is normal, yet the patient only has
tenderness over the internal ring region of the canal without a palpable
hernia, a sports hernia can then be suspected.
There are a wide variety of physical exam maneuvers that can be
employed to assess for hip joint injury as the cause of groin pain (Table
4.2) [1, 10, 2225]. Range of motion, strength, and provocative maneu-
vers may all be necessary; however, the majority of these clinical tests
have not been found to be of substantial quality to dictate clinical decision
making [26]. The majority of these maneuvers are outside the scope of
practice for most general surgeons, and if hip pathology is suspected, then
early referral to Sports Medicine or Orthopedic Surgery is warranted, as
radiographic studies will likely be necessary to make a firm diagnosis.
Another step in a pain physical exam will depend on the history. For
athletes, asking them to mimic the maneuver that was associated with
the onset of the symptom can help pinpoint the cause. Having the patient
mimic a basketball layup or a defensive tennis stance, for example, may
help reproduce the pain of an adductor tear.
Finally, the iliohypogastric, ilioinguinal, and genitofemoral nerve
distributions should also be examined and documented regarding the
Table 4.2. Clinical maneuvers for physical examination of the hip [1, 10, 2225].
34
Maneuver Examination procedure Results Possible diagnoses

Dynamic internal rotary Patient is laid supine with the contralateral leg flexed Pain Femoroacetabular
impingement beyond 90 at the hip. The ipsilateral hip is flexed to impingement
90 and passively taken through a wide arc of Labral tears
adduction and internal rotation
Dynamic external rotary Patient is laid supine with the contralateral leg flexed Pain Femoroacetabular
J.A. Greenberg
impingement beyond 90 at the hip. The ipsilateral hip is flexed to impingement

90 and passively taken through a wide arc of Labral tears
abduction and external rotation
Log roll In the supine position, the leg is internally and externally Pain and guarding Synovitis
rotated Septic joint
Heel strike In supine position, the heel is struck firmly Pain Femoral neck stress fracture
Foveal distraction With the patient supine, the leg is actively abducted to Relief of pain Intra-articular hip injury
30 and the leg is pulled away from the body
Patricks test (FABER) In the supine position, the hip is flexed, abducted, and Pain Sacroiliac joint pathology
externally rotated until the lateral heel is proximal to
the contralateral knee. The ipsilateral leg is then
lowered towards the table
McCarthy In the supine position, the hip is moved from maximal Pain in a specific Acetabular labral tear
flexion, adduction, and internal rotation to full position
extension. This is repeated with the hip starting in full
abduction as well
Maneuver Examination procedure Results Possible diagnoses
Stinchfield In the supine position, the leg is actively raised to 30 Pain or weakness Arthritis
against downward force from the examiner Synovitis
Femoral neck fracture
Iliopsoas tendinitis
Ely In the prone position, the knee is passively flexed Involuntary Rectus femoris contracture
compensatory hip
flexion
Gaenslen In the supine position with both knees flexed, one thigh Pain Spondyloarthritis
is extended over the edge of the table Arthritis
Sciatica
FADIR impingement test In the supine position, the hip is flexed, adducted, and Pain Intra-articular hip pathology
internally rotated
Ober In the lateral position with the knee flexed to 90, the hip Unable to adduct past IT band contractures
is brought into maximal extension and the leg is midline Adductor dysfunction
adducted
Thomas Both hips are flexed at the same time while one leg is Thigh cannot reach the Hip flexor contracture
brought back down to the table table
4. Chief Complaint of Groin Pain
35
36 J.A. Greenberg
presence or absence of pain or hypersensitivity along any of the

distributions. Pain mapping, described in Chap. 21, is another exam
tool to help isolate specific nerve dermatomes that are involved in
the pathology.
Radiographic Studies
While radiographic studies certainly play a role in the diagnosis and
potential management of groin pain, they are not needed for all patients.
In patients with symptomatic inguinal hernias that are palpable on physi-
cal exam, radiographic studies are unnecessary, as they will add cost to
the workup without significantly changing management. However, for
the patient with symptoms suggestive of an inguinal hernia and a normal
physical examination, imaging studies may be extremely beneficial.
Ultrasonography, magnetic resonance imaging (MRI), computed tomog-
raphy (CT), and herniography under real-time fluoroscopy can all be
used to aid in the diagnosis of occult inguinal hernias. In a systematic
review and meta-analysis of imaging techniques in the diagnosis of
occult inguinal hernias, herniography was found to have a higher sensi-
tivity and specificity than both ultrasound and computed tomography
[27]. Herniography is an invasive procedure and not without its own
complications; thus, ultrasound has become popular for the diagnosis of
occult hernias in the United States. While ultrasound has a sensitivity of
86 % and a specificity of 77 % [27], it is operator dependent and requires
some institutional expertise [28]. Despite being less sensitive and spe-
cific than other modalities, both CT and MRI of the groin can be per-
formed to assess for inguinal hernias. Of these two tests, the MRI has
less radiation exposure and a higher likelihood of discovering alternative
causes of groin pain.
For patients with histories consistent with sports injuries, osteitis
pubis, or hip joint injury, MRI of the groin and/or hip is likely to provide
the most high-yield information. Sports injuries have a variety of find-
ings seen on MRI. An MRI is dependent on the radiology read, and a
specializing sports injury MRI radiologist is often needed to get a thor-
ough enough dictation.
In skilled hands, patients with a true sports hernia can also be found
to have a protrusion of the transversalis fascia on dynamic ultrasound
[8]. Osteitis pubis can be diagnosed on MRI based on signs of inflam-
mation at the pubic symphysis [29]. Hip joint injury such as stress frac-
tures, labral tears, femoroacetabular impingement, and iliopsoas bursitis
can all be visualized on MRI as well [29]. Plain films and bone scans
may also be helpful in the detection of hip joint pathology such as regu-
lar or stress fractures and osteonecrosis.
There are no widely accepted imaging algorithms for the evaluation
of groin pain; studies should be ordered as needed on a case-by-case
basis. In my institution, herniography is not routinely performed, and
thus I utilize ultrasound when needed to diagnose an occult hernia. For
patients in whom the history and physical exam is more consistent with
an alternative source of groin pain, MRI is my diagnostic test of choice.
As expertise varies between institutions, it is prudent to discuss with
radiologists which diagnostic test is most high yield in ones hospital or
practice setting.
Documentation
Documentation of the history and physical exam should be extremely
thorough, both for accuracy and for medicolegal purposes. Whether dic-
tating, utilizing an electronic medical record, or handwriting notes, all of
the above aspects of the patients history should be incorporated into the
medical record. Many electronic medical records allow for the creation
of templates that may make it easier for practitioners to incorporate all of
the pertinent aspects of the patients history into the patients visit as well
as its documentation. When utilizing templates or copied notes, great care
must be taken to amend all documentation as appropriate, as there is a
high prevalence of errors, which may affect patient care and expose both
the patient and the physician to unnecessary risk [30].
Summary
The treatment of most causes of primary and secondary groin pain
will be thoroughly discussed throughout the remainder of this manual.
However, the initial step to all evaluations still remains obtaining and
documenting a thorough history and physical examination. When com-
bined with appropriate imaging studies, these key initial steps can help
to identify the cause of groin pain for the overwhelming majority of
patients.
Disclosures Dr. Greenberg is a paid consultant for Covidien and Bard-Davol.

38 J.A. Greenberg
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5. Groin Pain: An Overview
of the Broad Differential Diagnosis
Charles Ma and Archana Ramaswamy
Introduction
Groin pain or inguinodynia has a broad differential diagnosis.
Different processes, including but not limited to anatomic pathology,
neuromuscular, urinary conditions, trauma, and postsurgery, can cause
activation of pain fibers in the inguinal region and the subsequent sensa-
tion of pain. It is important to separate primary inguinodynia from sec-
ondary inguinodynia. This chapter first describes common causes of
primary inguinodynia and then briefly discusses groin pain after surgery.
Evaluation and management are addressed in detail in subsequent
chapters.
Inguinal Hernias and Femoral Hernias

The etiology of inguinal pain can be straightforward if a groin bulge
is the chief complaint and a hernia is palpated on exam. Common exac-
erbating factors to note in the history include major lifting or coughing.
Pain occurring later in the day, after prolonged standing or straining, is
also consistent with a hernia.
Inguinal hernias are the most common, accounting for 7075 % of
all hernias [1]. They are divided into indirect and direct forms, with the
indirect form being the most common. The pathophysiology behind an
indirect hernia is a patent processus vaginalis that failed to degenerate
after descent of testes during fetal development. This potential space
allows intra-abdominal contents to pass from the deep inguinal ring to
the superficial inguinal ring. Direct hernias are protrusions within
Hasselbachs triangle, directly through a weakened posterior wall of the

DOI 10.1007/978-3-319-21587-7_5
42 C. Ma and A. Ramaswamy
inguinal canal. Finally, femoral hernias account for a small percentage

of hernias. Classically quoted in textbooks as the third most common
type of primary hernia, femoral hernias account for 20 % of hernias in
females and 5 % in males [2]. They occur distal to the inguinal ligament
through a defect in the femoral ring, which is bound anteriorly by the
inguinal ligament, posteriorly by the iliopectineal ligament, medially by
the lacunar ligament, and laterally by the femoral vein. Though alto-
gether representing less than 10 % of all hernias, femoral hernias tend to
present more emergently with strangulation or incarceration of bowel
[3]. Definitive treatment of all hernias is surgical. Options include open
repair with or without mesh and laparoscopic repair with mesh.
Hip and Groin Pain in the Athlete

Athletes are a population of special consideration when it comes to
hip and groin pain, a symptom not uncommonly experienced by those
engaged in activities such as soccer, rugby, football, and ice hockey. The
aforementioned sports involve extensive use of the adductors and hip
flexors. Osteitis pubis, fractures, stress fractures, joint disorders produc-
ing referred hip pain, bursitis, hernias, muscular pain, tendonitis, tendon
or ligament injury, and nerve impingement are just some of the afflic-
tions that may result in groin pain [4]. Separating etiologies into extra-
and intra-articular disease processes can help narrow the differential.
Extra-articular causes include iliac apophysis injury, iliopsoas tendino-
sis, bursitis, snapping iliopsoas tendon, and athletic pubalgia. Intra-
articular causes include acetabular labral tears and femoroacetabular
impingement [5]. Fortunately, most groin pain is the result of muscle
strain and will resolve with rest. When conservative management
(including physical therapy) fails and other etiologies have been
excluded, the diagnosis of a sports hernia is made as one of exclusion.
First described by Gilmore when three professional soccer players
presented to him with unclear groin pain refractory to medical manage-
ment, sports hernias, also known as Gilmores groin, athletic pubal-
gia, or groin disruption, represent a small subset of groin pain
experienced by high-performance athletes [6]. It is a condition of
chronic inguinal pain caused by weakness in the abdominal wall without
a palpable hernia. Its true prevalence is difficult to pinpoint, as the diag-
nosis remains a clinical entity that is poorly understood, with estimates
ranging from 5 to 28 % [7]. The etiology, pathophysiology, and surgical
treatments have all been variously described in the literature. Pain is
5. Groin Pain: An Overview of the Broad Differential Diagnosis 43
located at the confluence of the origin of the rectus abdominis muscle,

the adductor longus tendon on the pubic bone, and the insertion of the
inguinal ligament on the pubic bone [8]. Pain onset is typically insidi-
ous, exacerbated by activity and improved with rest. Various surgical
techniques have been reported, ranging from standard inguinal hernia
repair with or without mesh, to incorporation of rectus reattachment in
combination with adductor release in select cases. A commonly found
area of pathology reported in the literature is the posterior inguinal wall
along the transversalis fascia [9].
Referred Groin Pain from Lumbar Disc Herniation

Referred groin pain in the absence of low back or radicular pain is
found in a small subset of patients with singular lumbar disc herniation.
A retrospective study of 512 subjects diagnosed with singular lower
lumbar disc herniation (L4-L5 and L5-S1) at Kakegawa City General
Hospital between July 1990 and December 1993 reported a 4.1 % inci-
dence of groin pain, especially in the subset of patients with L4-5
involvement [10]. A subsequent prospective study in 2010 found evi-
dence supporting degenerated intervertebral disc as an etiology for
referred groin pain: ten subjects with groin pain and single disc degen-
eration found on MR underwent evaluation of changes in pain scale after
local hip joint block, pain provocation on discography, and anesthetic
discoblock. All ten subjects had a negative hip joint block, while five
showed pain on discography and improvement in pain with discoblock,
and definitive improvement after surgical fusion [11]. The proposed
mechanism based on physiology studies in rats is the existence of over-
lapping segments of dorsal root innervation for the sensory nerve end-
ings in the lower lumbar discs, with some of the sensory nerves from the
L5 intervertebral disc coming from upper dorsal root ganglions of L2,
which supply the genitofemoral and ilioinguinal nerves [12]. Thus, it is
possible for patients to feel referred groin pain corresponding to the L2
dermatome.
Spermatic Cord and Testicular Causes

The urologic etiologies for groin pain are quite extensive, including
but not limited to epididymitis, hematocele, hydrocele, varicocele,
malignancy, orchitis, Fourniers disease, and testicular torsion.
Categorizing etiologies into urgent conditions and emergent conditions

requiring surgical intervention helps to elucidate workup and manage-
ment. Of the aforementioned etiologies, appendage torsion, epididymi-
tis, and testicular torsion make up most of the presentations of an acute
scrotum [13]. Appendage torsion occurs primarily in prepubescent
males, while the latter two occur more commonly in adolescents [14].
The true frequency of these three conditions is difficult to describe due
to variations in age distribution and study settings in the medical litera-
ture. A recent retrospective review of 523 pediatric emergency depart-
ment visits presenting with an acute scrotum found only a 3.25 %
incidence of testicular torsion, while epididymitis, appendage torsion,
and scrotal pain of unknown etiology accounted for 32.3 %, 7.7 %, and
34 %, respectively [15]. In contrast, a prior retrospective review of 238
cases of acute scrotal pain encountered in a similar pediatric emergency
department setting published in 1995 reported incidences of testicular
torsion, torsion of a testicular appendage, and epididymitis to be 16 %,
46 %, and 35 %, respectively [16]. Despite the reported disparity, the
final diagnosis of scrotal pain of unknown etiology is not uncommon as
previously mentioned. Physical exam findings such as Prehns sign
(relief of pain with scrotal elevation) and assessment of cremasteric
reflex are used in combination with ultrasound Doppler imaging to make
the appropriate diagnosis, though surgical exploration remains the only
definitive modality for assessing testicular torsion [17]. When vascula-
ture of the testicle is compromised, prompt surgical intervention within
6 h of pain onset has demonstrated greater than 90 % rate of salvage
[18].
Gynecologic Causes
Analogous to urologic etiologies in males, various gynecologic con-
ditions can also have groin pain as a presenting symptom. A 2014 retro-
spective study of 290 females of reproductive age presenting with right
lower quadrant abdominal pain found gynecologic pathology as the
etiology in 12.8 % [19]. The differential diagnosis includes but is not
limited to ectopic pregnancy rupture, ovarian cyst rupture, corpus hem-
orrhagicum cyst rupture, and adnexal torsion. Similar to management of
male urologic conditions, preserving fertility remains the goal in
management.
Ovarian cyst rupture can produce pelvic or groin pain secondary to
blood from the ruptured follicle irritating the peritoneum. A pregnancy
test and beta hCG can help quickly diagnose an ectopic pregnancy [20].
The spectrum of conditions causing ovarian cyst formation and subse-
quent rupture can range from benign physiologic conditions, such as
ovulation in the case of corpus hemorrhagicum, to malignant processes.
Large cystic lesions such as benign mature cystic teratomas, hemor-
rhagic cysts, and cystadenomas increase the risk for ovarian torsion by
predisposing the ovary to swing around its vascular pedicle [21].
Ultrasound imaging is commonly used to elucidate the diagnosis.
Hemodynamic instability can occur in all settings, and surgical options
include cyst excision and oophorectomy [22].
Secondary Inguinodynia
Ironically, chronic postoperative groin pain is one of the major com-
plications of inguinal hernia repairs with significant long-term pain seen
in a small proportion of patients after surgery. Stimulation, entrapment,
or injury to the nerves during hernia dissection can produce long-term
sequelae of neuralgia, paresthesia, hypoesthesia, or hyperesthesia. The
genital branch of the genitofemoral nerve, ilioinguinal nerve, and iliohy-
pogastric nerve are at risk with an open approach, while the lateral femo-
ral cutaneous nerve, anterior femoral cutaneous nerve, and genital or
femoral branch of the genitofemoral nerve are at risk with a laparoscopic
approach. Chronic groin pain can be potentially disabling, with signifi-
cant impact on quality of life.
The true incidence of chronic groin pain after inguinal hernia repair
is hard to determine, with varied incidence reported in the current litera-
ture. A prospective series of 419 subjects after open hernia repair found
19 % had reported residual pain at 1-year follow-up, with 6 % reporting
moderate to severe pain. Recurrent hernia and high pain score at 1- and
4-week post-op were identified as predictors of developing moderate to
severe pain [23]. Mesh use, nerve division, use of lightweight meshes,
and laparoscopic repair have all been studied for potentially reducing
post-herniorrhaphy pain, with only the latter two having shown potential
benefit [24].
A recurrence must be ruled out when confronted with this complica-
tion. Remnant cord lipomas from original surgery must also be distin-
guished from a recurrence. Neuropathic pain can be managed like other
chronic pain conditions. Anti-inflammatory medications, tricyclic anti-
depressants, nerve blocks, and acupuncture are all viable modalities,
with no strong evidence for one predominant modality in terms of effi-

cacy [25]. Operative intervention is a viable option if spontaneous reso-
lution has not occurred by 1 year. Neurectomy and neuroma excision,
adhesiolysis, muscle or tendon repair, and foreign body removal are all
possibilities, with inconclusive evidence despite favorable reported out-
comes [26].
Secondary groin pain has also been reported in the literature after
surgery in orthopedic procedures involving the lumbar spine. Injury to
the lumbar plexus is a well-known complication of lateral lumbar inter-
body fusion, a new and increasingly popular alternative for interbody
arthrodesis for degenerative spine disease that involves a lateral trans-
psoas approach to the lumbar spine. Reported incidence in literature
ranges from 0.7 to 25 % [27, 28]. Inconsistencies in defining postopera-
tive neurogenic injury and small sample size in the current literature
have contributed to this large variation. Operative time, inclusion of the
L4L5 level, and use of recombinant human bone morphogenetic pro-
tein-2 (rhBMP-2) have been identified as possible independent risk fac-
tors for iatrogenic nerve injury [29].
Conclusion
A comprehensive history and physical exam is the first step toward
differentiating primary from secondary groin pain. Though an inguinal
hernia is the most common cause of groin pain, other causes include
sports hernia, referred hip pain, spermatic cord, and testicular causes,
and various gynecologic etiologies. Secondary inguinodynia after sur-
gery is also an increasingly recognized complication of inguinal and
spine surgery.
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6. Groin Pain Etiology: The Inguinal
Hernia, the Occult Inguinal Hernia,
and the Lipoma
Ibrahim M. Daoud and Katherine Dunn
Inguinal Hernia
Epidemiology/Etiology The inguinal hernia is one of the most com-
mon reasons that a general practitioner would refer a patient to a general
surgeon. Inguinal hernias can present with a wide array of symptoms,
including groin pain, burning, aching, or worsening pressure in the groin
throughout the day. Those with hernias may also complain of a lump or
a bulge on the affected side. On the other hand, many patients do not
complain of a bulge, but instead present with a chief complaint of groin
painunaware of the vast differential diagnosis list involved. Though
the differential diagnosis for groin pain is quite long and can include
such diagnoses as chronic appendicitis, diverticulitis, urologic diseases,
and gynecological processes, an inguinal hernia is a common cause not
to be overlooked [1]. This chapter focuses on inguinal hernias, as well
as on the occult inguinal hernia, and the lipoma of the spermatic cord or
round ligament.
Abdominal wall hernias account for 4.7 million ambulatory care
visits each year, more than 600,000 of which are inguinal hernias that
undergo repair [2]. Inguinal hernias present with a 9:1 male predomi-
nance, are more common on the right, and are most commonly in the
4059 year age group. Indirect hernias are twice as likely to be present
when compared with direct hernias [3]. In women, as in men, indirect
hernias are the most common inguinal hernia. Femoral hernias, how-
ever, are relatively more common in women when compared to men,
comprising 20 % of all groin hernias in women [1].

DOI 10.1007/978-3-319-21587-7_6
50 I.M. Daoud and K. Dunn
Other pertinent hernias that could contribute to groin pain include

Spigelian hernias, obturator hernias, and Pantaloon hernias. Pantaloon
hernias occur when there is both a direct and indirect hernia component.
A Spigelian hernia is usually small and presents with bowel incarcera-
tion or strangulation in approximately 25 % of cases [1]. This defect is
seen as a protrusion through the transversals fascia lateral to the edge of
the rectus muscle, medial to the Spigelian line, and midway between the
umbilicus and pubis at the level of the semicircular line of Douglas [1].
The obturator hernia is rare and often presents as a surgical emergency
as a peritoneal pouch with accompanying small bowel, which may be
incarcerated or strangulated as it follows the course of the obturator ves-
sels through the obturator fossa. Such hernias are five times more com-
mon in women than men and most often present between the ages of 50
and 90 [1].
Diagnosis Though study data are limited, inguinal hernia can most
often be diagnosed with a detailed history and physical examination.
One such study by van den Berg et al. showed that history and physical
alone can detect an inguinal hernia with a sensitivity of 75 % and speci-
ficity of 96 % [4]. A history consistent with symptoms of gurgling and
burning pain in the groin area would raise suspicion of inguinal hernia.
Worsening symptoms or groin bulge with performance of Valsalva
maneuvers or any activities such as heavy lifting, straining, or coughing
that serve to increase intra-abdominal pressure help support this diagno-
sis. These activities could also cause a groin bulge to increase in size. If
a patient reports that this bulge disappears in the supine position, there
should be a high clinical suspicion of a groin hernia [5].
Physical exam should be performed with the patient in the upright
position. It should include a close inspection of the inguinal and femoral
regions for visible bulges. Palpation of the region should include a
Valsalva maneuver from the patient in an attempt to elicit a palpable
herniation [2]. If physical exam is inconclusive for inguinal hernia, there
are several radiographic modalities such as CT, MRI, and ultrasound
that can be utilized; these are discussed in further depth in the occult
inguinal hernia section.
Treatment The main debate in elective treatment of unilateral ingui-
nal hernia repair revolves around open versus laparoscopic herniorrha-
phy. The open, tension-free, Lichtenstein repair is one of the most
common general surgery procedures in the world and is the most
6. Groin Pain Etiology: The Inguinal Hernia, the Occult 51
accepted form of unilateral herniorrhaphy [6]. Laparoscopic repair,

including both TEP and TAPP repair, is recognized as superior in bilat-
eral hernia repair and in cases of recurrent hernia. Argument can also be
made to perform a unilateral hernia repair laparoscopically, leading to
less postoperative pain, quicker return to physical activity, lower inci-
dence of chronic groin pain, and similar recurrence rates [7].
The main disadvantage of unilateral laparoscopic repair involves the
long learning curve in mastering the delicate laparoscopic dissection
techniques and groin anatomy. It has been said that one becomes confi-
dent with the procedure with 80 cases and mastery comes with 250 cases
[7]. Other disadvantages include the need for general anesthesia, and the
complications with laparoscopic repair, though rare, can also be more
serious, as they include vascular or visceral injury [8].
With unilateral repair it is still, therefore, up for debate whether to
perform laparoscopic or open repair. This should depend on surgeon
preference and comfort level. The type of repair also depends on indi-
vidual patient needs, including if the patient has any contraindications
for laparoscopic surgery or general anesthesia, in which case open her-
niorrhaphy would be preferred.
Occult Inguinal Hernia

Epidemiology/Etiology Inguinal hernias, as discussed above, are
often diagnosed with history and physical exam alone, and treated
accordingly. Occult hernias, which include direct, indirect, femoral, and
obturator hernias, can present with a story consistent with that of a groin
hernia but without the physical exam findings to support the diagnosis
[9]. This is when radiographic studies may be of assistance. Additionally,
occult hernias can often be discovered at the time of laparoscopic hernia
repair.
In those who present with groin pain, aching, discomfort, or intermit-
tent groin swelling with equivocal or negative physical exam findings,
it is important to consider occult inguinal hernia as a possible diagnosis
[10]. The definition of occult inguinal hernia is not well defined in the
literature, and it is often left open to a wide range of interpretations. In
a 2013 study by van den Heuvel et al., there is a distinction made
between true occult inguinal hernia, which is repairable at the time of
surgery, and incipient hernia, which defines a small defect with a shal-
low hernia sac in which there is no herniation of intra-abdominal con-

tents [11]. In this study, they found that the incidence of a contralateral
occult inguinal hernia was 13 % when TAPP repair of a clinically
palpable inguinal hernia was performed. Of these, 8 % were true occult
hernias and 5 % were incipient. True occult hernias were repaired at the
time of exploration, and the incipient hernias were followed closely,
21 % of which became symptomatic, requiring additional surgery.
In a 2012 study by Garvey, it was found that of those with symptoms
suggestive of hernia, in the absence of clear physical exam findings,
33 % of patients who underwent CT examination were found to have an
occult inguinal hernia. This was then confirmed in the operating room
with 94 % accuracy. As discussed below, CT may not be the best imag-
ing modality, but this figure of 33 % serves to show the approximate
incidence of those with occult inguinal hernia who present with groin
pain [10].
In discussing occult hernia, women are an important population to
consider. Groin pain can be a common symptom in women with a dif-
ferential diagnosis similar to men, including urologic, gastrointestinal, or
musculoskeletal causes with the addition of gynecologic disorders [12].
The population of women with chronic pelvic pain is also important to
consider, as pelvic pain often includes the inguinal region [13]. Hernias
are often smaller in females, leading to an undetectable clinical impulse
on exam due to the absence of a processes vaginalis [14]. Of the approxi-
mately 20 million hernia repairs performed to date, only 68 % of these
have been performed in women. It has been suggested, however, that
occult hernias may be relatively common in women suffering from groin
pain, especially those who experience worsening of symptoms with
activity. Given the normal physical exam findings, these women can
often have a prolonged symptomatic period before a correct diagnosis of
groin hernia is achieved. As in men, it is important to consider and diag-
nose a hernia before it presents as a surgical emergency [15].
Diagnosis The diagnosis of occult inguinal hernia can be tricky, as
there is often groin pain and suspicion of a hernia but no discernible
physical exam findings by general practitioner or surgeon. A meta-
analysis by Robinson et al. served to evaluate herniography, CT, MRI,
and ultrasound in finding occult inguinal hernias in those presenting
with groin pain. Herniography proved to be the most accurate modality,
with an overall sensitivity of 91 % and specificity of 83 %. Conversely,
CT showed a sensitivity of 80 % and specificity of 65 %. Ultrasound,
being largely operator dependent and with limited available data for this
meta-analysis, has a sensitivity of 86 % and specificity of 77 % [9].

Towfigh and colleagues recently published a review of their series and
found that when an occult hernia is suspected, an MRI was the best
image modality to order [16].
All of the above diagnostic modalities have unique drawbacks.
Herniography, though seemingly the most accurate, is the most invasive,
second only to surgery, and utilizes contrast medium, which can elicit an
allergic reaction. It is also of no use in determining alternative causes for
the complaint of groin pain, and is thus rarely used in clinical practice.
CT carries with it the risk of radiation exposure, and the patient is unable
to stand for the study [10]. Ultrasound is largely operator dependent,
though inexpensive and noninvasive. With ultrasound, there is also
added benefit of the capability to image the patient in various positions
with certain maneuvers to better elicit the hernia impulse.
Not included in the meta-analysis discussed above is the study by
Garvey, which looks exclusively at the use of CT in the diagnosis of
occult inguinal hernia. This was chosen because it helps to evaluate
hernia in obese patients, where ultrasound may be limited. CT is more
affordable than MRI, for which there is still limited data on its use in
occult hernia diagnosis. CT was found to have an accurate diagnosis
94 % of the time in a carefully selected group of patients. The author of
this one study, however, continues to use ultrasound as his preferred
imaging method, and reserves CT for obese patients [10].
Although most of the studies mentioned above focus on a mixed
population, they favor diagnosis in men. Imaging to diagnose women
with occult hernia is similar, with herniography as a popular method in
Europe [12]. Given the invasive nature of herniography, Grant et al.
looked at ultrasound specifically for the diagnosis of groin hernia in
women with normal or inconclusive physical exam findings. The ultra-
sound was used to look for occult direct, indirect, and femoral hernias.
The main benefit of ultrasound is that fact that the Valsalva maneuver
can be performed, often making the hernia apparent [12]. Though the
literature reports that indirect inguinal hernias consist of 70 % of the
groin hernia diagnoses in women, the study by Grant et al. found that
direct hernias were more common in those with normal exam findings.
Of the hernias found on ultrasound and confirmed in the operating room,
48 % were direct hernias. This discordance is likely due to the fact that
direct hernias are more difficult to detect on physical examination. This
study showed that ultrasound in women with groin pain has a 95 %
sensitivity and 75 % specificity [12].
In the population of women with chronic pelvic pain, and a story

suggestive of occult hernia, laparoscopy may be the most effect diagnos-
tic tool. In a single center study done of 365 women with chronic pelvic
pain ranging from 6 months to 20 years, only 2 % had normal findings
on laparoscopy. These patients had suspicion of occult hernia based on
signs and symptoms of inguinal pain radiating to the labia or thigh and
reproduction of pain of the internal ring on external palpation or by
bimanual exam. Of those with abnormal laparoscopic findings, 77 %
indirect hernias were identified, 65 % of which had a large internal ring
with incarcerated fat. Additional findings included direct hernias in
20 % of the patients, femoral hernias in 40 %, obturator hernia in 2 %,
and bilateral hernias in 40 %. Overall, after repair, 74.69 % of the
patients reported complete relief of their pain, 17.83 % noted significant
improvement, and the remainder showed no change [13].
It is clear that more studies are needed to prove the best means of
diagnosing occult hernia, as everything from ultrasound to diagnostic
laparoscopy has been utilized. It seems, however, that modality of
choice should depend on physician preference, patient body habitus,
suspicion of occult hernia based on symptoms reported, and lack of any
other clear diagnosis.
Treatment Laparoscopic repair is advantageous, as those with a
known inguinal hernia may often be found to have an existing occult
hernia, notably as a femoral or obturator hernia. There is often a low
preoperative detection of femoral and obturator hernias. The dissection
during a laparoscopic hernia repair may more easily identify these
defects and prevent them from causing continued groin pain or becom-
ing a surgical emergency [17]. Occult hernia is found between 9 and
36 % of the time on the contralateral side during laparoscopic repair [8].
Despite longer operative times, Pawanindra et al. proposed bilateral
exploration and repair in all cases of TEP repair for unilateral hernia, as
they found contralateral occult hernia in 25 % of the cases [8]. They
noted that this should be done only in high volume centers in the hands
of advanced laparoscopic surgeons. With limited data on this matter, it
seems that contralateral exploration and repair are warranted in one
where there are risk factors for hernia development or high clinical
suspicion of an occult contralateral hernia. It is reasonable to offer bilat-
eral exploration and repair as an option to patients who may wish to
avoid further surgery [8].
Lipoma
Epidemiology/Etiology Lipoma of the spermatic cord and round liga-
ment is understood as an extension of the preperitoneal fat, and not as a
true benign neoplasm, in the majority of the anatomical and surgical
literature. The pathogenesis is largely unknown, but it is thought that
this projection of fat through the deep inguinal ring may cause it to dilate
and predispose one to indirect hernia. These cord lipomas most often do
not have a peritoneal sac, but can nonetheless cause symptoms identical
to that of a groin hernia [18]. By this definition of cord lipoma, they are,
in effect, all indirect in nature. Spermatic cord lipomas as direct exten-
sions of preperitoneal fat were found in the absence of a hernia with an
incidence of 3675 % on male autopsies, and lipomas of the cord and
round ligament are found with an incidence of 2173 % during hernior-
rhaphy [19, 20].
These lipomas have often been considered as an incidental finding at
the time of hernia repair. One such study by Carilli et al. showed that
there was a 72.5 % incidence of incidental cord lipoma found with an
indirect hernia at the time of open repair [21]. The incidence of cord
lipoma was greater with larger hernias, and it has also been suggested
that excessive body weight may predispose one to such a lipoma [21].
Cord or round ligament lipoma occurring in conjunction with an
inguinal hernia is more likely to be missed when performing laparo-
scopic herniorrhaphy, especially TAPP repair [22]. There are often times
when TAPP repair is to be performed for a clinically palpable mass, and
upon visualization, the peritoneum appears normal. In these several
instances, incision of the peritoneum and exploration have revealed an
inguinal cord lipoma [19]. This raises the question of the significance of
potentially overlooked lipoma in relation to groin pain with the increas-
ing popularity of laparoscopic herniorrhaphy [23]. These lipomas do
occur with significant incidence, and they can cause hernia-type symp-
toms even without the presence of a true inguinal hernia [18]. It is often
important to remember the potential presence of a lipoma if a patient is
still experiencing pain after inguinal herniorrhaphy, especially when
done laparoscopically.
Diagnosis Spermatic cord lipomas are diagnosed in much the same
way as an inguinal hernia. On imaging studies, they may be misdiag-
nosed as inguinal hernia. As they consist of preperitoneal fat, lipomas
of the round ligament or spermatic cord are not reliably diagnosed
with a herniogram [24, 25]. The one difference in imaging is on CT

examination, where an inguinal cord lipoma is mesenteric fat passing
through the inguinal ring, and an indirect inguinal hernia often has a
radiographically visible sac [20]. There is limited literature on the
diagnosis of inguinal cord lipoma alone, as it is mostly found on surgi-
cal repair of an inguinal hernia. This is an important diagnosis to
consider during the time of herniorrhaphy because an undiagnosed and
untreated cord lipoma may cause groin pain to persist or predispose
the patient to a recurrent hernia after repair. Exploration of the cord,
therefore, should take place if initial laparoscopic inspection is nega-
tive for hernia and the patient has a convincing history consistent with
hernia-type symptoms [19].
Treatment Though the lipoma, in most instances, has no pathologi-
cal changes suggesting it is a true lipoma, but rather an extension of
extraperitoneal fat protruding through the inguinal canal, it may still
cause hernia-type symptoms warranting treatment [21]. The distinction
between indirect inguinal hernias and inguinal cord lipomas is not nec-
essarily important; if they are symptomatic, they both should be treated
with open or laparoscopic surgical repair [20].
Conclusion
Inguinal hernias, whether occult or obvious, and lipomas of the sper-
matic cord or round ligament are important etiologies to consider in the
diagnosis of groin pain. A supportive clinical history and a well-per-
formed physical exam can diagnose inguinal hernias the majority of the
time. Imaging may be useful when there is a history indicative of hernia
but an equivocal physical exam. Given the multiple imaging modalities
available with different benefit and risk profiles, the choice of MRI, CT,
or ultrasound is often provider specific. MRI, however, has recently
been shown as potentially the best modality for diagnosis of occult her-
nia. Additionally, diagnostic laparoscopy serves an important purpose in
diagnosing the occult hernia. This is especially the case in women with
chronic pelvic pain, in whom it is beneficial because diagnosis and
repair can be performed at the same time. Lipomas of the cord and round
ligament cause similar pain to that of a hernia and should be diagnosed
and treated in the same fashion. In all cases, when a patient is symptom-
atic from a hernia or lipoma of the cord, it should be repaired via a
laparoscopic or open approach. Laparoscopic repair clearly has its

benefits with bilateral hernias and when contralateral occult hernias may
be suspected. Often the fashion of repair depends on surgeon preference
and proficiency as well as patient body habitus, previous abdominal
surgeries, risk factors, and preference.
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7. Groin Pain Etiology: Athletic
Pubalgia Evaluation and Management
Gregory J. Mancini
Introduction
Athletic pubalgia (sports hernia) is a cluster of distinct injuries that
are grouped together because of the common location of pain, overlap-
ping activity triggers, and lack of physical exam findings. The chronic
painful symptoms that occur in otherwise healthy, athletic, and young
individuals add a psychosocial layer to an already complicated medical
condition. Most injuries to athletes result from a single action or colli-
sion. There are obvious physical findings of this injury such as swelling
or a contusion. These injuries are routine and fully heal with time and
basic care. But athletic pubalgia is much more insidious. It develops
slowly over time without pain until a relatively minor event halts the
activity. There is rarely any outward sign of the injury. The pain may not
be present with walking or light physical activity, but manifests at full
athletic speeds. In athletic pubalgia, the routine 24 weeks of rest is
often not sufficient for full resolution of symptoms. The resulting confu-
sion and misinformation have clouded the understanding of athletic
pubalgia for athletes, trainers, coaches, parents, and even most medical
professionals. This chapter aims to show that athletic pubalgia can be
subdivided into three distinct entities, each with its individual treatment
recommendations. Most cases of athletic pubalgia are found to be an
occult inguinal hernia, osteitis pubis, or a regional nerve entrapment
syndrome. The description, diagnostic methodology, and treatment
options for each are hence detailed.

DOI 10.1007/978-3-319-21587-7_7
60 G.J. Mancini
Occult Hernia
Background An occult inguinal hernia is a true hernia of the
myopectineal orifice that is indicated by symptoms of groin pain,
worsened by activity, but not clinically apparent on physical exam or
basic imaging. This entity is a common clinical conundrum posed to
surgeons on nearly a daily basis. As an example, a middle-aged male is
sent by his primary care physician with left inguinal pain limiting his
daily work activities, but on exam no hernia can be found. This has been
traditionally labeled a groin sprain, and six weeks of lifting restrictions
and scheduled oral NSAIDs are recommended and prescribed. An occult
hernia is often termed athletic pubalgia, not because of its symptoms
without physical exam findings, but rather its presentation in the age and
demographics of the patient. If the prior example is changed to a healthy
18-year-old male soccer player who had left inguinal pain only while
playing, but not at rest, the label of sports hernia will be given. It is
estimated that occult hernia comprise 1015 % of inguinal hernia disease,
and therefore all patients presenting with symptomatic inguinal region
pain should be considered to potentially have an occult hernia [1]. Occult
hernia can be a cord lipoma or indirect hernia sac that tracks along the
spermatic cord within the inguinal canal creating compression on the
ilioinguinal or genitofemoral nerves. Similarly, an occult hernia can be a
weak transversalis fascia allowing the floor of the inguinal canal to
bulge, compressing the nerves. An intact superficial inguinal ring will
limit the physicians examination and thereby mask the true hernia,
making it difficult to diagnose.
Diagnosis Determining the presence of an occult hernia is difficult
based on physical exam alone. Clinical suspicion begins with a thorough
review of the patients duration, location, and triggers of the pain symp-
toms. Up to one-third of patients with groin pain will have occult hernia
as the pathologic cause of their symptoms. Patients with occult hernia
often have physical triggers of pain that can be provoked by a position
change such as bending over or increase of intra-abdominal pressure
such as Valsalva maneuver.
Imaging is an important adjunct to assist the identification of an
occult hernia. There are several different imaging modalities with each
having their relative strengths and weaknesses. Ultrasound is a low-cost
and low-risk diagnostic imaging test. For occult hernia, the sensitivity
and predictive values are greatly dependent on the ultrasound technolo-
gists expertise and the patient position during the exam. Performing the
ultrasound exam while the patient is standing and performing a Valsalva
7. Groin Pain Etiology: Athletic Pubalgia Evaluation 61
can enhance detection of the occult hernia [2]. Multiple published studies
from 1981 to the present show a sensitivity of 7097 % for occult hernia.
The positive predictive value ranges from 90 to 95 % [35].
Computed tomography (CT) scan of the abdomen, to include the
pelvis, is another diagnostic imaging option used to detect occult her-
nia. This modality is less operator dependent but has added cost and
radiation exposure to the patient. Though the patient is supine for this
test, a Valsalva maneuver during the scanning process can enhance her-
nia detection. Figure 7.1 shows the cross-sectional image of an occult
bilateral inguinal hernia, the left being more obvious than the right.
Garvey et al. showed that in 158 patients with groin pain, no hernia on
exam, and then a subsequent CT scan, 54 patients (33 %) had evidence
of an occult inguinal hernia. At surgery, 49 were confirmed to have a
hernia, 3 had cord lipoma, and 2 had no inguinal pathology. This study
modality yields a positive predictive value of 92 %, a negative predic-
tive value of 96 %, and an overall accuracy of 94 % [6].
Fig. 7.1. Cross-sectional image of an occult bilateral inguinal hernia, left more
obvious than right.
62 G.J. Mancini
Magnetic resonance imaging (MRI) of the abdomen has a significant

role in the diagnostic evaluation of athletic pubalgia. It has a cost higher
than both ultrasound and CT, but no ionizing radiation of CT. Its sensi-
tivity to demonstrate soft tissue edema differences in T2-weighted
images is critical to identify non-hernia causes of groin pain. As for
occult hernia detection, MRI has been shown to have a sensitivity and
specificity figures of 94.5 and 96.3 % [7].
Treatment Treatment of occult hernia is fairly straightforward. This
can be done as an open or laparoscopic technique. Laparoscopy is often
suggested as a bridge between a diagnostic and therapeutic modality for
occult hernia. This is a false logic, as a diagnostic laparoscopy will miss
fat-containing hernias that give a normal contour to the pelvic floor. The
peritoneum must be taken down in either a transabdominal pre-
peritoneal (TAPP) or totally extraperitoneal (TEP) technique to ensure
all hernia sites and pathologies are evaluated. By combining thorough
patient history, physical exam, and the optimal imaging modality, the
risk of missing an occult hernia can be less than 5 %.
Osteitis Pubis
Background Osteitis pubis is an important clinical entity that
deserves significant consideration in any patient who presents with groin
pain without obvious hernia on exam. Several clinical features separate
osteitis pubis from other groin pain diagnoses. The pain most commonly
localizes within the lower abdominal wall and tends to be more medial
(between the external ring and the pubic symphysis). As radiographic
technology has improved, osteitis pubis is now recognized as a cluster
of different injuries to the muscles, tendons, and osseous structures of
the lower abdominal wall and pelvis. These include rectus tendinitis,
conjoined tendonitis, pubic ramus avulsion fractures, and pubis
symphysitis, adductor tendonitis, and gracilis tendonitis. The mechanism
of injury in athletic pubalgia combines two physical phenomena:
repetitive motion injury and muscle development asymmetry. Individuals
at highest risk for the development of osteitis pubis are young athletes in
sports that require high-intensity training in which quick changes in
speed and direction are required. Another component of this injury
mechanism is long-term training in which asymmetric muscle
development is promoted. This muscle development imbalance can be
either between legs and torso or between right and left sides of the body.
For example, when the foot is planted to accelerate speed or change

of direction, the power in the legs must be balanced by the torso to move
the entire body in the same direction. As the adductor and gracilis
muscles contract, they exert pulling force on the inferior edge of the
pubic ramus and pubic symphysis. The pubic symphysis acts to stabilize
both halves of the pelvis to the opposing force vector. The rectus muscle
then contracts to bring the torso in line with the new vector force, exert-
ing a pulling force on the superior edge of the pubic ramus and symphy-
sis. If the athletic training activity promotes leg muscle development
over abdominal wall muscle development (typically the rectus muscle),
or promotes right-sided muscle development over the left, a relative
pelvic instability can develop. This allows chronic and recurring muscle,
tendon, or symphyseal trauma that is collectively known as osteitis
pubis. This injury mechanism helps to explain why certain sports and
athletic positions have a higher incidence of osteitis pubis: the football
player who stops and starts by planting the same pivot foot, the soccer
player or punter who plants the left foot and creates the burst kick with
the right foot, and the sprinter who explodes from the starting block
using the same staggered foot position.
Diagnosis The diagnosis of osteitis pubis begins with a history and
physical exam. High-intensity athletes doing year-round training in
sports like soccer, football, and track have the highest incidence of
injury for the reasons explained above [8]. Commonly, the patient will
admit to a chronic and recurring set of symptoms for which they have
self-medicated or self-limited their training to allow healing. But upon
restarting competitive training, the symptoms recur, and they seek the
surgeon to help get back to full speed.
The goal of the physical exam is to best localize the focal area of
pain. Osteitis pubis can be divided into three zones for focal pain: supra-
pubic, intrapubic, and infrapubic. Suprapubic sources of pain include
injuries to the rectus muscle, rectus tendon, conjoint tendon, and the
periosteum of the pubic rami. Intrapubic sources of pain stem mainly
from injury to the pubic symphysis and its fibrocartilaginous interpubic
disk. Infrapubic sources of pain include injury to the gracilis muscle, the
adductor longus muscle, the tendinous origins of these muscles, and
periosteum of the pubic rami.
On examination, the pain can often be elicited by manual palpation.
A pubic symphyseal injury can be assessed by performing the spring
test. With the patient in supine position, the examiner places direct
downward pressure with a hand on each side the pubis. Pain with a
64 G.J. Mancini
rocking motion can indicate instability and inflammation of the

fibrocartilaginous interpubic disk. Rectus abdominis tendonitis can be
assessed with downward pressure medially and above the pubis and
may elicit pain in rectus tendon origin on the pubic crest. It can be dif-
ficult to assess for laterality, and this injury can be bilateral in nature.
Manual pressure applied slightly more laterally, but medial to the exter-
nal ring, may indicate conjoint tendonitis. Less severe symptoms not
provoked by manual exam may be elicited by a series of exercise tests.
A simple bent-knee sit-up, a sitting resistance to thigh adduction
maneuver, or a cross-legged resistance to knee lift may produce the
typical symptoms [9]. The pain generated by injury to the adductor
longus or gracilis typically presents below the inguinal canal, but may
radiate to the medial thigh and scrotum. Both the adductor longus and
gracilis muscles share their origin on the anterior surface of the inferior
pubic ramus. The insertion on the surface of the femur defines the
adduction movement that this muscle group has. The adductor or graci-
lis damage most often occurs at the origin in the pubic rami. This can
be muscle and tendon tearing or periosteal microfractures of the pubic
bones. On physical exam, pain can typically be elicited by deep palpa-
tion of the inferior pubic ramus. A provocative maneuver on examina-
tion is a bent-knee raise or a sitting resistance to thigh adduction.
Radiographic evaluation of osteitis pubis is a valuable method to
validate the clinical exam in the diagnosis of osteitis pubis. Though
modalities such as plain pelvic x-ray, ultrasound, CT, and nuclear medi-
cine study have been used to help make the diagnosis, MRI has become
the main imaging modality to both diagnose and confirm resolution
of the inflammatory process [10]. Figure 7.2 demonstrates a tendon tear
in the adductor longus at the pubic bone. Note the increased tissue
edema indicated by the smudged appearance of the tissue. In fact,
because of MRIs sensitivity for musculoskeletal edema changes, it may
lack usefulness as a screening modality for asymptomatic at-risk indi-
viduals. A 2006 study of scholarship male soccer players showed that
MRI scans showed moderate to severe bone marrow edema at the pubic
symphysis in 11 of the 18 asymptomatic players. Substantial amounts of
bone marrow edema at the pubic symphysis can occur in asymptomatic
soccer players, and it is only weakly related to the development of oste-
itis pubis [11]. Therefore, MRI should be used to confirm the clinical
suspicions provided by the history and physical exam.
Treatment Treatment of osteitis pubis is a simple prescription that is
hard to follow for the patient and sometimes the trainer, coach, or parent.
After the diagnosis is made, immediate cessation of strenuous and
Fig. 7.2. Tendon tear in the adductor longus at the pubic bone. Note the
increased tissue edema indicated by the smudged appearance of the tissue.
aggravating activities is mandated. The mainstay treatment is typically

nonoperative, most commonly beginning with 6 weeks of rest, though
low-impact and cardiac workouts can often be tolerated. Daily sched-
uled nonsteroidal anti-inflammatory medications are prescribed as toler-
ated. After the 6 weeks of rest, a rehabilitation program focused on
cross-training types of stretching and lifting exercise can be started with
a physical therapist [12]. The goal with rehabilitation is to establish
muscular balance between the adductor and abdominal regions, thereby
reducing the risk of early reinjury. Fricker et al. reported an average time
to full recovery after conservative treatment of 9 months for men and
7 months for women [13]. If symptoms do not resolve after rest and
rehabilitation programs, a corticosteroid injection treatment may be
considered. A 3 mL mixture of 1 % lidocaine, 0.25 % bupivacaine, and
4 mg of dexamethasone injected into the interpubic disk of the pubic
symphysis has reported good results in immediate pain relief and pro-
gression to full activities in a case series [14].
66 G.J. Mancini
Unique to the adductor longus tendonitis is the possibility of surgical

tendon release. Due to the redundancy in adductor musculature of the
thigh, release of the adductor longus at its pubic bone origin is well
tolerated with little loss of adduction strength and function. Gill et al.
describe the surgical technique [15]. For those whose rest, rehabilitation,
and corticosteroid injection fail to permit full recovery, the diagnosis of
osteitis pubis must be questioned. Alternative chronic joint inflamma-
tory conditions such as rheumatoid arthritis should be considered. Also,
though rare, infectious osteoarthritis should be investigated. These diag-
noses may lead to surgical debridement of the pubic bone and the dam-
aged disk.
Nerve Entrapment Inguinal nerve entrapment is a painful condition
that is most associated with post-hernia surgery complaints. In the con-
text of athletic pubalgia, nerve entrapment is a primary anatomic prob-
lem that should be in the differential diagnosis of athletes with groin
pain that limits competitive or training activities. There are three distinct
nerves in the inguinal region that have well-documented pathology and
treatment strategies: ilioinguinal, genitofemoral, and obturator nerve
entrapment syndromes. We will consider each separately.
Ilioinguinal Nerve Ilioinguinal nerve entrapment was described by
Kopell in the New England Journal of Medicine in 1962 [16]. The
ilioinguinal nerve originates from the L12 nerve roots and has both
motor and sensory functions. The motor innervation of the transver-
sus abdominis and the internal oblique muscles generates muscle tone
in the lower lateral abdominal wall. The sensory function gives touch
and temperature sensation to the skin over the inguinal ligament, labia
majora or scrotum, and the medial thigh. The pain syndrome can be
caused by irritation, injury, or trauma to the nerve as it exits the ret-
roperitoneum and pierces both the transversus abdominis and internal
oblique muscles to travel within the inguinal canal. It is not a problem
limited to athletes, but rather the entrapment may be an anatomic vari-
ant whose injury is worsened by intense physical training. A second
mechanism is injury to the nerve and can be related to tears in the
overlying external oblique aponeurosis that entrap the nerve. This
injury has been coined hockey players hernia. Regional dermatome
mapping can be done in the office to demonstrate if a specific nerve
distribution correlates with the patients symptoms. Figure 7.3 is an
office dermatome mapping that shows ilioinguinal nerve distribution
as a possible source of pain.
Fig. 7.3. Office dermatome mapping that shows ilioinguinal nerve distribution
as a possible source of pain.
Knockaert et al. describe three hallmark clinical findings that suggest

ilioinguinal nerve entrapment in patients. First is unilateral groin pain
that radiates from the anterior spine of the anterior iliac crest to the scro-
tum or labia majora and medial thigh. The second feature is a cutaneous
hyper-, hypo-, or dysesthesia in the same nerve distribution as the pain.
The third finding is a reproducible trigger point located 23 cm below
and medial to the anterosuperior iliac spine. This trigger point should be
relieved by injection of a local anesthetic [17].
Genitofemoral Nerve The genitofemoral nerve is a less likely
source of pain in athletic pubalgia than any other nerve entrapment
syndrome. Most reports of genitofemoral pain symptoms can be attrib-
uted to previous surgery in the groin region, such as appendectomy, a
Pfannenstiel incision, or an inguinal hernia incision. Its sensory der-
matome overlap with the ilioinguinal nerve makes differentiating the
68 G.J. Mancini
two nerve injuries quite difficult. Like the ilioinguinal nerve, the geni-
tofemoral nerve arises from the ventral rami of L12 and follows the
psoas muscle into the pelvis. The nerve bifurcates, and the genital
branch accompanies the spermatic vessels through the inguinal canal.
Its branches pierce the internal spermatic fascia to supply muscular
fibers to the cremaster muscle, and its sensory fibers terminate in the
skin of the scrotum or labia majora. The location of the nerves bifur-
cation is variable, but typically occurs in the retroperitoneum, such
that injury to the nerve trunk is rare. Most of the symptoms and trig-
gers of genitofemoral nerve entrapment are therefore correlated to the
genital branch of the nerve.
Like the ilioinguinal nerve, genitofemoral nerve pain may be con-
stant and radiate to the groin region, and a hyperesthesia to the skin of
the region may be present. Pain may also be aggravated by activities
such as walking, bending over, or hyperextension of the thigh and ame-
liorated by lying flat and flexion of the thigh. Likewise, the trigger point
pain should be relieved by injection of a local anesthetic [18].
Obturator Nerve Obturator nerve entrapment can be a difficult diag-
nosis to make. Its anatomic course through the pelvis protects it from
injury in common surgical procedures, unlike the ilioinguinal and geni-
tofemoral nerves. The obturator nerve arises from the anterior divisions
of L24 nerves.
It descends through the fibers of the psoas major muscle and emerges
from its medial border, running behind the common iliac arteries toward
the obturator foramen. It then enters the thigh through the obturator
canal and splits into anterior and posterior divisions. The anterior divi-
sion descends between the adductor longus and adductor brevis muscles,
giving off motor branches to the adductor longus, adductor brevis, and
gracilis muscles. It then pierces the fascia lata terminating in the cutane-
ous branches, giving sensation to the medial thigh. The posterior divi-
sion passes anteriorly to innervate the adductor magnus. As the primary
motor nerve to this muscle group, the obturator nerve is critical for leg
adduction.
The clinical presentation of obturator nerve entrapment is pain, par-
esthesia, or hyperesthesia of the medial thigh, below the inguinal liga-
ment. Due to the distinct dermatome involvement, obturator neuralgia is
rarely confused with ilioinguinal or genitofemoral neuralgias. But its
pain localization below the inguinal ligament can make clinical differen-
tiation from adductor tendonitis quite difficult. Bradshaw et al. described
obturator neuropathy in athletes as a result of fascial entrapment as the
nerve enters the thigh, specifically in the adductor compartment [19].
Induced by exercise, the pain has a characteristic clinical pattern of

medial thigh pain commencing in the region of the adductor muscle
origin and radiating distally along the medial thigh, with strenuous
exercise. An anatomic study on cadaver limbs by Harvey and Bell
reinforced the concept that obturator neuropathy is caused by an entrap-
ment syndrome due to the angle that the nerve pierces the adductor
muscles and travels between the adductor fascial compartments [20].
In athletes, congenital anatomic nerve variants combined with physical
training that augments adductor muscle development may be the
main mechanism for obturator nerve entrapment syndrome in athletic
pubalgia.
In addition to the sensory abnormalities, motor deficits can be found
in advanced cases of obturator nerve entrapment. Physical exam may
reveal asymmetry between affected and non-affected sides, with weak-
ness and atrophy of adductor muscles on the affected. MRI will rarely
show nerve-related injury, but is helpful to rule out adductor or gracilis
tendonitis involvement. In cases where the MRI is normal, but clinical
suspicion is high, the best test to confirm obturator neuropathy is needle
electromyography (EMG). Kimura et al. noted that fibrillation potentials
or high-amplitude, long-duration complex motor unit potentials were
consistent with chronic denervation of the hip adductor muscle group,
but not in other lower extremity muscles [21].
Treatment of Nerve Entrapment Syndromes

Nerve pain is generally as hard to treat as it can be to diagnose. The
longer the pain symptoms have persisted, the more difficult it is to
achieve adequate cessation of pain. In fact, treatment strategies can be
divided into acute and chronic/recurring pain categories. For all three
neuralgia syndromes, acute pain is best treated with activity cessation
and NSAIDs for 36 weeks, followed by a strength and flexibility reha-
bilitation program that leads to competitive activity resumption. Regional
nerve blocks that are diagnostic of nerve entrapment can be modified
with long-acting local anesthetics (bupivacaine) and a corticosteroid
(prednisolone tebutate) for sustained pain relief. For chronic and recur-
ring pain that prevents full return to training and competition, nerve
surgery will be required. For the ilioinguinal and genitofemoral nerves,
neurectomy, often together, achieves good results. Since these nerves are
mostly sensory in function, resection at the level of the transversus
70 G.J. Mancini
abdominis has a reported success rate of 7085 % [18, 22]. This success
rate mirrors the surgical cure rates published for chronic inguinodynia in
post-hernia surgery nerve injury. For the obturator nerve, since its main
function is motor innervation, neurectomy would not be tolerated. In this
case, surgical neurolysis, or nerve decompression, is the best option.
This technique requires careful dissection of the nerve as it courses
through the different fascial compartments of the adductor muscle
groups. Release of the tendon and fascial fibrotic bands around the nerve
allows release of the nerve from its entrapment. In a case series of 29
elite athletes, all with clinical obturator nerve entrapment symptoms and
validated with abnormal EMGs, all 29 had significant recoveries in 26
weeks of neurolysis and returned to competition [19].
Summary: Putting It All Together

Athletic pubalgia has been described here as three distinct clinical
entities: as an occult hernia, osteitis pubis, or a regional nerve entrap-
ment syndrome. As clinicians, we are tasked in evaluating the patient,
accounting for the signs and symptoms, and making the right diagnosis
to help the patient make a full recovery. My goal is to take the presump-
tive diagnosis of a sports hernia and more clearly define it as one of the
three diagnoses. My evaluation process begins by interviewing to the
patients complaints to listen for clues that point to a hernia, a musculo-
skeletal injury, or nerve-related pain. I then begin the conversation by
saying that chronic groin pain can be very difficult to treat and a quick
fix is not likely to occur. If the patient, parent, coach, or trainer does not
walk out the door at this point, I will walk them through the diagnostic
testing process as well as the likely timeline for treatment, rehabilitation,
and return to competitive training. If the patient has had no prior ingui-
nal or pelvic surgery in the past, my first test of choice is an MRI of the
abdomen and pelvis (to the mid-thigh). In my practice, two-thirds of
patients with no prior inguinal or pelvic surgery are most likely to have
osteitis pubis as the diagnosis. MRI is the best modality for this, and
MRI will show inguinal hernias as well. In contrast, athletes with pre-
sumptive athletic pubalgia who have had prior inguinal or pelvic surgery
are more likely to have a hernia recurrence, meshoma, or regional nerve
entrapment syndrome. I therefore obtain a CT of the abdomen and pelvis
with Valsalva completed. Positive findings on CT or MRI will guide the
medical, surgical, and rehabilitation plans, as previously described.
Normal CT and MRI will prompt a more thorough neurologic exam to
Athletic Pubalgia Algorithm

Diagnosis First Line Therapy Second Line Therapy
Operative Hernia Operative Hernia
Occult Hernia
Repair Repair
NSAIDS, Rest &

Osteitis Pubis NSAIDS, Rest & Rehab
Rehab
Adductor Longus
Adductor Longus NSAIDS, Rest & Rehab
Release
Diagnostic/Theraputic Neurectomy +/-

Nerve Entrapment
Nerve Block Hernia Repair
Hip/Femur Refer to Orthopedic Refer Back to

injury Surgeon Orthopedic Surgeon
Inguinal Floor Operative Hernia

NSAIDS, Rest & Rehab
Weakness Repair
Fig. 7.4. Treatment algorithm for athletic pubalgia.
include dermatome mapping of the sensory of pain symptoms. If the

pain correlates with the sensory dermatome distribution of a specific
nerve, trigger point injections can be given for both diagnostic and
therapeutic effect. The toughest dilemma comes when the patients exam
has no major physical findings, a normal CT and MRI, little relief from
the trigger point injections, and continued patient pain that limits com-
petitive performance. This is the point at which the scope of the work-up
should be widened and alternative clinical opinions sought. Figure 7.4
demonstrates a treatment algorithm for athletic pubalgia.
References
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musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and
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2. Depasquale R, Landes C, Doyle G. Audit of ultrasound and decision to operate in
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femoral region. Surg Gynecol Obstet. 1981;152(3):31922.
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imaging. Eur Radiol. 1996;6(1):525.
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marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad.
Clin J Sport Med. 2006;16(2):11722.
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sources of hip pain. In: Byrd JWT, editor. Operative hip arthroscopy. 2nd ed.
Heidelberg: Springer; 2005. p. 7099.
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8. Groin Pain Etiology: Hip-Referred
Groin Pain
Joshua C. Campbell and Guy D. Paiement
Introduction
The differential diagnosis for groin pain originating from the hip is
extensive and includes many disease processes, ranging from degenera-
tive to autoimmune and from traumatic to genetic. It is important for any
physician to have a working knowledge of these clinical entities since
the presenting symptom, namely, groin pain, overlaps with so many
specialties.
More than two-thirds of patients with an intra-articular hip pathology
will present with groin pain, and many other extra-articular processes
around the hip will present with similar distribution of pain with very
subtle or no differences [1]. History taking is hard detective work and
the physical exam is critical. An absolute prerequisite is a good knowl-
edge of not only hip anatomy but also the structures around this
articulation.
Anatomy Around the Hip

The bony architecture of the hip is important to both its function and
its durability. The normal acetabulum is anteverted 15 and abducted
approximately 45 in the coronal plane. The femoral neck is anteverted
approximately 15 relative to the condylar axis of the distal femur, and
the angle between the femoral neck and shaft is around 125 in adults [2].
This relationship is important to preservation of motion between bony
structures and the function of the soft tissue structures surrounding the
joint. Surrounding the acetabulum is the labrum, which increases the sta-
bility of the hip joint through a suction seal effect. Recent biomechanical

DOI 10.1007/978-3-319-21587-7_8
74 J.C. Campbell and G.D. Paiement
studies show that the labrum additionally contributes to both cartilage

nourishment and synovial fluid lubrication [3].
The hip capsule is innervated by femoral, sciatic, and obturator
nerves [1]. Hip pain may present as pain reported in any of these nerve
distributions. This often makes symptoms of hip pathology somewhat
vague and nonspecific.
Several muscles are in proximity of the hip joint and may be the
source of pain about the hip. These include the hip abductors (glutei
maximus, medius, and minimus) and the tensor fascia lata with the ilio-
tibial band that runs from the anterior and lateral iliac crest along the
side of the thigh to insert onto the anterolateral tibia. Flexors crossing
the hip include the iliopsoas, which originates within the pelvis, exiting
below the inguinal ligament to attach on the lesser trochanter, and the
rectus femoris, which lies directly anterior to the hip, with its direct head
attaching just above the anterior hip capsule. Lastly, the adductor mus-
cles (adductors magnus, longus, and brevis) lie medial to the hip, origi-
nating from the pubic rami and inserting on the medial femur.
Basics of Evaluation
A detailed history is crucial in the differential diagnosis. It is impor-
tant to ask the patient about any types and changes of physical activities
at work and any history of trauma, however minor or remote it may
seem. Ideally, a patient should be able to provide a detailed history of
the pain, including when and how it started as well as what makes the
pain better or worse. It is important to establish objective measures of
the symptoms: I used to run 3 miles, but now I can barely walk 3
blocks, or I cannot sleep on my back anymore. A complete medical,
occupational, and family history is important, as many conditions have
familial (Gauchers disease), developmental (hip dysplasia), environ-
mental (caisson disease), or exposure-related risk factors (avascular
necrosis).
A complete physical evaluation should include inspection and palpa-
tion of all bony prominences: anterior superior iliac spine (ASIS), ante-
rior inferior iliac spine (AIIS), pubic symphysis, ischial tuberosity,
sacroiliac joints, and greater trochanters, with special emphasis on ten-
derness at these areas. Close attention to the exact location of the pain
can narrow the differential diagnosis dramatically. Abnormal active and
passive hip range of motion may also point the clinician in the right
direction (Table 8.1; Figs. 8.1, 8.2, and 8.3). Comparison with the
8. Groin Pain Etiology: Hip-Referred Groin Pain 75
Table 8.1. Range of motion of the normal hip (from Thompson [4]).
Extension 20
Flexion >120
Adduction 20
Abduction 40
Internal rotation hip in extension 30
Internal rotation hip in flexion at 90 20
External rotation hip in extension 50
External rotation hip in flexion at 90 30
Fig. 8.1. The physical examination maneuver to determine range of motion

about the hip. The extent of flexion of the hip is assessed in neutral rotation.
contralateral side (if asymptomatic) will help to detect otherwise subtle

clinical signs. Lastly, an evaluation of gait is critical to detect any limp
or abnormal posture.
When thinking about groin pain referred from the hip, it is helpful to
think of the differential as problems related to either the soft tissue or
skeleton. Further separating these into architectural versus physiological
causes helps to clarify thinking. Although considerable overlap occurs
with many processes, it remains a useful analytical framework. For the
sake of brevity, trauma will be excluded from the discussion; however,
suspicion of fracture following even minor trauma should remain high.
Any fracture of or about the hip or pelvis should be treated with pro-
tected weight bearing and immediate referral to an orthopedic surgeon.
Fig. 8.2. The extent of external rotation of the hip is assessed with the hip in 90
degrees of flexion.
Groin Pain from the Bone

Architectural Problem
Osteoarthritis
Presentation Osteoarthritis (OA) is extremely common in an aging
patient population. It is estimated to affect 60 million Americans by the
year 2020 [5]. In any patient over 50 years, it should be high on ones
differential as the cause of groin pain. Most patients with OA present
Fig. 8.3. The extent of internal rotation of the hip is assessed with the hip in 90
degrees of flexion.
with a slowly progressive pain in the groin, hip, or thigh, typically worse
in the morning and at night. Patients describe an aching pain that
improves with light activity and is worse with strenuous activity. Patients
commonly report difficulties with initial motion after prolonged periods
of rest, with improvement after a few steps. More advanced hip OA
eventually results in stiffness and difficulty with activities of daily living.
Physical Exam The classic finding of crepitus with range of motion is
rare. Patients may present with a very stiff joint, often with back pain that
is more severe than the hip pain. Alternatively, some patients present with
severe pain on weight bearing, with an almost normal range of motion. An
important and early clinical sign of hip OA is decrease in internal rotation.
Passive external rotation during flexion of the hip is known as Drehmanns
sign and is indicative of this loss of internal rotation. Eliciting a positive
Fig. 8.4. The Stinchfield test. The patient performs a forced straight-leg raise
against downward resistance at the thigh placed by the examiner. Pain in the
groin with this maneuver is considered positive.
Stinchfield test, which results in pain at the hip with resisted straight-leg
raise, is sensative however has low specificity (Fig. 8.4).
Diagnostic Exams The most useful radiological study is a standing
low anteroposterior (AP) pelvis (including both hips) with the patient
bearing weight equally on both sides (Fig. 8.5). A supine lateral radiograph
of the affected side (frog leg lateral) will complete the examination.
These two simple views will help to elucidate more than 90 % of hip-
referred groin pain originating from the bone. OA will have an obvious
appearance on plain x-rays, and no further imaging is needed to arrive at
this diagnosis (Fig. 8.6).
Differential Patients, especially young ones, with no obvious OA but
bony abnormalities should receive a consultation with an orthopedic
surgeon. Some of these pathologies can be treated early (e.g.,
impingement or hip dysplasia), leading to decreased rates of degeneration
about the hip.
Appropriate Treatment/Referral Osteoarthritis is very common, and
its first line of treatment is simple: nonsteroidal anti-inflammatory drugs
(NSAIDs), stretching, physical therapy (including pool therapy), and
weight loss. Once these treatments have been exhausted, the patient
should probably be referred to a specialist. Steroid injection under
ultrasound or other imaging modalities should be considered if the pain
Fig. 8.5. Radiograph of a normal pelvis.
Fig. 8.6. Radiograph of the left hip showing changes typical of advanced osteo-
arthritis. Note joint space narrowing, subchondral sclerosis, osteophyte and cyst
formation in the femoral head and acetabulum.
is very acute. Hip arthroplasty is an effective and reproducible procedure

but should be carefully weighed against the risks of the procedure.
Finnish Registry data suggest a 15-year revision-free survival rate of
7186 % for total hip arthroplasty [6]. Not unlike other complex
procedures, outcomes are better when performed by high-volume
surgeons in high-volume centers.
Femoroacetabular Impingement
Presentation Femoroacetabular impingement (FAI) is a
developmental abnormality of either the femoral head-neck junction
and/or the acetabulum, either of which leads to abnormal hip function.
These patients are generally young and/or active. They fall into two
broad categories: cam-type impingement (loss of femoral head-neck
offset) and pincer-type impingement (acetabular over-coverage). These
biomechanical abnormalities lead to tears of the acetabular labrum
(discussed in the next section) and delamination of the cartilage. This is
theorized to be the precursor of the so-called idiopathic OA; however, it
is not yet clear if surgical intervention has any influence on development
of OA later in life [7].
Physical Exam Groin pain with anterior impingement is exacerbated
with high flexion, adduction, and internal rotation at the hip (Fig. 8.7).
Alternatively, posterior impingement is made worse with extension and
external rotation [1]. Either of these may be combined with or exclusively
present with labral-type symptoms, often with a popping and catching
sensation with motion, which causes pain.
Diagnostic Exams Low AP weight-bearing pelvis (including both
hips) with a supine lateral radiograph of the affected side (frog leg
lateral) is recommended. Radiographic measurements are taken to
assess for these abnormalities, as they are often subtle (Fig. 8.8).
Differential Cam-type impingement is classically described among
young athletic males. Given this population, it is important to rule out
muscular strain or even sports hernia. Femoral hernia should be
considered among women, even if pincer-type impingement is noted.
The strict definition of cam versus pincer type impringement is somewhat
of an oversimplification, however, with as much as 80 % of cases being
considered a combined mechanism [9].
Fig. 8.7. The impingement maneuver consisting of flexion, adduction, and

internal rotation. Pain or a pinching sensation in the groin during this maneuver
is considered to be indicative of impingement.
Appropriate Treatment/Referral Both open and laparoscopic

treatments have been effective in the control of symptoms. If FAI is
suspected on clinical or radiographic examination, referral to an orthopedic
surgeon who has experience with FAI is important, as early intervention
may delay or prevent progression of the degeneration of the joint.
Labral Tear
Presentation The acetabular labrum has been shown to have a role in
maintaining appropriate synovial fluid pressure for adequate lubrication
of the hip joint [3]. The best analogy is a rubber gasket in a hydraulic
Fig. 8.8. Anteroposterior (AP) radiograph of the left hip showing the typical
cam deformity of the proximal femur with os acetabulum (an accessory bone
unrelated to the pathology).
joint. As such, the labrum has received new attention regarding its
potential role in preserving the hip cartilage. Patients with tears of the
labrum often present with deep-seated hip or groin pain or report a
popping or clicking sensation with motion.
Physical Exam Painful range of motion is present, most pronounced
with flexion or extension of the hip in abduction, combined with a
rotational movement. Rolling the hip through this range of motion often
produces pain and a popping sensation for a patient with labral pathology.
Diagnostic Exams X-rays may occasionally show a small calcification
at the acetabular rim, indicating a calcified labrum from recurrent trauma
and degeneration. However, most labral pathologies are not diagnosed
with plain radiographs. Magnetic resonance (MR) arthrogram is the
imaging study of choice for diagnosis and when a hip joint preservation
procedure is a consideration (Fig. 8.9).
Fig. 8.9. T2-weighted MR arthrogram showing contrast tracking between the

acetabular rim and the labrum indicative of a labral tear.
Differential Up to 90 % of patients with labral pathology have some

degree of FAI according to some authors [7]. As such, an evaluation
should include radiographic measurements, including the alpha angle
and center edge angle to evaluate for this entity.
Appropriate Treatment/Referral Referral to an orthopedic surgeon
with experience treating FAI is indicated due to the common coexistence
of these pathologies. Although not an emergency, early intervention may
decrease long-term degeneration of the joint.
Hip Dysplasia
Presentation Whereas symptoms of acetabular impingement occur
due to actual or effective over-coverage of the femoral head, hip dysplasia
represents the other side of this spectrum: under-coverage of the femoral
head leads to increased stresses on the chondral surfaces. Congenital hip
dysplasia in its extreme form will lead to dislocation of the hip among
infants; however, the disease process lies on a spectrum, and many
patients with dysplastic hips may be asymptomatic for many years prior
to diagnosis. Additional conditions such as spondyloepiphyseal dysplasia
and achondroplasia commonly lead to malformations of the hip that lead
to increased rates of osteoarthritis. As such, any patient affected with

dwarfism should be evaluated for orthopedic causes with any presentation
of groin pain.
Physical Exam Painful range of motion, positive Stinchfield test (see
the section on Osteoarthritis above), and classic signs of early
osteoarthritis are present among these patients (see Fig. 8.4).
Diagnostic Exams Plain x-rays are often adequate to diagnose both
the architectural problems and any early degenerative process occurring
of the joints. However, patients without radiographically obvious
degenerative changes but clinically evident hip dysplasia should continue
to receive further orthopedic evaluation.
Appropriate Treatment/Referral As hip dysplasia is a congenital
problem, patients with this malformation often present at relatively young
ages with the beginning of degenerative changes. If caught early enough,
operative options exist to increase the coverage of the femoral head with
periacetabular osteotomies that may lead to decreased rate of degeneration
of the hip. Once a patient has progressed to advanced degeneration of the
joint, the only effective option is joint arthroplasty, which, although
successful in pain relief and restoration of more normal biomechanics, has
a limited life span. Revision surgery has much less reliably positive results
and a higher complication rate. Referral to an orthopedic surgeon with
experience with these procedures is important to delay progression as
long as possible.
Occult Fracture
Presentation Although it is uncommon for a patient to initially
present to the doctors office with a hip fracture, it is possible that a
patient may have had a prior workup that was falsely negative and is now
presenting with groin pain that is in fact due to a missed hip fracture.
This scenario may be seen among patients who suffered a trauma or fall
with no clear x-ray evidence of a fracture. Although most emergency
departments or urgent care centers will adequately work up a nondisplaced
fracture seen on x-ray with computed tomography (CT) scan or MRI, an
occult hip fracture is an important diagnosis to consider among patients
who have a history of trauma or fall and pain, but with no obvious x-ray
evidence of fracture. Nondisplaced fractures of the femoral neck, pubic
rami, and sacrum are common following falls in elderly patients.
Physical Exam Patients present with groin and hip pain, typically
exacerbated with any movement about the hip. Among patients with
pubic ramus fractures, palpation of the pubic symphysis is often
particularly painful. It is also important to palpate the sacrum, as
tenderness to palpation may represent a fracture of the sacral ala.
Diagnostic Exams Among those with nondiagnostic x-rays, CT scan
will help demonstrate nondisplaced and minimally displaced fractures
about the hip. However, MRI is preferred, specifically for femoral neck
fractures, as it is 100 % sensitive in the detection of radiographically
occult femoral neck fractures [8]. A black line within the bone on
T1-weighted images indicates a nondisplaced fracture.
Appropriate Treatment/Referral Nondisplaced pubic ramus and
sacral ala fractures may be treated with simple pain control and
radiographic follow-up to ensure that no unrecognized instability is
present. If x-ray examination remains stable following mobilization, the
patient does not require protected weight bearing; however, a walking
aid should be recommended to ensure stability. On the other hand,
nondisplaced femoral neck and intertrochanteric fractures require strict
non-weight bearing and immediate referral to an orthopedic surgeon, as
displacement may lead to a more difficult surgical treatment or
displacement of the fragment.
Physiological
Septic Hip
Presentation A septic joint typically presents with acute onset hip
and/or groin pain that is exacerbated by movement. Patients may or
may not demonstrate erythema and swelling, due to the extent of the
soft tissue surrounding the hip. A history of recent sexual contacts
should be obtained among those who are sexually active, as gonococcal
infections are known to present with monoarticular septic joints.
Consideration of this diagnosis should also be considered among
immunocompromised patients.
Physical Exam Patients report a painful joint, with dramatic increase in
pain with any motion. It is this sign of irritable range of motion, with
even small movements, that is the most reliable of the clinical signs.
Fevers, chills, and leukocytosis may be seen; however, their absence

does not exclude the diagnosis of a septic hip.
Diagnostic Exams X-rays most often do not show any abnormalities,
with the exception of long-standing cases of osteomyelitis in which a
sequestrum and involucrum have had time to evolve. MRI can be useful
if considering osteomyelitis. However, in the case of a simple septic joint,
MRI will provide no more information other than the presence and size
of the effusion. Aspiration and targeted surgical and antibiotic treatment
are used as the standard of treatment. Synovial fluid is routinely sent for
crystal examination, cell counts, and cultures. Cell counts above 50,000
white blood cells (WBC) and with greater than 75 % polymononuclear
(PMN) cells are considered indicative of infection and are typically taken
to the operating room for joint irrigation and debridement [9]. It is
important to note that immunosuppressed patients may have an infected
joint space in the presence of lower cell counts. Culture examination,
although a critical part of the examination, does not trump the need for
operative decompression and irrigation of the septic hip.
With any prosthetic joint in which infection is a concern, erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP) need to be
checked in addition to a complete blood count (CBC). ESR above
30 mm/h and of CRP greater than 1 mg/dL should raise suspicion for
prosthetic joint infection. As in native hips, aspiration of the joint with
cell counts is the gold standard for diagnosis, however cell counts as low
as 1760 cells/L are suggestive of a periprosthetic infection [2].
Differential It is important to consider crystalline arthropathy in the
differential diagnosis of a septic joint, as its clinical presentation is nearly
indistinguishable from that of a septic joint. Additionally, even if crystals
are seen on joint aspiration, in the scenario of high number of WBCs and
a high percentage of PMNs, the physician should consider the possibility
of a superimposed infectious process. Cultures should be followed for a
minimum of 3 days to rule out this possibility. However, if the suspicion
is high for an infection, one should expeditiously proceed with operative
treatment, i.e., decompression, irrigation, and debridement of the
infected joint.
Appropriate Treatment/Referral In any patient with an examination
concerning for septic hip, it is important to initiate an orthopedic
consultation immediately. A septic joint is considered an operative
emergency due to the unchecked inflammatory reaction that occurs as a
result of the infection within the joint space. Metalloproteases and other
destructive enzymes are released by immune cells in response to the

infection, thereby causing irreversible damage to articular cartilage.
Failure to intervene early in the process leads to cartilage destruction and
may lead to chronic osteomyelitis if the infection spreads into the
adjacent bone. As such, should cell counts be diagnostic or cultures be
positive, urgent irrigation and debridement of the joint, either
arthroscopically or open, should be performed.
Stress Fracture and Pathological Fracture

Presentation Stress fractures are most common among running
athletes. Typically, patients present with pain of insidious onset, often
associated with increases or changes in training. The pain is worse with
weight bearing and with increased activity. Stress fractures are more
common among female athletes, especially those with low body weight
and amenorrhea.A stress fracture forms when the body is unable to
remodel at the rate necessary to deal with the increased repetitive stresses
imposed on it. These can occur in the sacrum, pubic rami, and femoral
neck. Although only 10 % of stress fractures occur at the femoral neck,
they require immediate attention. There is a risk of fracture displacement
which may lead to complications such as a vascular necrosis (AVN)
[10].Another subset of patients who may present with groin or thigh pain
are elderly patients with known osteoporosis who have been on
bisphosphonate therapy for several years. These patients, ironically, may
also have stress fractures. Bisphosphonates have become extremely
common for the treatment of osteoporosis, as they have been shown to
decrease the rate of hip fracture by up to 51 % in some series [11].
Bisphosphonates function by incorporating into the mineral content of
bone, consequently decreasing osteoclastic activity. However, due to the
coupling of osteoclastic (bone resorbing) and osteoblastic (bone building)
cell activities, this leads to the decreased ability of the bone to remodel.
Whereas this is helpful in decreasing the rate of bone resorption in
patients with osteoporosis, the reduced rate of bone turnover does not
allow for adequate remodeling of bones with high stresses. The
subtrochanteric femur is particularly prone to this process. These patients
present with thigh or groin pain of insidious onset that is worse with
activity and on rising from a seated position. Patients with this process
are prone to fractures of the subtrochanteric femur with very minimal
trauma, often as little as a twisting moment while walking.
Physical Exam Range of motion and examination of the hip are

essentially normal. Weight bearing may demonstrate some pain.
Clinically, stress fractures of the femoral neck may be difficult to
differentiate from early AVN. Consideration of the risk factors and
advanced imaging may be required to differentiate between the fractures
and AVN.
Diagnostic Exams For stress fractures, x-rays may show a periosteal
reaction in the area of the stress fracture. However, x-rays are not
sensitive or specific for this process.
In the case of bisphosphonate-related stress fractures, the x-ray may
show lateral breaking of the subtrochanteric femur (Fig. 8.10). Although
bone scans are 100 % sensitive for stress fractures, they lack specificity
[10]. MRI is highly sensitive and specific for stress fracture. On
T2-weighted imaging, edema will be seen in association with the area of
the stress reaction; a dark line will represent the fracture line on
T1-weighted imaging (Fig. 8.11).
Differential Consideration of a pathological fracture due to either
primary or metastatic infiltration of the bone should be considered
among patients who present with pain of insidious onset associated with
weight bearing. Any lytic or blastic lesion on x-ray should be worked up,
which may include an open or fluoroscopically guided biopsy, especially
in patients with risk factors for malignancy.
Appropriate Treatment/Referral Any patient with confirmed or
suspected stress fractures should be referred to an orthopedic surgeon
for evaluation. In addition to activity modification, patients require
protected weight bearing until their pain resolves. With regard to those
patients with stress fractures involving the superior aspect of the femoral
neck (tension-side femoral neck stress fractures), or those with complete
stress fractures that are still nondisplaced, urgent operative intervention
may be indicated to prevent displacement.
Inflammatory Arthritis
Presentation Although less common than OA, rheumatologic disease
must be considered in any differential of joint pain. Rheumatoid arthritis
(RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis
may all present with polyarticular complaints that may involve the hip.
Generally, patients with inflammatory arthritides present with
symmetrical joint complaints. It is important to note that these will rarely
cause isolated hip pain without other systemic complaints. Evaluation
for low back pain and other articular complaints is important for accurate
diagnosis. Classically, patients with RA will complain of at least 1 h of
morning stiffness.
A similar clinical picture is present among those with SLE, with the
addition of further systemic complaints such as skin rashes with sun
exposure and possible renal complications. Consideration to the diagno-
sis of SLE should be given with any workup for rheumatological
disease.
In patients with ankylosing spondylitis, involvement of the lumbar
spine needs to be evaluated. Patients will report chronic low back or hip
pain that waxes and wanes, with limited range of motion, sometimes
with groin pain and pain down the inner thigh.
Physical Exam The disease predominantly affects the cervical spine,
wrist, elbows, knees, hands, and feet. It is not classically described as
affecting the hip and typically spares the lumbosacral spine and distal
interphalangeal joints [9]. The presence of rheumatoid nodules on the
extensor surface of the forearm is considered pathognomonic and is seen
in up to 30 % of patients with the disease. Examination is otherwise often
nondiagnostic and needs to be combined with other modalities for
accurate diagnosis.
Diagnostic Exams X-rays may show periarticular osteopenia, with
loss of joint space and minimal to no osteophytes. Laboratory examination
shows elevated inflammatory markers (ESR and CRP). If the clinical
presentation fits with an inflammatory condition, it is not unreasonable
to consider sending specific blood tests checking for rheumatoid factor
(RF), antinuclear antibody (ANA), and HLA-B27 antigen. It may be
reasonable to defer the workup to a rheumatologist.
Appropriate Treatment/Referral In situations where an inflammatory
arthritis is suspected, referral to a rheumatologist for a complete yet
targeted workup and treatment is warranted. In severe cases with
advanced joint disease, total joint arthroplasty is an option for treatment,
and referral to an orthopedic surgeon should be considered in patients
with advanced disease.
Fig. 8.10. Radiograph of the right femur showing breaking of the proximal
lateral cortex. There is an associated stress fracture characteristic of a bisphos-
phonate-related fracture of the proximal femur.
Avascular Necrosis
Presentation Patients with AVN present with groin pain of insidious
onset, most often with no other symptoms. As AVN progresses to
subchondral collapse, pain can be severe. Risk factors may include prior
fracture or dislocation, alcoholism, steroid use, and caisson disease (the
bends or decompression sickness). AVN has also been associated with
use of protease inhibitors for treatment of human immunodeficiency
virus [12]. Less common causes of AVN are sickle cell disease or
lysosomal storage diseases. As such, groin pain of insidious onset in
these patient populations should prompt high clinical suspicion.
Assessment of risk factors is an important part of the history taking in
patients with suspected AVN.
Fig. 8.11. Coronal STIR sequence MRI showing marked left femoral neck bone
edema (white) with inferior femoral neck cortical disruption (black line) typical
of a compression-side stress fracture.
Physical Exam Early examination of patients with AVN is essentially

normal. As the physiological changes progress toward squaring of the
femoral head and subchondral collapse, the range of motion of the hip
becomes increasingly limited.
Diagnostic Exams X-rays are appropriate in the initial diagnosis,
classically graded on the Ficat scoring system, ranging from a normal
examination to advanced collapse of the femoral head with resulting
joint degeneration [13]. However, positive x-ray findings are generally
noted late in the disease progress. MRI has the highest specificity and
sensitivity for AVN. Early signs include diffuse edema seen on T2
imaging that evolves to a focal crescent beneath the chondral surface of

the femoral head with advanced disease.
Differential Early AVN may present in a similar fashion to transient
osteoporosis (see below). Subtle differences do exist between their MRI
findings.
Appropriate Treatment/Referral Once a hip has progressed to AVN,
there is no proven effective treatment for reversal. Some centers advocate
for bisphosphonate therapy and surgical core decompression. Although
both of these modalities have shown to be somewhat effective in the
management of the pain related to the diagnosis, neither has consistently
shown to have an effect on the progression of AVN to subchondral
collapse. Once a hip has progressed to subchondral collapse, the only
option for the patient is total hip arthroplasty.
Transient Osteoporosis
Presentation Transient osteoporosis presents as unilateral hip pain of
insidious onset. Diffuse groin and hip pain without inciting event is
common. The pain progresses over the course of weeks, generally to the
point of non-weight bearing. This entity was originally described in
1959, among women in their third trimester of pregnancy [14]. Today, it
is recognized more commonly among middle-aged men [15]. The natural
history of the disease is for pain to resolve over the course of 23 months,
with bone remineralization expected within approximately 6 months
without intervention.
Physical Exam Patients may present with sufficient pain to not permit
weight bearing. Range of motion and other physical exam findings are
typically unremarkable.
Diagnostic Exams X-rays are often normal at the onset of pain and
progress to show diffuse loss of trabecular bone mineralization of the
femoral head without detectable cortical disruption after several weeks
of symptoms. Importantly, there should not be involvement in the
acetabulum; if there is, then inflammatory or infectious causes should be
considered.
MRI shows diffuse low signal on T1-weighted imaging and high
signal on T2-weighted imaging. Of note, these findings are nearly iden-
tical to early AVN of the femoral head; therefore, the two processes are
difficult to differentiate. However, the changes are typically more dif-
fuse for transient osteoporosis as compared to the more classic band-
like pattern of femoral head involvement seen in AVN [16].
Differential Early AVN and inflammatory or infectious causes should
be considered.
Appropriate Treatment/Referral In patients with radiographically
recognizable lesions, patients should practice protected weight bearing
for 46 weeks and be supplemented with vitamin D and calcium. Although
relatively rare, fracture of the demineralized femoral head and neck is
reported, and the patient should be aware of such a complication. If pain
is uncontrollable with mild analgesics, consideration may be given to
bisphosphonate therapy and/or core decompression via an operation. That
said, there is poor evidence to strongly recommend either option. Small
case series report early resolution of clinical symptoms with both
bisphosphonate therapy and core decompression therapy [17, 18].
Groin Pain from the Soft Tissue

Architectural Problems
Snapping Hip Syndrome
Presentation Patients with snapping hip syndrome present with

painful popping sensations in the groin with movement. The problem is
common and is estimated to occur in 510 % of the general population
[10]. The differential for a snapping hip includes intra-articular and
extra-articular causes.
Intra-articular causes include labral tears, osteochondral lesions, or
loose bodies. Rarely, injuries to the ligamentum teres following disloca-
tion may also present with intra-articular snapping.
An external snapping hip pops or catches while in hip flexion. It is
typically related to either the iliotibial band or tensor fascia lata catching
over the greater trochanter. Alternatively, the gluteus tendon may also
catch over the trochanter. This catching leads to inflammation and pain
over the lateral greater trochanter and may present similar to bursitis.
Internal snapping hip by contrast presents with a popping or catching
sensation upon external or internal rotation. Here, it is typically the
iliopsoas tendon or the iliofemoral ligament that is catching over the

lesser trochanter, anterior aspect of the hip joint, or the superior pubic
ramus. Internal snapping hip may also occur as a result of a poorly posi-
tioned acetabular cup after total hip arthroplasty.
Physical Exam An audible or palpable popping with associated pain
is noted in flexion or in rotation of the hip. Often, the involved tendons
may develop tendonitis and are tender to palpation.
Diagnostic Exams Careful history needs to exclude intra-articular
causes of snapping hip, such as labral tear or a loose body. Snapping hip
relieved by intra-articular steroid injection are often caused by labral
tears [19]. MRI is commonly employed to look for evidence of tendon
impingement or snapping; edema around or within the tendons may
indicate this. Some authors advocate for the use of dynamic ultrasound
in the diagnosis of snapping hip. The sensitivity and specificity of this is
operator dependent and may not be available at all institutions.
Differential Intra-articular anesthetic and steroid injections are an
excellent diagnostic tool to differentiate intra-articular causes of snapping
hip from extra-articular causes. If pain resolves with intra-articular
injection, then the pain is likely of intra-articular origin.
Appropriate Treatment/Referral The mainstay of treatment for both
internal and external snapping hip is physical therapy and NSAIDs
combined with activity modification. Among patients resistant to this
treatment, tendon lengthening or tendon release has been shown to
improve symptoms. For snapping hip of intra-articular cause, referral
to an orthopedic surgeon is appropriate.
Lateral Femoral Cutaneous Neuralgia

Presentation Lateral femoral cutaneous nerve pain, also known as
meralgia paresthetica, presents with an uncomfortable, numb, and/or
painful sensation in the anterolateral upper thigh. It is reported to be
more common among the obese and diabetic patient groups. It also may
present during pregnancy and with hypothyroidism due to the associated
peripheral edema [20]. The cause of symptoms is theorized to be the
pannus direct compression of the nerve, either due to a pannus or
entrapment by the inguinal ligament as the nerve crosses under or
through it. Additionally, this condition may occur as a result of hip
replacement performed through an anterior approach or anterior iliac
crest bone grafting, where the lateral femoral cutaneous nerve may be
injured. Direct trauma to the nerve, such as a shear injury from a seat
belt, is another possible cause of meralgia paresthetica.
Physical Exam Examination of the hip for any prior scars or
operations is advisable. Tapping of the inguinal ligament laterally, 1 cm
medial to the ASIS where the nerve crosses, elicits a Tinels sign, with
stinging or burning into the anterolateral thigh [21]. Hypesthesia and/or
allodynia of a patch of skin along the upper lateral thigh is consistent
with the dermatomal findings for this neuralgia. Extension of the thigh
may also aggravate symptoms as it places the nerve on stretch.
Diagnostic Exams The diagnosis of meralgia paresthetica is clinical
and does not require imaging. X-rays will be unrevealing. MRI may
reveal edema and swelling of the nerve in extreme cases, best seen on T2
images proximal and laterally along the inguinal ligament; this is subtle
and not universally present. Ultrasound may show swelling of the nerve
between the inguinal ligament and deep circumflex iliac artery, with
flattening of the nerve as it courses under the inguinal ligament. Sensory
nerve conduction velocities may be ordered to confirm the diagnosis if
questions exist [21].
Differential It is important to rule out lumbar disk herniation as a
cause of symptoms. Any focal weakness or other symptoms in the L2
distribution should prompt evaluation for this. Additionally, intrapelvic
masses have been known to compress this nerve along its course and
should be considered in the differential.
Appropriate Treatment/Referral Referral to a pain specialist for
corticosteroid injections should be considered in patients in whom
meralgia paresthetica is suspected. Typically, this is undertaken with the
use of ultrasound guidance. These can be both confirmatory of the
diagnosis and therapeutic. Small series have shown good results and
high rates of resolution over the course of 12 months [22]. If there is no
long-term improvement, neurectomy may be considered.
Physiological Problems
Gluteus Medius Tendonitis
Presentation Tears and tendonitis of the gluteus medius tendon have
only recently become recognized as causes of hip pain. They can also
present with primary complaint of groin pain. Likened to the rotator
cuff tear of the hip, some authors of small series advocate arthroscopic
debridement and repair for large tears [22], although limited evidence
currently exists to advocate for or against these procedures. Additionally,
its role in greater trochanteric bursitis is becoming clearer, as some
believe the presence of tendonitis of either the gluteus medius or minimus
is the primary pathology in greater trochanteric bursitis [23].
Physical Exam Patients with gluteus medius tendonitis present with
pain in the hip or groin, exacerbated with activity. Patients have focal
tenderness to palpation and pain with resisted abduction. In severe
tendonitis or in cases in which a gluteus medius tear is present, patients
may demonstrate weakness of the abductors and a positive Trendelenburg
gait. Testing will reveal they are unable to keep their hips level during
single-leg stance of the affected side.
Diagnostic Exams X-ray is unrevealing, and the diagnosis is clinical.

MRI has a role if there is concern for a gluteus medius tear. MRI should
be considered in cases of tendonitis nonresponsive to multimodality
treatment, such as physical therapy and steroid injections.
Differential Greater trochanteric bursitis is almost identical in

presentation, and as understanding of the process grows, it is increasingly
becoming inseparable from gluteus medius tendonitis.
Appropriate Treatment/Referral The first line of treatment is a

dedicated course of NSAID therapy combined with physical therapy.
Referral to an orthopedic surgeon for steroid injections is warranted if
the patient does not respond to 46 weeks of physical therapy. If patients
fail to improve, it is reasonable to consider an MRI to evaluate for a tear
or other causes for the patients pain.
Greater Trochanteric and Iliopsoas Bursitis

Presentation With greater trochanteric bursitis, patients will typically
present with lateral hip and leg pain radiating down the side of the leg
and into the knee, along the iliotibial (IT) band. Patients have difficulty
sleeping on the affected side. They have increased pain with flexion of
the hip, as this tightens the IT band against the greater trochanter.
Iliopsoas bursitis may occur in internal snapping hip syndrome with

or without the presence of an audible snap (see Snapping Hip Syndrome
above). Due to either acute or repetitive trauma from the recurrent
dragging of the tendon over the lesser trochanter, AIIS, or iliopectineal
eminence, the bursa between the tendon and the pelvic brim becomes
inflamed. Patients report a history of anterior hip or groin pain exacer-
bated by flexion and extension of the hip. Although most commonly
associated with an audible snap, up to 31 % of patients have no history
of snapping or popping.
Physical Exam Patients have focal tenderness to palpation over the
lateral trochanter. The Ober test is used to evaluate tightness of the IT
band, which is thought to be the cause of the problem. The patient lies on
his/her contralateral side, the affected leg is extended and allowed to fall
behind the patient; inability to adduct beyond the midline is considered a
positive test [23].
Patients with iliopsoas bursitis present with anterior hip or groin pain,
exacerbated by flexion or extension of the hip. Tenderness to palpation
over the course of the iliopsoas tendon deep in the femoral triangle is
common, but not universal, and when seen is considered pathognomonic
for the process.
Diagnostic Exams X-ray and ultrasound are not sensitive or specific
for any of the bursitis conditions around the hip. Occasionally,
calcification may be present in the bursa, which indicates chronic
inflammation and calcium deposition. MRI does have some role, as it is
the most sensitive and specific for these conditions; however, diagnosis
of bursitis is mostly clinical, and confirmatory imaging is not usually
required.
Appropriate Treatment/Referral With all bursitis, the mainstay of
treatment is NSAID therapy and physical therapy for stretching and
strengthening. Corticosteroid injection may be performed with or
without the use of ultrasound guidance in greater trochanteric bursitis;
for iliopsoas bursitis, ultrasound guidance is required due to the proximity
to neurovascular structures. In the event that conservative treatment is
unsuccessful, iliopsoas tenotomy or surgical lengthening of the IT band
may be considered.
Muscle Sprain or Strain

Presentation Muscle strain injuries are common in the young athletic
population. Patients typically will have an injury during eccentric
contraction of the muscle and suffer immediate pain. This is reported as a
chronic and nagging pain that lasts an extended period of time with delayed
recovery. Adductor strains, in particular, present with medial groin pain
that worsens with resisted adduction. They are particularly common
among hockey players and represent as many as 10 % of all injuries to
hockey players at the professional level [24]. By contrast, rectus femoris
strains will present with anterior pain and swelling, approximately 810 cm
below the AIIS, and may be seen among sprinting athletes and soccer
players [25].
Physical Exam After adductor strain, pain is localized medially and
in the groin. Pain is exacerbated by forced adduction and direct palpation
of the muscle belly. The attachment of the adductor muscles at the
inferior pubic ramus is focally tender to palpation.
After rectus femoris strains, pain and swelling localize anteriorly,
directly over the hip. Pain is exacerbated with extension of the hip and
flexion of the knee and worsens with resisted flexion of the hip.
Diagnostic Exams AP x-ray should be obtained to rule out avulsion
type fractures associated with such strains. Occasionally, calcification of
the tendon or tendinous insertion may be seen in some patients. MRI is
more helpful in clinical situations in which the diagnosis is unclear,
however, it is not required for the diagnosis. If obtained, focal edema
involving the muscle is seen on T2-weighted signals. In more severe
cases, tears in the muscle may also be seen.
Differential It is important to consider the possibility of avulsion
fracture of the tendinous insertions when evaluating these injuries,
especially in patients who have not yet reached skeletal maturity or
patients with massive muscle volume, such as certain professional
athletes. These are often findings seen in the spectrum of sports hernias.
Appropriate Treatment/Referral Rest, ice, compression, and elevation
are the mainstays of treatment. Activity modification is recommended
until pain subsides. Return to activity should start with range of motion
exercises and gradually increase in intensity over several weeks. Physical
therapy should focus on stretching and strengthening exercises. The use of
NSAIDs should be avoided in the management of the pain associated with
muscular strain due to concern over long-term healing [25]. In patients
without improvement despite a period of immobilization followed by

physical therapy, adductor tenotomy may be considered. However,
although small series have shown improvement in symptoms in 100 % of
patients, as few as 63 % of patients are able to return their prior level of
competitive sport [24].
Sacroiliac Joint Pain

Presentation Although typically presenting with low back pain
radiating down the back of the leg, sacroiliac (SI) joint pain may also
present as pain radiating into the groin. Due to its proximity to the lumbar
spine and hip, it is very commonly mistaken for pain coming from either
of these sources. The diagnosis remains somewhat controversial, but
some small series have shown it to be a notable cause of residual pain in
patients with prior lumbar fusion [26]. Patients typically report pain
while lying on their side, in a prolonged seated position, upon initial
rising, and with sitting down. Patients with altered gait mechanics (such
as favored weight bearing of an injured or painful extremity) are prone
to SI joint pain and dysfunction.
Physical Exam Palpation over the SI joint may reproduce the patients
pain. Provocative tests include compression of either the posterior
superior iliac spine or the ASIS, medially directed force over the iliac
crests, pain with resisted external rotation, and FABER test (forced
flexion, abduction, external rotation or the figure of 4 position) [27].
Diagnostic Exams Occasionally, x-rays show spurring inferiorly at
the SI joint; however, most will not have radiographic findings. A
fluoroscopically guided SI joint injection with anesthetic and steroids is
both diagnostic and therapeutic.
Differential SI joint pain is difficult to differentiate from back or hip
pain and is often overlooked as a source of pain. Any differential
including SI joint pain should rule out lumbar causes and any intra-
articular hip pathology that may be causing the symptoms. Sacroiliitis,
either infectious or arthritic, is also part of the differential diagnosis (see
Inflammatory Arthritis above).
Appropriate Treatment/Referral NSAIDs are the mainstay of
treatment. This is typically combined with physical therapy for core
strengthening and pelvic stability exercises. Fluoroscopically guided
injections of the SI joint are also helpful in more severe cases. If all else
fails, fusion of the SI joint is an option, but this is reserved for severe
cases in which repeated injections and courses of physical therapy are
unsuccessful in relieving pain.
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9. Groin Pain Etiology: Spine
and Back Causes
Charles H. Li, Victor W. Chang, Irene Wu,

and Daniel C. Lu
Introduction
Groin pain is a common cause of complaints in the primary care
clinic setting [1]. Groin injuries are responsible for approximately 5 %
of all athletic injuries and account for 10 % of visits to sports medicine
clinics [2]. In the clinical evaluation of groin pain, it is important to elicit
the history of onset [3]. Although the differential is wide, altered sensa-
tion or weakness can raise suspicion for neurological causes such as
peripheral nerve entrapment, herniated disc, or lumbar disc degeneration
[3]. Fractures or malignancy are always within the differential and
should be suspected when there is a history of pain at rest or at night.
Sacroiliac joint dysfunction can be a chronic cause of groin and lower
back pain that is commonly underdiagnosed [4].
Sacroiliac (SI) Joint Dysfunction

The SI joint is a synovial joint with hyaline cartilage on the sacral
side of the joint [4]. It is believed that the joint is entirely innervated by
the sacral dorsal rami [5]. The joint is mostly a bony structure supported
by a number of ligaments and the surrounding muscles. The joint shares
these muscles with the hip joint and is subject to all the same shear
forces that the hip experiences [4]. SI joint pain is commonly due to
trauma or strain. Repetitive motions associated with athletic activities
can also cause repetitive shear.

DOI 10.1007/978-3-319-21587-7_9
104 C.H. Li et al.
Physical Exam Most of SI joint pain is referred to the buttocks (94

%), lower lumbar region (72 %), and lower extremities (50 %) [6]. Pain
that is localized to the groin is an unusual presentation, seen in around 14
% cases [6]. There are extensive innervations in the hip and groin area,
making physical examination difficult and nonspecific. Three provocative
SI joint movements can detect SI joint dysfunction with a sensitivity of
7787 % [7]. Common tests of SI joint function include Laguere, Gillette,
Patrick, and the Gaenslen tests [79]. Further, radiographic exam may be
helpful in corroborating physical exam findings, but radiology alone is
not sufficient for diagnosis [4]. Elgafy et al. [10] showed that CT scans
for SI joint dysfunction had a sensitivity of 57.5 % and a specificity of 69
%. SI joint blocks can be used as a diagnostic tool and have been
associated with a positive predictive value of 60 % when used with three
physical exam tests [6, 11].
Treatment Patients with SI joint dysfunction should be treated with a
multimodal approach. Results of treatment consisting of physical
therapy, orthotics, joint blocks, surgery, and neuroaugmentation have
been highly variable [4]. Physical therapy exercises focus on movements
that can strengthen the hip muscles and stabilize the pelvis [12].
Placement of an orthotics belt has also been useful in some treatments as
a way of limiting further motion that can cause increased injury to the
joint [13]. Several studies have also noted relief of symptoms and
improvement in function with intraarticular injections of the SI joint
[1417]. This can further be followed with radiofrequency rhizotomies
of the innervation to the SI joint for more lasting analgesia. There is no
class I evidence to support this procedure.
Historically, surgical treatment was used only when the SI joint was
proven to be unstable [18]. Traditional techniques for SI joint fusion
involved large open procedures, which introduced a great amount of
morbidity and were of limited clinical benefit. With the recent advent of
minimally invasive techniques to fuse the SI joint, there is growing
interest among spine surgeons to pursue this technique. However, to date
there is not a great deal of high-level evidence to support this procedure.
Neuroaugmentation is a new modality for treatment of SI joint pain, and
case reports [19, 20] have suggested that it may be a standard treatment
option in the future.
9. Groin Pain Etiology: Spine and Back Causes 105
Lumbar Disc Degeneration

Lumbar disc degeneration is a known cause of persistent groin pain
[21]. The groin is innervated by the genitofemoral and ilioinguinal
nerves; degeneration of the spinal canal can cause referred pain to the
groin. In particular, patients with herniated discs (most commonly in the
L4L5 or L5S1 levels) have been known to report groin pain [21].
These discs can cause compression on transversing sacral nerve roots
(S1S3). Additionally, herniation at the L1/L2 levels is rarer but can
cause characteristic symptoms of groin pain, manifesting as buttock pain
and anterolateral thigh pain [22].
Diagnostic Workup Studies have shown that around 21 % of patients
with lower lumbar disc degeneration or herniation have had associated
symptoms of groin pain [23]. Making a diagnosis of discogenic groin
pain is difficult due to the nature of the disease presentation. There has
been controversy in the use of discography to diagnose discogenic pain
[24]. MRI is commonly used as a noninvasive approach to diagnosing
lower back pain from degenerative disc disease [25], and ultrasound
imaging has been shown to have a 90 % sensitivity and 75 % specificity
for finding disc degeneration when combined with discography [26].
Lumbar Stenosis
Stenosis is defined as the narrowing of the spinal canal, usually to an
absolute diameter of less than 75 mm2 as characterized by imaging [27].
Similar to degeneration, nerve root stenosis at the L1/L2 levels will
affect the L2/L3 nerve roots, manifesting in a positive femoral stretch
test and anterolateral thigh pain [28]. Imaging is not definitive; in one
study, more than 30 % of patients had images consistent with lumber
stenosis but did not feel any of the associated symptoms [29]. Diagnosis
is made through physical examination using similar tests reported for SI
joint dysfunction, as well as through exclusion of other possible diagno-
ses. Once diagnosed, the most effective treatment for spinal stenosis
involves patient education, therapy, exercise, and training [27]. For
symptoms of pain, exercises that focus on strengthening the muscles
involved in thoracic extension and lumbar rotation were found to be
most effective in relieving pain [30, 31], presumably because these types
of exercises were the most important for increasing flexibility in the
groin region. Intervention for severe spinal stenosis includes epidural
106 C.H. Li et al.
steroid injections and surgery. Injections have increased in popularity in

recent years, but their efficacy has been controversial [32]. Surgical
versus nonsurgical approaches have recently been evaluated by the
Spine Patient Outcome Study (SPORT) [33]; the authors concluded that
patients with degenerative spondylolisthesis treated with surgery had
significantly better outcomes at four years compared to those who were
managed noninvasively. The outcomes for patients with stenosis without
spondylolisthesis were not as clearly defined.
Herniated Disc
Herniated discs are one of the most common discogenic causes of
groin pain. The most common sites of herniation are at the L45 and
L5S1 levels. Additionally, other sites of herniation that will manifest as
groin pain include the L1/L2 and S3/S4 levels. S3/S4 involvement likely
is not due to direct S3/4 disc herniation, rather by S3/4 nerve root
compression by more rostral disc herniations (i.e., L45 or L5S1). L1/
L2 disc herniation will localize to the inner thigh, while a herniation that
affects the S3/S4 level will localize to the scrotal region. It is believed
that decreased hydration of the annular disc leads to decreased ability of
the disc to cushion load. This dehydration can be due to age, genetics,
and environmental factors. A sharp stabbing pain that radiates down to
the extremities below the knees is highly suggestive of herniation [34].
On physical exam, increased pressure on the annular fibers of the disc
will help distinguish herniation from low back pain, which is typically
made worse by twisting motions of the lower back muscles. The straight
leg raise is usually indicative of a pinched nerve or nerve root.
Nonsurgical approaches to the management of a herniated disc are
similar to those for other forms of disc degeneration. These approaches
include physical therapy, focused exercises, and epidural injections. The
natural history of lumbar herniated disc is that a majority of patients will
resolve their symptoms without intervention given enough time. Surgery
may be indicated in severe cases that cause significant pain or disability
and also in cauda equina syndrome [34].
Spondylolisthesis
Spondylolisthesis refers to anterior subluxation of the vertebral body
that is caused by a defect in the pars interarticularis [35]. Spondylolisthesis
falls into three categories: spondylolysis, isthmic, and degenerative [36].
Isthmic is the most common form, occurring in 48 % of the general

population and is found twice as often in males compared to females
[37]. Although isthmic spondylolisthesis can usually be detected in
childhood, patients usually do not present with symptoms until later in
life. Presenting symptoms include pain in the lumbar area that can mani-
fest as groin pain that radiates into the buttocks and thighs [37]. The pain
can be exacerbated with weight lifting maneuvers or Valsalva. Higher
grade spondylolisthesis can also manifest in hamstring tightness [37].
Degenerative spondylolisthesis usually presents much later in life and is
caused by long-standing instability in the lumbar segments. The instabil-
ity is most frequently due to arthritis, malfunction of the ligaments sta-
bilizing the lumbar joints, or ineffective muscle stabilization [38]. The
treatment for spondylolisthesis is dependent on the extent of listhesis.
Most patients who present are asymptomatic and can be managed non-
operatively using modalities such as steroid injections, brace therapy,
and restriction of heavy lifting and intense athletic activities [37]. When
nonoperative therapies fail, surgical intervention may be needed.
Generally, the indications for surgery include (1) persistence of debilitat-
ing pain and function, (2) progression of listhesis greater than 30 %, and
(3) cosmetic deformities that result in functional disability [37]. Typical
surgical procedures involve decompression and fusion of the segments
undergoing listhesis.
Neoplasm
Tumors that arise from the nerve root can also cause radicular symp-
toms due to mass effect that can radiate into the groin, resulting in com-
pression of the nerve roots. A lesion arising from any of the lower
thoracic or upper lumbar nerve roots can cause symptoms along their
corresponding dermatomal distribution, which can manifest as groin
pain. The most common types of neoplasms encountered are benign
nerve sheath tumors: schwannomas or neurofibromas [39, 40]. Such
lesions are typically slow growing, and the onset of symptoms can be
fairly insidious. MRI with gadolinium-enhanced sequences is the diag-
nostic imaging modality of choice to identify these lesions. Such tumors
can arise anywhere along the course of the nerve, and can be intradural,
extradural, or both. Surgical resection can be curative in such benign
lesions. In addition, stereotactic radiosurgery is another option in treating
these lesions, depending on their location [40].
108 C.H. Li et al.
Metastasis to the spinal canal or column can also manifest as groin

pain [41]. Similar to nerve sheath tumors, those lesions that involve the
lower thoracic or upper lumbar areas can cause nerve root compression
or irritation, which would be referred to the corresponding dermatome.
Such lesions typically seed into the vertebral body and can cause bony
destruction leading to pathological fractures and/or compression of neu-
rological structures. MRI with gadolinium contrast as well as CT of the
area can be helpful in making a diagnosis and identifying the lesion.
Treatment options in such patients must be weighed on a case-by-case
basis. Overall disease burden, prognosis, histology of the tumor, and the
general medical condition of the patient must be weighed given the
potential morbidity from surgery. In patients who are good surgical can-
didates, surgery can be fairly effective in improving pain and neurologi-
cal function. Other treatments such as stereotactic radiosurgery, palliative
radiation, or palliative chemotherapy are additional options to consider
in this difficult patient population [41].
Summary
The differential for groin pain from spinal causes can be fairly exten-
sive. Presenting signs and symptoms can be helpful for identifying these
conditions, while MRI of the lumbar spine is a very effective diagnostic
tool for identifying any potential causes. Treatment for patients who
have identifiable pathology on MRI that correlates with their symptoms
can be fairly efficacious. Differentiating spinal and back pathologies
from inguinal etiologies is challenging, but the characteristics, distribu-
tion, symptoms, signs, and imaging help to appropriately guide the
evaluation and subsequent therapy.
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10. Groin Pain Etiology: Spermatic
Cord and Testicular Causes
Juzar Jamnagerwalla and Howard H. Kim
Introduction
Chronic groin pain can persist for months and even years. Symptoms
can be vague and often linger as the patient seeks care from multiple
providers. Although historically urologists were the primary specialists
in managing men with chronic groin pain, now various specialties are
involved, using a multidisciplinary approach. The etiologies of chronic
groin pain are not limited to testicular and spermatic cord causes and can
be referred from other sources within the pelvis, abdomen, and lower
extremities. As urological, gynecological, orthopedic, and general sur-
geons often collaborate for complex cases of chronic groin pain, each
specialist should be familiar with the different etiologies and treatment.
Furthermore, as more patients are diagnosed with chronic pelvic pain
syndrome (CPPS), understanding the anatomy and pathophysiology of
the genitourinary system can help physicians accurately diagnose and
treat patients with chronic groin pain.
Groin pain is often used interchangeably with pain of testicular,
epididymal, spermatic cord, scrotal, inguinal, and pelvic origin; in this
chapter, although the discussion broadly encompasses the concept of
urological groin pain, further distinction of anatomic origin is made
when appropriate to keep consistent with the referenced studies.
Definition
Groin pain can be acute or chronic. The acute scrotum is characterized
by pain, erythema, or swelling, with onset measured in hours to days.
Chronic testicular pain is defined as intermittent or constant, unilateral

DOI 10.1007/978-3-319-21587-7_10
112 J. Jamnagerwalla and H.H. Kim
Table 10.1. Common Acute

urological causes of acute Testicular torsion
and chronic groin pain. Infectious (epididymo-orchitis)
Torsion of the appendix testis
Fourniers gangrene
Nephrolithiasis
Chronic
Testicular masses
Chronic pelvic pain syndrome/chronic scrotal
pain syndrome
Infectious (epididymitis/prostatitis)
Varicocele
Hydrocele
Epididymal cysts/spermatocele
Post-vasectomy pain syndrome
or bilateral pain for at least 3 months duration that compromises the

patients daily activities to such a degree that he seeks medical attention
[1]. Common urological causes of acute and chronic groin pain are listed
in Table 10.1. Referred groin pain is covered in other chapters.
While there are many identifiable causes, groin pain of unclear etiol-
ogy is often given the nonspecific diagnosis of chronic epididymitis. But
with better understanding of pelvic floor anatomy, there has been a
concerted effort toward a more nuanced approach to chronic groin pain,
or more expansively, CPPS. In 2010, the European Association of
Urology (EAU) released guidelines that broadly defines chronic pelvic
pain as nonmalignant pain perceived in pelvic structures that is present
in a continuous or recurrent fashion for at least 6 months, with the caveat
that if non-acute and central sensitization pain mechanisms are well
documented the pain can be considered chronic irrelevant of time period
[2]. Chronic scrotal pain syndrome is a subset of CPPS characterized by
persistent or episodic scrotal pain with symptoms suggestive of urinary
tract or sexual dysfunction [2]. The EAU classification system of
chronic urogenital pain syndromes is shown in Table 10.2.
Epidemiology
The true incidence of chronic groin pain in the general population is
difficult to assess. Bartoletti et al. found the prevalence and incidence of
CPPS in men aged 2550 years to be 13.8 % and 4.5 %, respectively,
with 18 % of those patients already diagnosed with chronic scrotal pain
Table 10.2. European Association of Urology classification of chronic pelvic pain syndromes.
Axis III
End-organ as pain Axis IV Axis V Axis VII Axis VIII
Axis I Axis II syndrome as identified Referral Temporal Axis VI Associated Psychological
Region System from Hx, Ex, and Ix characteristics characteristics Character symptoms symptoms
Chronic Specific Urological Prostate Suprapubic Onset Aching Urological Anxiety
pelvic disease- Bladder Inguinal Acute Burning Frequency About pain or
pain associated Scrotal Urethral Chronic Stabbing Nocturia putative cause
pelvic Testicular Penile/clitoral Ongoing Electric Hesitance of pain
pain Epididymal Perineal Sporadic Dysfunctional Catastrophic
OR Penile Rectal Cyclical flow thinking about
Pelvic Urethral Back Continuous Urge pain
pain Post-vasectomy Buttocks Time Incontinence Depression
syndrome Gynecological Vulvar Thighs Filling Gynecological Attributed to
Vestibular Emptying Menstrual pain or impact
Clitoral Immediate post Menopause of pain
Endometriosis-associated Late post Gastrointestinal Attributed to
Chronic pelvic pain Trigger Constipation other causes
syndrome with cyclical Provoked Diarrhea Unattributed
exacerbations Spontaneous Bloatedness PTSD
Dysmenorrhea Urge symptoms
Gastrointestinal Irritable bowel Incontinence Reexperiencing
Chronic anal Neurological Avoidance
Intermittent chronic anal Dysaesthesia
Hyperaesthesia
(continued)
Table 10.2. (continued)
Axis III
End-organ as pain Axis IV Axis V Axis VII Axis VIII
Axis I Axis II syndrome as identified Referral Temporal Axis VI Associated Psychological
Region System from Hx, Ex, and Ix characteristics characteristics Character symptoms symptoms
Peripheral nerves Pudendal pain syndrome Allodynia
Sexological Dyspareunia Hyperalgesia
Pelvic pain with sexual Sexological
dysfunction Satisfaction
Psychological Any pelvic organ Female
Musculoskeletal Pelvic floor muscle dyspareunia
Abdominal muscle Sexual avoidance
Spinal Erectile
Coccyx dysfunction
Medication
Muscle
Function
impairment
Fasciculation
Cutaneous
Trophic changes
Sensory changes
From Engeler et al. [2], with the kind permission of the EAU
Hx History, Ex Examination, Ix Investigation, PTSD Post-traumatic stress disorder
10. Groin Pain Etiology: Spermatic Cord and Testicular Causes 115
[3]. The prevalence of chronic epididymitis in men visiting urology clin-

ics in Canada was estimated to be about 0.9 % [4]. In 2005, Strebel et al.
found that urologists had an average of 6.5 new encounters for chronic
scrotal pain per month, and 2.5 % of all urological visits led to a diag-
nosis of chronic scrotal pain syndrome [5]. The incidence of chronic
scrotal pain was estimated to be about 350450 per 100,000 men aged
2585 years [5]. Multiple publications have reported the peak age of
chronic pelvic pain in their cohort to be at ages 4049, with range from
20 to 83 [610]; however, these numbers were based on trials of men
seeking interventions for chronic pain, and not direct epidemiological
measurements.
Anatomy
Testicular pain is mediated by scrotal and spermatic branches of the
genitofemoral and ilioinguinal nerves, as well as by sympathetic fibers
along the testicular artery [8]. The genital branch of the genitofemoral
nerve supplies the cremaster muscle and scrotal skin, and a branch of
the ilioinguinal nerve supplies the skin of the upper scrotum and base
of the penis. There is significant sensory overlap among the ilioingui-
nal, iliohypogastric, and genitofemoral nerves [11]. The course of the
nerves through the inguinal canal can be seen in Fig. 10.1 [12].
Spermatic cord traction during scrotal surgery may trigger peritoneal
stimulation [13]. The superior and inferior spermatic nerves provide
autonomic innervation [14]. The superior spermatic nerve originates
from the celiac and aortic plexuses and descends along the testicular
vessels and forms the major nerve supply of the testis [14]. Sympathetic
fibers arise from the thoracic segments 10 and 11, whereas the para-
sympathetic fibers arise from the vagus nerve [14]. The inferior sper-
matic nerve travels with the ductus deferens and the epididymis to the
lower pole of the testis [14]. Sympathetic fibers arise from the inferior
mesenteric and hypogastric plexuses and parasympathetic fibers branch
from the pelvic nerve [14]. Animal models indicate that the nerve sup-
ply to the testis helps to regulate its endocrine function, but the precise
function of testicular innervation in humans remains unclear. Epididymal
innervation consists of a high density of sympathetic nerve endings in
the corpus and cauda of the epididymis, with progressive concentration
approaching the ductus deferens, consistent with their contractile role
during ejaculation [15].
Quadratus
lumborum m.
Ilio hypogastric n.
Genital-
femoral n.
Ilio inguinal n.
Sympathetic
trunk
Psoas m.
Genital n.
Ilio hypo-
Lateral femoral gastric n.
cutanious n.
Femoral n.
External
spermatic n. Ilio inguinal n.
Fig. 10.1. Pelvic nerves in relationship to the inguinal canal. Note the location
of the genital branch of the genitofemoral nerve, ilioinguinal nerve, and iliohy-
pogastric nerve as they travel through the inguinal ring (redrawn from Kapoor
et al. [12] with kind permission of Medscape Reference from WebMD).
Acute Groin Pain

Although the focus of this chapter is spermatic cord and testicular
causes of chronic groin pain, a review of acute groin pain highlights the
range and complexity of pain in this region. Men with acute scrotal pain
must be quickly triaged to identify those who need immediate surgical
intervention, as a delayed diagnosis may result in significant morbidity
and even mortality.
Testicular Torsion Testicular torsion must be suspected in a man

presenting with sudden onset unilateral pain without a history of trauma,
often accompanied by nausea and vomiting. This may be seen after an
open inguinal hernia repair, especially if the hernia had scrotal extension
of its contents. During the operative manipulation, the testicle may be
raised into the operative field, i.e., the groin incision, and returning the
testicle back down into the scrotum may initiate the torsion. The window
of time to save the testis is 48 h [16]. Physical exam findings include
scrotal edema, erythema, and exquisite diffuse tenderness over the testis.
Pain localized over the epididymis may be due to epididymitis or torsion
of the appendix testis. Although the cremasteric reflex is often absent in
testicular torsion, the presence of the reflex does not rule out torsion
[17]. Ultrasound is helpful in the diagnosis of testicular torsion, with
specificity approaching 100 % [18, 19]. If suspicion for torsion is high,
surgical exploration should proceed without need for ultrasonic
verification [20]. Surgery involves either orchiopexy or orchiectomy of
the affected testis and orchiopexy of the contralateral testis if it was a
spontaneous torsion.
Fourniers Gangrene Fourniers gangrene is an infected, necrotizing
fasciitis of the perineal, genital, or perianal regions [21]. Patients present
with local discomfort associated with erythema, swelling, and crepitus.
Abnormal vital signs and metabolic derangements predict worse
prognosis and higher mortality risk [22]. Fourniers gangrene is a clinical
diagnosis, requiring emergent surgical intervention if suspicion is high
[23]. CT scan may demonstrate subcutaneous emphysema along fascial
planes in the scrotum, perineum, and inguinal regions [24]. Treatment
includes aggressive fluid resuscitation, broad-spectrum antibiotics, and
early extensive debridement of the involved fascial planes [25]. The
mortality of Fourniers gangrene even with appropriate treatment is high,
approaching 1540 % [23, 26, 27].
Torsion of the Appendix Testis One of the most common causes of
acute scrotal pain in the pediatric population is torsion of the appendix
testis. Torsion of the appendix testis is a far more common cause of acute
scrotal pain in boys than testicular torsion; one series showed that only
16 % of children presenting with testicular pain had torsion of the testicle
as opposed to 46 % diagnosed with torsion of the appendix testis [20].
The appendix testis is a remnant of the Mllerian duct located on
the upper pole of the testis. Differentiating torsion of the appendix
testis from true testicular torsion can be challenging. Patients with torsion
of the appendix testis may have a more insidious onset of pain over
several days, with waxing and waning of pain levels. The blue dot sign
of a palpable, infarcted appendix testis can be seen on exam in
up to 21 % of patients [28]. Ultrasound can reliably identify torsion of
the appendix testis and differentiate it from testicular torsion [29].
Treatment consists of rest and nonsteroidal anti-inflammatory drugs
(NSAIDs).
Acute Epididymitis Acute epididymitis is an inflammation of the
epididymis presenting acutely with pain and swelling. Objective findings
of acute epididymitis include fever, scrotal erythema, leukocytosis on
urinalysis, and positive urine culture. The pathophysiology is unclear but
is thought to be secondary to retrograde flow of infection into the
ejaculatory ducts [30]. In men under age 35 years, the most common
etiology of acute epididymitis is sexually acquired Chlamydia tracho-
matis and Neisseria gonorrhoeae, while in men aged 35 years and over,
the organisms that cause urinary tract infections (e.g., Gram-negative
rods) are the predominant isolates [31, 32]. Men presenting with possible
acute epididymitis should have a midstream urine collection along with
Gram stain of a urethral smear, although empiric treatment should begin
at the time of initial evaluation. Treatment involves bed rest, scrotal
support, NSAIDs, and antibiotics.
Orchitis Isolated acute orchitis is relatively rare, as it usually occurs
by local spread of infection from the epididymis. Isolated orchitis often
has a viral cause, with mumps being the most common etiology. Mumps
orchitis is characterized by painful testicular swelling 48 days after the
appearance of parotitis [33]. Orchitis develops in 1530 % of men with
mumps. Mumps orchitis is not common before puberty [34]. Mumps
orchitis is associated with reduced testicular size in up to half of patients
and with semen analysis abnormalities in about 25 % [35]. Treatment is
largely supportive.
Nephrolithiasis Nephrolithiasis is a common urological problem,
with lifetime prevalence of approximately 10 % in men [36]. Although
the classic presentation includes flank pain and hematuria, a stone
impacted in the distal third of the ureter can cause referred pain to the
groin. A stone should be considered in a patient who has groin pain
associated hematuria, flank pain, or a history of nephrolithiasis. A non-
contrast helical computed tomography (CT) scan is the preferred imaging
study, with a specificity of 98 % and sensitivity of 95 % [37]. Spontaneous

passage rates of stones are directly related to size: as high as 60 % for
57 mm stones and less than 25 % for stones larger than 9 mm [38].
If surgical intervention is indicated, ureteroscopy with laser lithotripsy
results in a stone-free rate up to 96 % [39].
Chronic Groin Pain

Chronic pain, whether epididymal or testicular in origin, has been
defined as symptoms of at least 3 months duration [1, 40]. Chronic pain
may be of neuropathic origin. When a nerve is sensitized by repeated
stimulation, pain can persist even after the initial insult has resolved.
This hard-wiring is mediated by peripheral and central modulation
that reduces the threshold for activation of the action potential and
decreases response latency [11]. Reversible causes of chronic groin pain
must be ruled out before diagnosing CPPS.
Testicular Mass Testicular cancer is the most common cancer among
men between ages 15 and 35 yearsan age group that overlaps with that
of chronic groin pain [41]. Although the majority present with a painless
palpable testicular mass, some report a dull ache or heaviness in the
scrotum or lower abdomen. Approximately 10 % of men with testicular
cancer present with groin pain [42]. Ultrasound confirms the diagnosis,
after which tumor markers are sent prior to prompt inguinal orchiectomy.
Conversely, an incidental impalpable testicular mass may be diag-
nosed during an evaluation for chronic groin pain. With increasingly
finer resolution of ultrasound, masses as small as 1 mm can be detected
long before they would be palpable [43]. Among men undergoing scro-
tal ultrasound for reasons other than for the evaluation of a retroperito-
neal mass, Powell and Tarter found the incidence of testicular mass to be
0.38 % [44]. In men undergoing testicular ultrasound for infertility, the
incidence of testicular tumors was 0.5 % [45]. Generally, the treatment
of any sized testicular mass is radical orchiectomy, but some centers now
perform excisional biopsies of small masses under 1 cm in diameter with
the aid of an operating microscope, intraoperative ultrasound, and frozen
section pathologic analysis. In one review, 19 of 49 cases of incidental
testicular masses were found to be malignant [46].
Varicocele Varicocele is a dilation of the pampiniform plexus of

spermatic veins, which can result in a dull, aching scrotal pain [47]. Vari-
coceles affect 15 % of adolescent and adult men [48]. In men seeking
treatment for infertility, the prevalence of varicoceles has been found to
be as high as 40 % [49]. Varicoceles almost always occur on the left side
or are bilateral. The pathophysiology of varicoceles is poorly understood.
Anatomy may play a role, as the left gonadal vein drains into the higher
pressure left renal vein at almost a 90 angle, as opposed to the right
gonadal vein, which drains into the lower pressure inferior vena cava.
The left gonadal vein is also longer, with fewer valves compared to the
right gonadal vein [48].
Unilateral right-sided varicoceles raise concern for extrinsic compres-
sion of the gonadal vein by a retroperitoneal mass. Also, among patients
who have undergone inguinal hernia repair, note that the scar tissue and/
or the mesh implant may be causing the extrinsic compression resulting
in secondary varicocele. In such cases, further imaging is indicated, and
workup should be directed to the offending cause of the varicocele.
Varicocelectomy can be performed by the open or laparoscopic
approach, but microsurgery remains the gold standard (Fig. 10.2) [50].
Because of the proximity of scrotal lymphatic channels to the ligated
veins during varicocelectomy, hydrocele formation is a possible compli-
cation. The rates of postoperative hydrocele range from 0 to 1.2 % in the
microsurgical group, 520 % in the laparoscopic group, and 615 % in
the open group [5154]. A recent meta-analysis of randomized trials
comparing open, laparoscopic, and microsurgical varicocelectomy
showed both the hydrocele formation and varicocele recurrence rates to
be significantly lower in the microsurgical group [55]. The recurrence
rate after microsurgical varicocelectomy is low, ranging from 0 to 2.5 %,
compared to 716 % and 1720 % in the open and laparoscopic groups,
respectively [52, 53, 56].
Hydrocele A hydrocele is a fluid collection around the testis contained
within the tunica vaginalis and is a common finding in both adults and
children. Although usually asymptomatic, a large hydrocele can cause a
pulling sensation on the scrotum and significant discomfort. Hydroceles
are either communicating or noncommunicating, with the former more
often seen in boys and the latter in men. Communicating hydroceles
represent a patent processus vaginalis, while noncommunicating hydro-
celes result from an imbalance of fluid production and reabsorption. The
Fig. 10.2. Microsurgical varicocelectomy. The testicular artery is identified and

isolated with a vessel loop, lymphatics channels are seen to the right of the artery
and are preserved, and all venous structures are ligated with 40 silk or clips.
incidence of acquired or noncommunicating hydrocele is estimated at

about 1 % in men [57].
Pediatric hydrocelectomy is similar to a pediatric herniorrhaphy.
A small inguinal incision is made, the spermatic cord is visualized, and
the hernia sac is dissected off the cord, taking care not to injure the
spermatic cord structures. High ligation of the hernia sac is recom-
mended to prevent future recurrence [58].
The treatment of adult hydroceles is almost always through a scrotal
incision, and a variety of techniques have been described [59]. At our
institution, we commonly use the Jaboulay technique, which involves
delivering the testis through a scrotal incision, excising the excess portion
of the tunica vaginalis, and everting the remnant [60]. Communicating
hydroceles in men, although rare, may be a sign of an underlying inguinal
hernia. Hydroceles associated with hernias can be a cause of groin pain,
and an inguinal exploration with herniorrhaphy is indicated.
Epididymal Causes of Chronic Scrotal Pain Chronic epididymitis is
a common cause of chronic scrotal pain. Nickel developed a classification
system for chronic epididymitis (Table 10.3) [40]. Workup and treatment
Table 10.3. Classification of chronic epididymitis.

1. Inflammatory chronic epididymitis: pain and discomfort associated with
abnormal swelling and induration
a. Infective
b. Post-infective (following acute bacterial epididymitis)
c. Granulomatous (tuberculosis)
d. Drug induced (amiodarone)
e. Associated with syndromes (Behets disease)
f. Idiopathic
2. Obstructive chronic epididymitis (i.e., congenital obstruction vs. post-vasectomy
scarring)
3. Chronic epididymalgia: pain or discomfort in a normal feeling epididymis with
no identifiable etiology
From Nickel et al. [40], reprinted with permission of MedReviews, LLC. Reviews
in Urology is a copyrighted publication of MedReviews, LLC. All rights reserved
of chronic epididymitis is difficult because there is no identifiable cause

in the majority of cases.
Granulomatous Epididymitis Tuberculosis should be suspected in
men presenting with chronic granulomatous epididymitis, especially if
they have a known history or recent exposure. Those with tuberculosis
epididymitis should have further evaluation for systemic disease along
with treatment with 6 months of triple drug therapy of isoniazid, rifampin,
and pyrazinamide [30]. Sarcoidosis is a less common cause of granu-
lomatous epididymitis, with an estimated 0.25 % of cases having
genitourinary involvement [30, 61].
Drug-Induced Epididymitis The most common drug implicated in the
development of epididymitis is the anti-arrhythmic amiodarone. While
the exact mechanism is unknown, tissue levels of amiodarone and its
metabolites have been shown to be 25400 times higher in the epididymis
than serum, which may lead to fibrosis and lymphocyte infiltration [62].
The incidence of amiodarone-induced epididymitis in men taking high-
dose amiodarone is 311 %, with discontinuation of the drug generally
leading to resolution of symptoms [63].
Idiopathic Chronic Epididymitis In the absence of an identifiable
cause of epididymal pain, the diagnosis of idiopathic chronic epidi-
dymitis is often made. Idiopathic inflammatory epididymitis involves
focal epididymal tenderness with swelling and induration, whereas
chronic epididymalgia involves referred epididymal pain as part of
CPPS. In a cohort of 488 men evaluated for CPPS, 47 % had subjective

symptoms of testicular pain, of whom only 7.5 % had reproducible
tenderness [64], highlighting the importance of properly classifying
patients with CPPS. The treatment of CPPS is discussed below, but
patients with idiopathic inflammatory epididymitis are often treated
with long-acting NSAIDs and rest [30]. If pain persists despite conser-
vative management, surgical options such as microsurgical spermatic
cord neurolysis or epididymectomy are considered.
Lesions of the Epididymis Mass lesions can cause noninflammatory
epididymal pain, although the majority of these are painless. In a series
of 1000 men undergoing ultrasound for testicular pain or swelling, 24 %
were found to have epididymal cysts [65]. In a series of men undergoing
ultrasound for infertility, the incidence was 7.6 % [45]. Spermatocele is
another common cystic epididymal lesion that is usually asymptomatic.
Solid masses of the epididymis are usually benign, with adenomatoid
histology being the most common [30].
Post-vasectomy Pain Syndrome A small subset of men develop
chronic testicular pain after vasectomy that can be debilitating and
difficult to treat. Post-vasectomy pain syndrome (PVPS) is defined as a
scrotal pain syndrome that follows vasectomy and falls under the second
type of chronic epididymitis as described by Nickel (see Table 10.3) [2].
Prospective studies have found that almost 15 % of men who had no
scrotal pain before vasectomy have some scrotal discomfort 7 months
postoperatively, with 0.9 % having severe pain affecting quality of
life [66]. Overall the incidence of PVPS ranges from 1 to 52 % [6770].
The pathogenesis of PVPS is unclear; theories include the extravasation
of sperm with resultant sperm granuloma, infection, nerve entrapment,
and testicular engorgement from sperm due to long-standing obstruction
[67, 71]. Mechanical obstruction may be a significant contributor, as
Moss et al. found closed-ended vasectomies have a threefold higher rate
of PVPS than open-ended vasectomies [72]. Conservative management
with NSAIDs, scrotal support, and limitations in activity is first choice.
While many respond to conservative measures, often further intervention
is needed. Spermatic cord blocks can provide relief of the pain, and
definitive interventions may include microsurgical spermatic cord dener-
vation, vasectomy reversal, epididymectomy, or orchiectomy [73].
Post-inguinal Herniorrhaphy Testicular Pain Similar to the post-
vasectomy pain syndrome, patients can develop post-inguinal hernior-
rhaphy groin pain, also known as inguinodynia. The incidence ranges

from 0 to 62.9 %, with up to 10 % of patients falling into the moderate to
severe pain group [74]. In a large population study of over 2400 patients
who underwent either inguinal or femoral hernia repair, the incidence of
groin pain significant enough to interfere with daily activity was as high
as 6 % [75]. Inguinodynia differs from hernia-related groin pain, as the
pain is new onset after the hernia repair and lasts longer than 3 months.
The pain may be secondary to a variety of factors, including nerve trauma
from retraction and dissection, neuroma formation after partial or
complete transection, or nerve entrapment either by suture material or
mesh associated fibrosis [74]. The pain can be classified as neuropathic
or non-neuropathic, with approximately 50 % of patients falling into
each category [76]. Neuropathic pain tends to be exercise induced with
radiation down into the scrotum, and can be relieved by stretching or
positioning techniques. Spermatic cord blocks can be diagnostic and
therapeutic with up to 80 % of men with neuropathic inguinodynia
reporting relief of their pain [76]. Non-neuropathic pain is secondary
to a variety of etiologies, including recurrent hernias, periostitis, and
spermatic cord congestion [76].
The treatment of inguinodynia begins with conservative treatment
including rest and NSAIDS, similar to the treatment of post-vasectomy
pain syndrome. In patients who have chronic, debilitating pain
despite conservative management, surgical intervention is indicated.
Surgical management is dependent on the underlying pathology of the
pain. 8095 % of patients with neuropathic pain have relief from triple
neurectomy (ligation of the ilioinguinal, iliohypogastric, and genital
branch of the genitofemoral nerve) [77]. Removal of mesh is effective
for non-neuropathic pain secondary to spermatic cord compression from
local mesh fibrosis. A microsurgical spermatic cord neurolysis can be
performed concurrently if there is a significant component of associated
spermatic cord/testicular pain. Intraoperative guidelines to prevent
inguinodynia during routine hernia and further management are discus-
sed in Chap. 28, Prevention of Pain: Optimizing the Open Primary
Inguinal Hernia Repair Technique.
Chronic Pelvic Pain Syndrome Although a majority of patients evalua-
ted for chronic groin pain have a diagnosable, identifiable source of pain, no
cause is identified in up to 25 % of cases [1]. Often these men are given the
nonspecific diagnosis of chronic epididymitis and/or chronic prostatitis
(CP). However, with new understanding of the pelvic floor, symptoms

previously described as idiopathic chronic scrotal pain are now being
classified within CPPS as chronic scrotal pain syndrome (CSPS). The EAU
definitions of chronic pelvic pain are listed in Table 10.4 [78].
Isolated pelvic organ complaints may link to a more generalized pel-
vic floor dysfunction. For example, Planken and colleagues found that of
41 patients with chronic testicular pain, 93 % had at least one symptom
Table 10.4. European Association of Urology definitions of chronic pelvic pain.

Terminology Description
Chronic pelvic Nonmalignant pain perceived in structures related to the pelvis
pain of both males and females. In the case of documented
nociceptive pain that becomes chronic, pain must have been
continuous or recurrent for at least 6 months. If nonacute and
central sensitization pain mechanisms are well documented,
the pain may be regarded as chronic, irrespective of the time
period. In all cases, there are often associated negative
cognitive, behavioral, sexual, and emotional consequences.
Chronic pelvic pain is subdivided into pelvic pain syndromes
and non-pelvic pain syndromes
Pelvic pain Persistent or recurrent episodic pelvic pain associated with
syndrome symptoms suggesting lower urinary tract, sexual, bowel,
or gynecological dysfunctions. No proven infection or other
obvious pathology
Bladder pain Suprapubic pain is related to bladder filling accompanied by
syndrome other symptoms such as increased daytime and nighttime
frequency. No proven urinary infection or other obvious
pathology
Prostate pain Persistent or recurrent episodic prostate pain, associated
syndrome with symptoms suggestive of urinary tract and/or sexual
dysfunction. No proven infection or other obvious pathology.
Definition adapted from the NIH consensus definition and
classification of prostatitis and includes conditions described
as chronic pelvic pain syndrome
Scrotal pain Persistent or recurrent episodic scrotal pain associated with
syndrome symptoms suggestive of urinary tract or sexual dysfunction.
No proven epididymoorchitis or other obvious pathology
Pelvic floor Persistent or recurrent episodic pelvic floor pain with associated
muscle pain trigger points either related to the micturition cycle or
syndrome associated with symptoms suggestive of urinary tract, bowel,
or sexual dysfunction. No proven infection other obvious
pathology
From Fall et al. [78] with kind permission from the EAU
NIH U.S. National Institutes of Health
suspicious for pelvic floor dysfunction and 22 % had either micturition,

defecation, or sexual complaints [79]. Patients who have symptoms of
interstitial cystitis often have other disorders of the pelvis, including irri-
table bowel syndrome and defecatory dysfunction [8082]. This link may
be explained by cross-sensitization between the bladder and colon via
primary afferent fibers [83, 84]. Although interstitial cystitis is classically
associated with bladder pain and urinary symptoms, some men may pres-
ent with complaints of isolated groin or genital pain [85].
Yoshioka et al. reported that noxious stimuli applied to the testes in
rats resulted in significantly decreased bladder capacity compared to
controls [86]. Rats pretreated with capsaicin had normal bladder func-
tion even after noxious stimuli, suggesting that testicular primary affer-
ent C-fibers are responsible for the bladder overactivity [86]. The neural
cross talk between the bladder and the testes may explain why almost
50 % of patients with CP/CPPS endorse symptoms of chronic testicular
discomfort [64]. Urodynamic studies in men with chronic pelvic pain
(with almost 40 % complaining of primary testicular discomfort)
demonstrated a high percentage of urethral sensitivity, increased sphinc-
ter length and tone, and decreased peak urine flow [87].
Despite mounting evidence of CSPS as part of a systemic pelvic floor
dysfunction as opposed to a disorder of infectious etiology, men often
receive a course of antibiotics as initial therapy. A survey of Swiss urolo-
gists in 2005 showed that 98 % believed CSPS was secondary to infec-
tious etiologies [5]. Despite the belief that CSPS is of bacterial origin,
studies report only 21 % of those who present with CSPS were found to
have a significant bacterial colony count or positive PCR with bacteria
[88]. Antibiotics should not be considered first-line treatment for CSPS
in the absence of culture proven infection.
NSAIDs may have a limited efficacy for CPPS, but it may be reason-
able to try them, given their minimal potential morbidity. An EAU
update for the treatment of CPPS/CP indicated level 1b evidence that
NSAIDS may be beneficial in symptom reduction [2]. Alpha-blocker
therapy was also hypothesized to improve CPPS symptoms, but ran-
domized controlled trials have demonstrated no significant benefit [89].
Pharmacological treatment may be more beneficial in alleviating associ-
ated symptoms of CPPS such as urinary complaints.
In men with CPPS refractory to analgesia and muscle relaxant ther-
apy, biofeedback and pelvic floor retraining and relaxation may provide
modest symptom improvement [7, 90]. Given that 88 % of CPPS
patients have an increased pelvic floor resting tone [79], these conserva-
tive therapies may be beneficial.
Surgical Management: Chronic Pain

Conservative measures such as rest, scrotal support, and sitz baths
should always be attempted first for chronic groin pain, with surgery
reserved for those who have persistent refractory pain that significantly
diminishes their quality of life. Medical therapy includes antibiotics,
anti-inflammatory agents, phytotherapy, anxiolytics, narcotics, acupunc-
ture, and injection therapy with steroids and anesthetics [40]. A consul-
tation with the pain service can be helpful before surgical intervention is
considered.
Microsurgical Spermatic Cord Neurolysis Microsurgical denervation
was first described in 1978 by Devine and Schellhammer [91]. Branches
from the ilioinguinal nerve, the genital branch of the genitofemoral
nerve, and autonomic fibers all merge at the spermatic cord, making it
amenable to neurolysis.
Microsurgical denervation is a primary surgical option for men with
chronic testicular pain in the absence of identifiable pathology. Potential
candidates should undergo spermatic cord blocks preoperatively with
demonstrated improvement in pain. If there is no pain relief with the
nerve blocks, neurolysis may not be an appropriate therapy and other
options should be considered.
Heidenreich et al. showed that 97 % of men who had complete relief
of pain with preoperative nerve blocks were pain free at a mean of 34
months after surgery [8]. In another series, 71 % had complete pain
relief and 17 % had partial relief [92]. Overall, a review of the literature
including more than 600 testicular units demonstrated 82 % pain-free
rate after microsurgical spermatic cord neurolysis [93].
The operation involves identification of the external inguinal ring
where a 3 cm transverse incision is made. The spermatic cord is isolated
and delivered into the field. The external and internal spermatic fasciae
are incised. The operating microscope is used to identify the vas bundle.
This is preserved. The testicular artery and several lymphatic channels
are preserved. All other veins and nerves are ligated or clipped. Some
authors advocate dividing the periadventitial tissue of the testicular
artery to achieve further denervation, but the success rate is comparable
and this step may increase the risk of arterial injury [8].
Vasovasostomy Microsurgical vasovasostomy (or vasoepididymostomy)
is used for two primary indications: reversal of sterility or relief of intractable
testicular pain after vasectomy (Fig. 10.3) [94]. Some cases of PVPS are
Fig. 10.3. Microsurgical vasovasostomy. The ends of the vas deferens to be

reapproximated using 100 and 90 monofilament sutures (from Kim et al. [94],
with kind permission from Elsevier).
thought to be secondary to mechanical obstruction, and vasectomy reversal

relieves the pressure. In men undergoing vasectomy reversal for PVPS,
75100 % had relief of symptoms, with 5069 % rendered pain free [71,
9597]. For those who continue to have pain after vasectomy reversal,
redoing the reversal can be beneficial. In a series published by Nangia et al.,
two out of three men with persistent pain after vasovasostomy were pain
free after a second vasovasostomy or vasoepididymostomy [96]. It is
important to counsel patients after vasectomy reversal that they are no
longer sterile and must consider other forms of contraception.
Epididymectomy Epididymectomy has been proposed as an option
for chronic epididymal pain refractory to conservative therapy and
PVPS. It is significantly less technically demanding than microsurgical
denervation or vasovasostomy and less morbid than an orchiectomy. The
surgical technique involves a trans-scrotal incision, unless there is concern
for a malignant lesion, which would necessitate an inguinal approach. The
tunica vaginalis is opened, and the epididymis is dissected free from
the testis before the epididymal branch of the testicular artery is ligated.
The distal vas deferens is ligated, and the epididymis is removed [30].
Long-term outcomes of epididymectomy depend on the indication
for surgery. About 52 % of men undergoing epididymectomy for chronic
epididymitis report being pain free after surgery, 22 % have persistent

but improved pain, and 25 % have no improvement. Efficacy rates for
epididymectomy performed for PVPS are similar, with 53 % being pain
free postoperatively [98]. Those with a primary complaint of epididymal
pain or discomfort related to a spermatocele or epididymal cyst had bet-
ter outcomes. One series reported 75 % were pain free after epididymec-
tomy and only 4 % reported no improvement [99]. Epididymectomy is
also effective for PVPS with epididymal obstruction or sperm granu-
loma formation. West et al. found 90 % had long-term relief of scrotal
pain [100]. Given the association of chronic epididymitis and groin pain
with CPPS, it is not surprising that many fail to respond to epididymec-
tomy. Careful patient selection and counseling are critical; with the
exception of findings of epididymal masses or PVPS, other interventions
may be more appropriate.
Orchiectomy Orchiectomy should only be considered as a last option
among men with intractable pain. There is little data on outcomes as
orchiectomy appropriately is not often performed for pain. Orchiectomy
for referred pain is unlikely to be successful, and careful patient selection
and counseling are critical.
An inguinal surgical approach is preferred. Davis et al. reported
superior results compared to the scrotal approach (73 % vs. 55 % com-
plete relief of pain) [1]. Unfortunately, up to 80 % have persistent pain
following orchiectomy [101]. The benefit of inguinal orchiectomy likely
involves high ligation of the spermatic cord, with resultant denervation
and release of nerve entrapment.
Conclusion
There are many urological causes of groin pain, and it is useful to
triage groin pain into acute and chronic causes. Urological chronic groin
pain has many reversible, treatable causes such as infection, hydrocele,
varicocele, or PVPS; however, a significant number of men do not have
an obvious etiology and fall under the CPPS domain. A multidisci-
plinary approach should be used for those without a clear etiology of
groin pain, and operative management should be considered only after
failure of more conservative multimodal therapies.
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11. Groin Pain Etiology:
Pudendal Neuralgia
Michael Hibner and Catherine Coyne
Introduction
The definition of pudendal neuralgia is pain in the area innervated by
the pudendal nerve [1]. Due to such an extensive definition, pudendal
neuralgia is often confused with other diseases such as vulvodynia, pros-
tatodynia, vaginismus, levator syndrome, pelvic floor tension myalgia,
and painful bladder syndrome.
The pudendal nerve arises from S24 sacral plexus. It courses ven-
trally to the piriformis muscle and exits the pelvis through the greater
sciatic foramen. It then wraps around the dorsal surface of the sacrospi-
nous ligament and reenters the pelvis through the lesser sciatic foramen.
The nerve continues to travel through the fat of ischiorectal fossa until it
enters the pudendal nerve canal also called Alcocks canal. The pudendal
nerve then branches into the rectal nerve, perineal nerve, and dorsal cli-
toral/penile nerve branches. The rectal branch innervates the external
anal sphincter, distal anal canal, and perianal skin. It may also provide
sensation to the lower edge of the vagina in women. The perineal branch
supplies sensation to the labial and scrotal skin, and lower edge of the
vagina. Motor branches provide innervation to the pelvic floor, perianal,
and urethral muscles. The dorsal clitoral/penile innervates the clitoris and
penile skin (Fig. 11.1).
Throughout this chapter, the use of pudendal neuralgia will be
referred to as a symptom, rather than as a diagnosis. Pudendal nerve
entrapment is defined as compression of the pudendal nerve, typically
by scar tissue or surgical material such as sutures or mesh products.
The true prevalence of pudendal neuralgia is unknown. The Portal for
Rare Diseases and Orphan Drugs (orpha.net) estimates that 15 out of

DOI 10.1007/978-3-319-21587-7_11
138 M. Hibner and C. Coyne
Piriformis muscle
Sacrospinous
ligament
Pudendal nerve
artery & vein
Obturator muscle
Sacrotuberous
ligament
Ischial tuberosity
MH
Transversus
Alcocks canal perineal muscle
Levator ani muscle Reflected gluteus

Anus muscle, fat and skin
Fig. 11.1. Course of the pudendal nerve. Posterior, close-up view of the sacral
region. Important anatomical landmarks such as ligaments and muscles are rep-
resented, illustrating the course of the pudendal nerve.
10,000 patients have pudendal neuralgia, and of their population suffer-

ing from chronic pain, around 4 % have this condition.
Etiology: Types of Pudendal Neuralgia

Pudendal neuralgia is broadly defined. We define this as pain in the
distribution of the pudendal nerve that can arise from a series of separate
mechanisms (Fig. 11.2).
Pain that mimics pudendal nerve compression may be caused by
pelvic floor muscle spasm. Since the pudendal nerves course through the
pelvic floor muscles toward the surface of the skin, any muscle spasm
that occurs in the pelvic floor can result in further compression of the
nerve and severe pain. Causes of pelvic floor spasm include direct pelvic
floor injury, other pain conditions in the pelvis, psychological influ-
ences, or idiopathic causes (Fig. 11.3) [2].
11. Groin Pain Etiology: Pudendal Neuralgia 139
Genital branch of the

genitofemoral nerve
Obturator nerve
Pudendal
nerve
Inferior cluneal
nerve
Fig. 11.2. Dermatomal distribution of the perineum. (a) Pudendal nerve, (b)
inferior cluneal nerve (or gluteal branch of posterior femoral cutaneous nerve),
(c) obturator nerve, and (d) genital branch of the genitofemoral nerve and ilio-
inguinal nerve.
Pudendal nerve entrapment (PNE) is the direct result of pelvic trauma

[3]. Causes of trauma can include surgery, childbirth, bicycle seats, sex,
or athletic activities. Pelvic surgery is among the more common causes
of PNE today.
Symptoms: What the Patient Experiences

Patients with pudendal neuralgia commonly describe their pain as
a burning sensation in the region innervated by the pudendal nerve.
Patients often state that the pain is exacerbated by sitting and
improved with lying down [4]. The pain can be bilateral or unilateral.
However, those with direct pudendal nerve injury tend to have unilat-
eral pain.
It is important to appreciate that this pain is neuropathic in nature and
often accompanied by significant allodynia and hyperesthesia. Common
complaints or descriptions that arise during consultations include feel-
ings of a foreign body sensation in the rectum or vagina, without an
Fig. 11.3. Posterior view of the pelvis shows the anatomical course of the
pudendal nerve from a posterior view of the patient (from Kastler et al. [2], with
kind permission of Springer Science + Business Media).
actual foreign body present (allotriesthesia). Depending on which

branches of the nerve are involved, patients can experience pain with
micturition, full/distended bladder, bowel movements, intercourse, or
during an orgasm.
How to Diagnose Pudendal Neuralgia

Patient History It is important to determine the events that preceded
the symptoms for pudendal neuralgia as well as its progression. Many
patients will present after traumatic injury to the pelvis with either
gradual onset or immediate pain. Their pain is located in the area of
innervation supplied by the pudendal nerve. It is neuropathic in nature

and is exacerbated by sitting [4]. The gradual progression in pain for
patients usually is minimal in the morning and progressively worsens
throughout the activities of daily living, becoming most severe in the
evening. Classically, most patients will note they have less pain sensa-
tion when sitting on the toilet seat in comparison to a chair.
Almost all patients with pudendal neuralgia have pain with inter-
course and postcoital dyspareunia. Patients often state that it is so severe
they will refrain from having intercourse altogether, which negatively
affects their partners as well. Along with dyspareunia, common com-
plaints also include pain with bowel movements, urination, or sexual
arousal, as discussed above.
Physical Examination The physical examination is extremely impor-
tant in order to rule out other possible causes of pain. Common findings
among patients with pudendal neuralgia include pelvic floor muscle
spasm and pain on pelvic examination; therefore, it can be difficult to
determine any underlying nerve injury until the spasms are treated [5].
Among patients with pudendal neuralgia, the physical examination
should always confirm pain within the dermatome supplied by the
pudendal nerve. In patients with pudendal nerve entrapment, there will
be tenderness over the sacrospinous ligament just medial to the ischial
spine. Palpation of this area precipitates a tingling sensation commonly
known as Tinels sign.
Ancillary Testing As noted in Table 11.1, pudendal nerve motor ter-
minal latency (PNMTL) testing may help determine nerve conduction
and the integrity of the nerve [6]. Electrical impulses are applied trans-
vaginally or transrectally using a pudendal electrode (St. Marks) on the
tip of the examiners finger. Increased conduction time signifies damage
to the nerve. It is a nonspecific test, as it does not determine the cause or
the level of the injury. Also, the results of the study have been shown to
have wide range, as the length of this nerve can be variable [7]. The
value of this testing therefore remains controversial.
Quantitative sensory threshold testing and mapping have been used
for the diagnosis of other peripheral nerve disorders, but have not been
validated for the pudendal nerve [8]. These tests gauge the ability to
discern between hot and cold temperatures and also between two pres-
sure points. Compressed nerves lose the ability of fine discrimination.
Magnetic resonance imaging (MRI) of the pelvis is superior to other
imaging modalities of the pelvis, as it can determine abnormalities of
the muscles and soft tissue in great detail [9]. Higher resolution 3 T
Table 11.1. Ancillary testing [69].

Test How to perform Comments
Pudendal nerve Measures speed of impulse High inter- and intra-
motor conduction between ischial observer variability. Test
terminal spine and pelvic floor. unreliable due to inability
latency Performed with St. Marks to measure the length of
(PNMTL) electrode pudendal nerve
Quantitative Warm detection testbased Used in diagnosis of other
sensory on patients perception of neuropathic conditions
testing change in temperature but not validated for
Two point discrimination pudendal nerve
testbased on patients
ability to distinguish
between one and two points
Magnetic 1.5 and 3 T MR with specific Pudendal nerve smaller
resonance pelvic floor protocols than resolution of MRI.
imaging Studies on normal
(anatomic) subjects not done
Magnetic Magnetic resonance Studies on normal subjects
resonance neurographynovel not done
imaging technique to enhance image
(functional) of neurovascular bundle
using water properties of
the nerve
MRI can provide more detailed information along the pathway of the
pudendal nerve, including scarring, inflammation, and entrapment.
Magnetic resonance neurography (MRN) may also help identify the
pudendal nerve along its pathway. Often the nerve is too small to be
viewed accurately, unless it is grossly damaged and enlarged. In addi-
tion, MRN is typically performed in highly specialized centers, as it
requires radiologists to be familiar with specific neuroanatomy to accu-
rately interpret the images.
The Nantes Criteria The Nantes Criteria for diagnosing pudendal
nerve entrapment was established by Professor Roger Robert in Nantes,
France. He is one of the pioneers of surgical treatment of pudendal neu-
ralgia. Table 11.2 lists these criteria, which have been validated [10].
Patients who meet these criteria are more likely to respond positively to
surgical options than those who partially meet these criteria.
Table 11.2. Nantes criteria for the diagnosis of pudendal neuralgia (from Labat
et al. [10], with kind permission of John Wiley & Sons).
Inclusion criteria
Pain in the area innervated by the pudendal nerve
Pain more severe with sitting
Pain does not awaken patient from sleep
Pain with no objective sensory impairment
Pain relieved by diagnostic pudendal block
Exclusion criteria
Pain located exclusively in the coccygeal, gluteal, pubic, or hypogastric area
(without pain in the area of distribution of pudendal nerve)
Pruritus
Pain exclusively paroxysmal
Abnormality on imaging (MRI, CT) which can account for pain
Complementary criteria
Pain characteristics: burning, shooting, numbing
Allodynia or hyperesthesia
Allotriesthesia
Pain progressively throughout the day
Pain predominantly unilateral
Pain triggered by defecation
Significant tenderness around ischial spine
Abnormal neurophysiology testing (PNMTL)
Associated signs
Buttock pain (around ischial tuberosity)
Referred sciatic pain
Pain referred to the medial side of the thigh
Suprapubic pain
Urinary frequency with full bladder
Pain after orgasm/ejaculation
Dyspareunia or pain after intercourse
Erectile dysfunction
Normal PNMTL
Differential Diagnosis
Pelvic Floor Tension Myalgia (Also Called Levator Syndrome) This is
a diffuse spasm of pelvic floor muscles. Symptoms are associated with
pain during and after intercourse [11]. Patients also report hesitancy and
sensation of incomplete voiding. On pelvic examination, there are pelvic
floor muscle spasms. This may be confirmed by urodynamic testing.
Of note, pelvic floor muscle spasms are nonspecific findings that often
present among patients with other painful conditions, including pudendal

nerve entrapment, endometriosis, and even inguinal hernia.
Painful Bladder Syndrome/Interstitial Cystitis Symptoms of intersti-
tial cystitis are primarily suprapubic discomfort associated with filling
of the bladder, including frequency, urgency, and/or nocturia. These
symptoms overlap with that of pudendal neuralgia [12]. There is pain
relief with bladder emptying. Patients can also experience pain in the
labia/scrotum, vagina, and clitoris/penis. Inflammation of the bladder
may be incited by exogenous factors, including certain foods. On exami-
nation, the patient may demonstrate bladder tenderness. Cystoscopy
with hydrodistention should be included as part of the workup. The
potassium chloride sensitivity test involves instillation of KCl into the
bladder during cystoscopy. Eliciting pain is diagnostic of, though not
specific to, interstitial cystitis and predictive of positive response to
medical therapy for this disease. After this test, local anesthetic can be
instilled in the bladder. Relief of pain with this anesthetic challenge test
is also diagnostic.
Vulvodynia The diagnosis of vulvodynia can be enigmatic. It is often
chronic, and diagnosis and treatment are difficult, as no single variant
exists. As the term denotes, patients suffer from pain of the vulva.
This may involve the labia, vagina, and clitoris. It is often due to a der-
matologic condition, but similar symptoms can be mimicked by puden-
dal neuralgia [13].
Provoked Vestibulodynia This disease results in pain at the vulvar
vestibule, also referred to as vulvar vestibulitis syndrome. Patients have
a burning pain only upon entry to the vagina, such as with sexual inter-
course. On examination, palpation with a Q-tip results in tenderness of
vestibule.
Vaginismus This is a spasm of the muscles surrounding the vagina.
It is typically elicited upon any insertion or penetration, similar to pelvic
floor tension myalgia or levator syndrome. On pelvic examination, pel-
vic floor muscle spasms are obvious in response to digital examination.
As explained prior, treatment of pelvic floor muscle spasms must be
completed prior to initiating treatment for pudendal neuralgia.
Endometriosis Endometriosis should be included in all diagnoses of
the pelvis among women. The pelvic pain is cyclical and typically in the
lower abdomen. More severe cases may result in continuous pain.
Hormonal therapy may help address the symptoms. Laparoscopy will
confirm the diagnosis.
Treatment
Noninvasive Treatment and Modalities Avoiding activities that are
causing the pudendal pain is the single most important step to treatment
[14]. Scarring around the pudendal nerve can increase with repeat
trauma from certain activities, and some of these can also cause pelvic
floor muscle spasms, leading to severe pain. High-risk patients include
those who perform specific activities such as cycling, gymnastics, ballet,
and competitive athletics. These patients can halt progression of their
symptoms and reduce the risk of developing chronic pudendal neuralgia
if they decrease or stop their activity altogether.
Physical therapy provides excellent benefits in this patient population.
Pelvic floor therapists address muscle spasms and improve upon muscle
imbalances. Their therapies can help release restrictive connective tissue
and improve other symptoms that patient may be experiencing [5]. Pelvic
floor therapy applies hands-on techniques, improves posture and range
of motion, strengthens surrounding muscles, and provides patient
education to prevent further injury and trauma to the area. A majority of
patients with pudendal neuralgia suffer from significant pelvic floor
muscle spasms, with subsequent muscle shortening throughout the pelvic
girdle. Manual techniques help release the spasms and result in lengthen-
ing of the muscles. Techniques focus on myofascial release, soft and
connective tissue mobilization, and trigger point release. Other modali-
ties therapists might include in their treatment approach include biofeed-
back, ultrasonography, and electrical stimulation.
Pharmacotherapy Medical therapy can play a role in multimodal
therapy for the effective treatment of pudendal neuralgia. Table 11.3
lists options for medical therapy. However, little research has been per-
formed to validate the efficacy of any of these medications as a pre-
ferred treatment for pudendal neuralgia. Since the symptoms are a result
of neuropathy with or without muscle spasm, medical therapy is
directed to these entities [15, 16]. No single medical treatment regimen
is currently recommended; the patient may need to attempt multiple
different combination treatments for symptomatic control.
Botulinum Toxin Injections If patients with significant pelvic floor
muscle spasms do not have improvement with physical therapy, the next
line of treatment is botulinum toxin injections [2, 17]. These have been
found to be very effective in decreasing the muscle spasms of the pelvic
floor. Doses between 50 and 400 units of botulinum toxin have been
Table 11.3. Medications for treatment of pudendal neuralgia.

Medication Dose Comments
Oral muscle relaxants (e.g., Variable Marginally effective
diazepam,
cyclobenzaprine,
carisoprodol, tizanidine)
Diazepam and Baclofen Diazepam 5 mg Appears effective
vaginal suppository Baclofen 4 mg No studies available
Start qHS, increase
to BID
Belladonna and opium Belladonna 16.2 mg Appears effective
rectal suppository Opium 30 mg No studies available
Gabapentin Titrate to 2400 Significant side effects
3600 mg/day in No studies available for
three divided doses pudendal neuralgia
Pregabalin Start at 75 mg BID Side effects
and titrate up or No studies available for
down pudendal neuralgia
reported to block these spasms. The timeline for effect of the toxin is
5 days postoperatively with a maximum effect occurring 2 weeks post-
operatively. Response to botulinum toxin will vary per patient. Some
will improve after a single dose and will not require further treatment.
However, the majority of patients will need repetitive injections every 3
months as the effects of the toxin wear off. Approximately 7080 % of
patients have significant improvement of pain after the toxin injection.
Pudendal Nerve Block Pudendal nerve blocks can be completed
either unguided or guided. Unguided, they are performed through the
vagina, perineum, or buttock. Guidance can be completed with the assis-
tance of ultrasound, fluoroscopy, or computed tomography (CT) imaging
[18]. Guided blocks are used to both diagnose and treat pudendal neural-
gia. If a patient experiences temporary relief of pain after the block, this
establishes that the pain is directly related to the pudendal nerve or the
area innervated by the pudendal nerve. A positive block with temporary
relief of the pain does not confirm pudendal nerve compression. If the
block is negative, meaning the patient does not receive any pain improve-
ment, it rules out the pudendal nerve as the cause of pain.
Along with local anesthetic injection, patients also experience long-
term relief with injected steroids. One study found that 92 % of patients
experienced some relief after undergoing a steroid injection [19]. In our
clinical practice, this number seems inflated; approximately 3040 % of

our patients experience long-term relief with the addition of steroids to
the nerve injection.
Surgical Treatment Approach

Transgluteal Pudendal Neurolysis Transgluteal pudendal neurolysis
is currently the most common procedure performed for surgical decom-
pression of the pudendal nerve. It allows surgeons to access the region
between the sacrospinous and sacrotuberous ligaments in order to visu-
alize the longest segment of the pudendal nerve. This is also a common
area for pudendal nerve compression [20].
To perform this operation, the patient is placed in the prone, jackknife
position. An incision is made on the buttock of the affected side, imme-
diately over the sacrotuberous ligament. The area is dissected until the
ligament is identified and the space between the sacrotuberous and sacro-
spinous ligaments is found, revealing the pudendal neurovascular bundle
(Fig. 11.4). The initial dissection is usually difficult, particularly in
patients who have significant scarring in this area, who have undergone
previous operation in the area, or who experience thinning of the nerve.
Piriformis muscle
Sacrotuberous
ligament (cut)
Ischium with ischial
spine
Sacrospinous
ligament
Entry to obturator
(Alcocks) canal
Obturator internus
muscle
Sacrotuberous
ligament (cut)
Fig. 11.4. View of the left pudendal nerve during transgluteal pudendal neurolysis.
Patient is in prone jackknife position.
Once the nerve is identified, scar tissue is carefully removed from

around the nerve.
When the pudendal nerve is cleared of scar tissue, the sacrospinous
ligament is transected and the nerve is transposed anteriorly, thus
decreasing the pressure off the nerve and allowing it to run a more direct,
straight course anteriorly. Once the nerve is transposed, it can be wrapped
in a nerve wrap product of the surgeons choice, further decreasing the
reoccurrence of scar tissue build up. The sacrotuberous ligament is sub-
sequently repaired and the multilayered surgical wound is closed.
In our practice, approximately 75 % of patients have at least 20 %
improvement in pain after this operation (ranging from 100 % improve-
ment to 20 % improvement). This is similar to reports by Robert et al.,
among others [20]. Patients usually report improvement within 4 months
of the operation, and maximum improvement can be expected in 1824
months postoperatively.
Transischiorectal Pudendal Neurolysis Transischiorectal pudendal
neurolysis is preformed transvaginally in women and through a perineal
incision in men. One advantage of this procedure is that it does not
require transection of the sacrotuberous ligament, and therefore may
decrease the risk of instability of the sacroiliac joint postoperatively. The
biggest drawback seems to be the limited visualization and poor access
to the nerve itself. Particularly in male patients, a perineal incision is
painful and is difficult to heal. In a French study, 83 % of patients had
resolution of their pain after this procedure. Controversially, this high
rate of success has not been confirmed by other studies.
Transperineal Pudendal Neurolysis Transperineal pudendal neurol-
ysis is a procedure developed specifically for patients with entrapment
of the terminal branches of the pudendal nerve. Thus, first the patients
experiencing pain from the main trunk of the pudendal nerve, found
between the sacrotuberous and sacrospinous ligaments, must be excluded
[21]. This procedure is most widely applied to patients who experience
isolated clitoral/penile or perineal pain. It is performed with the patient
placed in the lithotomy position and the incision made just lateral to the
labia majora in women or lateral to the scrotum in men.
Endoscopic Transperitoneal Pudendal Neurolysis The pudendal
nerve can be approached through the abdominal cavity during a
laparotomy, laparoscopy, or robotic-assisted laparoscopy [22]. With
this approach, the trunk of the nerve found between the sacrospinous
and sacrotuberous ligaments can be accessed. Visualizing the nerve
distal to this area would require extensive transection of the levator ani
muscle, increasing possible complications and postsurgical pain and

recovery. There are several surgeons who perform transperitoneal
pudendal neurolysis, but due to their small number and the mixed
patient outcomes, it is difficult to validate its complete effectiveness.
Specific Case Discussion: Pudendal Neuralgia

as a Complication of Surgical Implantation
of Vaginal Mesh
In 2011, the Food and Drug Administration released a warning of
potential complications of transvaginal mesh used in the treatment of
incontinence and prolapse [23].
When examining the type of pain that patients may experience after
vaginal mesh implantation, clinicians find that the majority will experi-
ence pudendal neuralgia. Logically, this could be directly related to the
technique with which the mesh biomaterial is required to be implanted.
For example, several mesh products are designed to anchor directly to
the sacrospinous ligament. In cases where patients experience pudendal
neuralgia after a vaginal mesh procedure, we initially advocate a conser-
vative treatment approach. This includes first exploring the options of
pelvic floor physical therapy, botulinum toxin injections to the pelvic
floor, and nerve blocks. If conservative treatment fails, we recommend
removing the mesh completely. Several studies have found that removal
of mesh is beneficial in patients who experience post-vaginal mesh pro-
cedure pain [24]. Although most of the mesh can be removed, there is a
small portion of the mesh located posterior to the sacrospinous ligament
that cannot be removed through either a vaginal or abdominal approach.
If the patients pain persists, they might benefit from a transgluteal
neurolysis procedure to remove the part of the mesh posterior to the
sacrospinous ligament.
References
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Gynecol. 2010;17(2):14853.
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20(2):938.
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12. Chronic Pelvic Pain in Women
M. Jonathon Solnik and Matthew Thomas Siedhoff
Introduction
Our ability to provide optimal care for women who suffer from
chronic pelvic pain (CPP) has traditionally been limited, in part, by the
complexity of the presentation and the relative lack of understanding of
the mechanisms involved and data to support consistent therapeutic
options that relieve pain. Although some women can prove to be
challenging with regard to applying suitable diagnostic and treatment
paradigms, identifying a clinician who is comfortable accepting chronic
patients who can be perceived as difficult to manage can likewise
prove to be problematic.
Inconsistencies in nomenclature, along with the lack of a consis-
tently utilized definition of CPP, affect our ability to determine the
prevalence of this disorder in women, and they also contribute to the
global clinical problem. The American College of Obstetricians and
Gynecologists proposed defining CPP as noncyclic pain of 6 or more
months duration that localizes to the anatomic pelvis, anterior abdomi-
nal wall at or below the umbilicus, the lumbosacral back, or the but-
tocks, and is of sufficient severity to cause functional disability or lead
to medical care [1]. One general estimation of prevalence was 4 %
across different populations of women, which included pain from non-
gynecologic origins [2]. Using a common set of definitions, a systematic
review of high-quality prevalence studies published by the World Health
Organization cited a range of 16.881 % for dysmenorrhea (pain that
occurs with menstruation), 2.124 % for women with noncyclic pain
(pain that occurs outside of the menstrual cycle), and 821.1 % for dys-
pareunia (pain with intercourse) [3].
Notwithstanding, a substantial number of women are exposed to
potentially nontherapeutic surgical procedures; approximately 40 % of
diagnostic laparoscopies and 20 % of all hysterectomies are performed

DOI 10.1007/978-3-319-21587-7_12
154 M.J. Solnik and M.T. Siedhoff
for the indication of pelvic pain [4, 5]. The observation that the majority
of women who have a negative laparoscopy will continue to experi-
ence chronic pain suggests that more careful and systematic evaluation
before or instead of a laparoscopy might be more productive and benefi-
cial to the patient.
The purpose of this chapter is to provide clinicians who see female
patients with a prcis and guide to allow for more effective triage of CPP
and to implement appropriate, contemporary diagnostics and therapeutic
interventions. Critical to this process is a real understanding of the
pathogenesis behind chronic pain and how this may be associated with
the spectrum of related disorders.
History and Background

The last half-century has seen significant evolution in the under-
standing of chronic pelvic pain. Conceptualization was largely Cartesian
in the 1950s, where the degree of tissue damage should correlate with
the degree of pain experienced, and anything more was the result of
psychological distress. Beginning in the 1960s, Wall and Melzack began
developing the gate control theory, a concept represented by the nervous
system having both the ability to carry nociceptive input from the
periphery and the ability of central systems to temper that input with
descending modulation. The degree to which these gates are open or
closed relates to the amount of discomfort experienced by the patient.
Relative gate closure could thus explain how the basketball player can
play her championship game through a knee injury without thinking, but
experiences significant pain once the competition is complete. The gate
control theory is still a useful concept, but many now have grown to
accept a concept of central sensitization in understanding chronic pain.
In this paradigm, repeated noxious stimuli ramp up the patients pain
signaling over time, and coupled with a genetic predisposition or trau-
matic life experience, results in a general pain hypersensitivity, regard-
less of the stimulus. This helps explain the frequent finding of multiple
chronic pain syndromes comorbid in a single patient, such as dysmenor-
rhea, vulvodynia, interstitial cystitis (IC)/painful bladder syndrome
(PBS), irritable bowel syndrome (IBS), temporomandibular joint disor-
der (TMJ), migraines, and fibromyalgia [6]. These conditions are known
as functional pain syndromes, meaning that there is no readily identi-
fiable anatomic or physiologic abnormality, but rather the disease is
defined by the symptoms the patient suffers.
12. Chronic Pelvic Pain in Women 155
While theories of pain perception evolved, gynecologists began

incorporating laparoscopy into their diagnostic armamentarium.
Endometriosis, for example, had long been understood as a cause of
pelvic pain, but the presence of milder disease could now be investi-
gated without the morbidity of a laparotomy. This led to great attention
paid to endometriosis, adhesions, simple ovarian cysts, hernias, and
other variations as pain etiologies. However, it became apparent over
time that these findings could be completely incidental in some cases.
On the other hand, patients with pristine pelvic anatomy could have
the same constellation of symptoms that were thought to be caused by
laparoscopic findings in others. Over time, enthusiasm about endome-
triosis and adhesions as concrete causes of pelvic pain has waned,
but the remnants of these impressions left us with three significant
problems [7]:
1. The signicance of laparoscopic ndings is exaggerated, either by
well-intentioned physicians or in the desperate patients interpreta-
tion. The result can be that every twinge of pain can be translated
as the development or rupture of a follicular cyst or the spread of
endometriosis throughout the abdomen and pelvis like metastatic
cancer.
2. These diagnoses are ogged with unhelpful repeated laparoscopic
lysis of adhesions, excision or ablation of endometriosis, or ovar-
ian cystectomies. In the worst case, belief that the root of pain is
housed in gynecologic organs (Doctor, I feel like I want to just rip
it all out of me) results in serial removal of the uterus and ovaries
at a young age and leaves the patient with an unaddressed chronic
pain syndrome.
3. When minimal or no abnormalities are detected on laparoscopy,
the patient is made to feel crazy or that her pain is all in her
head.
This chapter outlines some of the more common contributors to
gynecologic pain syndromes (Table 12.1). Put in the context of central
sensitization, where the patients pain response can be globally abnor-
mal no matter the stimulus, these contributors can be understood as
peripheral pain generators. The aim of treatment is thus to (1) turn
down the overall master volume dial through an individualized
regimen of medication (e.g., antidepressants, neuroleptics, etc.),
psychotherapy, and/or alternative strategies (e.g., mindfulness-based
Table 12.1. Peripheral pain generators.

Gynecologic
Endometriosis
Pelvic inflammatory disease, chronic endometritis, chronic salpingitis
Pelvic congestion syndrome
Ovarian remnant syndrome
Residual ovary syndrome
Vulvodynia
Vulvar vestibulitis
Vaginismus
Urologic
Interstitial cystitis/painful bladder syndrome
Chronic urethritis
Gastrointestinal
Irritable bowel syndrome: constipation-dominant, diarrhea-dominant, mixed
Chronic constipation
Dyspepsia
Musculoskeletal
Pelvic floor tension myalgia, including levator spasm, piriformis syndrome
Abdominal wall trigger points
Low back pain
Temporomandibular joint disorder
Fibromyalgia
Neurologic
Peripheral neuropathies
Headaches, migraines
meditation, yoga, hypnosis, etc.); and (2) treatment of the peripheral

generatorsendometriosis, dysmenorrhea, bladder pain, bowel dys-
function, and pelvic floor muscular tension.
Endometriosis
The presence of endometrial glands and stroma documented outside
of the uterine corpus occurs in approximately 15 % of reproductive-aged
women [8]. Notwithstanding the relatively high prevalence of this dis-
order, may women remain asymptomatic. This feature is somewhat criti-
cal to the surgeon who incidentally notes endometriotic lesions at the
time of surgery for non-pain indications. It is absolutely acceptable to
leave these lesions undisturbed; however, if preoperative symptoms are
suggestive of endometriosis, which is subsequently encountered, then

surgical management is recommended. Typical symptoms include pro-
gressively worsening menstrual cramps that often begin quite painfully
at menarche (dysmenorrhea), deep pain with intercourse (dyspareunia),
dyschezia (pain with bowel movements), or chronic, noncyclic pain that
occurs regardless of timing during the menstrual cycle. Endometriosis
can also contribute to infertility. Although we are focusing on reproduc-
tive-aged women, endometriosis has been documented in many stages
of life, from premenarcheal to postmenopausal years.
Endometriosis is characteristically described as a disease that affects
peritoneal surfaces and the ovary (seen as endometrioma, or chocolate
cysts), but it also represents an inflammatory process, whereby chronic
fibrosis and infiltrating disease can occur. Sampson originally described
his theory of retrograde menstruation in the early twentieth century, but
most menstruating women will demonstrate this phenomenon [9]. It has
been suggested that women with endometriosis then have a deficiency
in their cell-mediated immune response, and foreign bodies, such as
menstrual effluent passed retrograde through the oviducts, remain untar-
geted after being exposed to peritoneal surfaces [10]. Repeated expo-
sure, facilitated stromal infiltration, and an activated inflammatory
response result in the development of persistent lesions that can manifest
in a myriad of ways from small peritoneal blebs to peritoneal fibrosis.
Fig. 12.1. Endometriosis as peritoneal blebs in the midline posterior cul-de-sac.

Fig. 12.2. Endometriosis as powder burn lesions in right ovarian fossa.
Fig. 12.3 Endometriosis as fibrotic lesions on pelvic brim (white ridge).
See Figs. 12.1, 12.2, 12.3, and 12.4 for varying types of disease seen at
laparoscopy.
Endometriosis is a disease state most readily diagnosed with a good
history and physical examination. A tender, retroverted, and fixed uterus
can be suggestive of deeply infiltrating endometriosis (DIE) that distorts
normal and mobile pelvic anatomy. However, physical findings may
Fig. 12.4. Fibrotic cecal nodule with proven endometriosis (obliterated

appendix).
also be unremarkable. Patients with progressively worsening pain com-

plaints who are often refractory to first-line agents raise a diagnostic
flare. This process is often aided by simple measures such as transvagi-
nal ultrasound (TVUS). TVUS is used to evaluate for ovarian or the
occasional bladder infiltrative disease, which is clinically useful because
treatment options, to be discussed later, would then differ. Pelvic exam
is a relatively poor predictor for DIE, but TVUS is consistently more
effective than more sophisticated and expensive tools such as MRI [11].
Surgery with histopathologic confirmation has been the historical gold
standard for diagnosing endometriosis; however, treatment can be initi-
ated based on clinical suspicion alone without visual confirmation.
Traditional first-line therapies used to manage pain from endome-
triosis include pharmacological agents that suppress endogenous steroid
hormone production [1215]. Table 12.2 provides a summary of medical
options.
Most operative strategies used to treat women with symptomatic
endometriosis focus on conservative measures designed to preserve
reproductive options. Hysterectomy with bilateral adnexectomy and
excision of infiltrating disease, however, may have the potential to
eliminate pain in women with refractory symptoms [16]. Any therapy
short of hysterectomy predisposes women to recurrent symptoms.
Laparoscopic ablation or excision of endometriotic lesions has been
evaluated in a number of clinical trials, with up to 80 % of women
160
Table 12.2. Medical options for treating endometriosis-associated pain.

Medication Route of administration Notes
Combined oral Cyclic or continuous oral daily use Lack high-quality clinical trials
contraceptives No agent seems to be more effective than another
(COCs)
Progestins Continuous oral daily use (Norethindrone acetate Reduction in pain compared to placebo in clinical trials
520 mg daily; Medroxyprogesterone acetate Depot form no more effective with more side effects
(5100 mg daily)) Intrauterine administration effective even for DIE with fewer
Intramuscular depot form (150 mg IM q 3 side effects
months)
Intrauterine (levonorgestrel-intrauterine system;
M.J. Solnik and M.T. Siedhoff
LNGIUS)
Androgens Daily oral, vaginal or intrauterine Not all forms available in the US
Untoward androgenic side effects especially with oral forms
Gonadotropin- Intramuscular depot (leuprolide acetate 3.75 mg Reduction in pain compared to placebo in clinical trials
releasing hormone IM [1 month], 11.25 mg [3 month]) Comparable to COCs and progestins
agonists Positive response in empiric trial
(GnRH-a) Hormonal add-back therapy required after 6 months of use to
minimize side effects (vasomotor symptoms, reduction in
bone mineral density); can be initiated immediately
Aromatase inhibitors Daily oral use Limited data, but may be effective in reducing pain for DIE
Use with progestins or GnRH-a to prevent ovarian follicle
development
DIE Deeply invasive endometriosis
reporting significant improvement in pain symptoms [17].

Notwithstanding adequate trial design, these studies documented a 30 %
placebo effect; the difference, however, was that the therapeutic benefit
was much longer-lasting for those in the treatment arms [18].
DIE is not consistently recognizable by the unfamiliar surgeon, and
since depth of infiltration correlates with pain symptoms, excising these
lesions seems more logical [19]. Ovarian endometrioma, often associ-
ated with DIE, are better managed by enucleating the cyst rather than
ablation [20, 21]. Data to support postoperative suppression are limited,
although the benefits of surgery may be extended with combined oral
contraceptives (COCs), progestins, or gonadotropin-releasing hormone
agonists (GnRH-a).
Adenomyosis
Adenomyosis is an enigmatic disorder characterized anatomically as
endometrial glands and stroma existing within the myometrium dif-
fusely. Focal lesions are referred to as an adenomyoma. Although tradi-
tionally gynecologists have considered adenomyosis a cause of heavy,
prolonged, and/or painful menses, it is apparent from studies of hyster-
ectomy specimens for a spectrum of benign disorders that adenomyosis
is an extremely common entity, found in approximately 2565 % of
hysterectomy specimens.
Until relatively recently, adenomyosis was something diagnosed
based on clinical suspicion and confirmed only at the time of hysterec-
tomy. Advances in uterine imaging have provided the clinician with the
opportunity to diagnose this entity with reasonable accuracy. In the rela-
tively small uterus, TVUS is an effective means of identifying adeno-
myosis, assuming adequate sonographer skill and real-time evaluation
of the study, as opposed to review of still images [21]. Magnetic reso-
nance imaging (MRI) may be an effective secondary tool used to con-
firm adenomyosis, especially when the uterus is large or associated with
concomitant uterine myoma.
The relationship between adenomyosis and abnormal uterine bleed-
ing (AUB) or CPP remains unclear, in particular because many trials
were performed to evaluate symptom reduction without performing a
hysterectomy. The levonorgestrel intrauterine system (LNG-IUS) has
proved to be more effective than other modalities in quality of life mea-
sures when compared to hysterectomy in a randomized trial [22].
Fig. 12.5. Dense uterine adhesion to anterior abdominal wall from prior cesar-
ean section.
Adhesions
There is a tendency to associate pelvic adhesions with CPP, but there
is very little evidence that a clear relationship exists. The exception may
be for dense connections involving viscera, but the lack of control
groups for surgical studies weakens the cause-and-effect association,
and the therapeutic benefits are more difficult to quantify [23]. As an
example, Fig. 12.5 demonstrates a thick adhesion between the uterus
and anterior abdominal wall after Cesarean section. Clinical trials to
determine the incidence of such adhesions, its correlation with pain, and
recurrence after adhesiolysis would require second-look laparoscopic
evaluation; such trials have not been approved to date. Current recom-
mendations focus on the implementation of microsurgical techniques to
minimize the risk of de novo adhesions. When adhesions are encoun-
tered during surgical exploration in a woman with CPP, seek to identify
an underlying cause of adhesions such as endometriosis, and divide only
adhesions necessary to accomplish the surgical objectives.
Myofascial and Musculoskeletal Pain

Patients with myofascial pain complain of aching pain that is worse
with activity or at the end of the day, and improved with rest or relaxation
such as a warm bath. Just as lumbar muscles can be the source of pain in
low back pain, pelvic floor muscles can be the source in patients with
pelvic pain [24]. Dyspareunia is a common presenting symptom.
Evaluation begins with a careful examination of the lower back and
sacroiliac joints, and then progresses to a complete abdominal exam. The
patient is asked to locate any discrete locus of pain and examine herself
with palpation until pain is elicited. At this point, a Carnett maneuver
(having the patient contract her rectus muscles by raising her head into a
half situp) can be helpful to help distinguish a visceral from a somatic
source. Finally, the examiner moves to the pelvic exam, using a single
digit to palpate the levator muscles (iliococcygeus, pubococcygeus,
puborectalis) just inside the introitus. Moving further back, the obturator
is palpated as a square-shaped muscle just deep to levator ani. Finally, the
piriformis can be palpated as a rubber-band-like structure that emerges
during isometric contraction when the knee is externally rotated at the hip
against the examiners hand. In each case, the examiner asks the patient if
the muscle is tender, if pain is felt at the site or migrates elsewhere, and if
the pain experienced is similar to symptoms offered in the history, such as
dyspareunia. Trigger point injections can be helpful for abdominal wall
pain, but the treatment of myofascial pain is generally physical therapy,
where a variety of strength, balance, relaxation, and control modalities are
employed. In pelvic pain, referral should be made to a therapist specifi-
cally trained to address womens health and pelvic floor issues.
Pelvic Congestion Syndrome

Similar to the case for pelvic adhesions, high-quality data linking
pelvic pain with radiological evidence for pelvic congestion of the
gonadal veins are lacking. It has been suggested that faulty valves within
these vessels create flow disruption and resultant distention, similar to
what has been described for varicoceles in men. Pelvic congestion syn-
drome (PCS) is not an uncommon finding in women; however, it is not
clear if the finding is associated with the complaint of pain. Controlled
studies are needed to provide better guidance regarding treatment
outcomes [25]. To date, multiple procedures have been described in

observational trials and include internal iliac/ovarian vein embolization,
sclerotherapy, and ovarian vein ligation.
Ovarian Remnant Syndrome

Women at risk for ovarian remnant syndrome (ORS), whereby a func-
tional portion of the ovary is inadvertently left in place after oophorec-
tomy, include those in whom the fibrovascular attachments are obscured
from dense pelvic adhesions, endometriosis, or reproductive malignancy
[26]. Resulting pain symptoms are typically cyclic and are accompanied
by a solid pelvic mass with ovarian follicular development. Follicle
stimulating hormone (FSH) and serum estradiol levels are in the pre-
menopausal range if bilateral salpingo-oophorectomy was undertaken;
however, hormone levels are not conclusively diagnostic. Nonsurgical
attempts to manage pain with steroid hormone suppression should first be
considered, given the predisposing surgical risks. Properly identifying
and resecting the remaining disease can also prove to be extremely dif-
ficult, and has not been evaluated sufficiently in clinical trials.
Pain of Neurosensory Origin

Chronic pain can arise from virtually any organ system, implicating
a framework for a common origin within the neurosensory system. This
concept is corroborated by surgical research, whereby the presumed
underlying pathology was adequately treated, but symptoms persisted or
recurred soon after the targeted operation [27].
Two major areas of interest, as mentioned previously, include IBS
and IC/PBS. Notwithstanding similarities such as pelvic pain, some
form of visceral dysfunction, and the label of diagnosis of exclusion,
there is no consensus upon which a diagnosis for either of these can be
confirmed. Treatment has thus focused on lifestyle modifications or
reducing inflammatory exposure and sensory input. Pharmacological
agents such as tricyclic antidepressants (TCAs) represent the most
widely studied neuroleptic agents. Although they are routinely used in
CPP management paradigms, there is no high-level evidence to support
their use [28]. One small trial evaluating nortriptyline in women with
CPP resulted in a 50 % dropout rate because of intolerable side effects.
Neuroablative techniques can be performed surgically by transecting

specific nerve or nerve bundles or percutaneously by injecting scleros-
ing agents. These procedures are typically reserved for women with
refractory pain where the distribution is aligned within an identifiable
nerve or nerve plexus. Nevertheless, the role for surgical management of
pain that is likely neurosensory in origin remains limited. Laparoscopic
uterosacral nerve ablation (LUNA) has been described as a technique
that interrupts pain conduction to the uterus, but is of limited to no use
for managing pain of gynecologic origin. Presacral neurectomy (PSN) is
a procedure that excises a segment of sympathetic nerve bundles at the
level of the superior hypogastric plexus. When used as a surgical
adjuvant in the setting of endometriosis, PSN may add a component of
relief to those with midline pain [29].
Hysterectomy clearly represents one of the more aggressive surgical
maneuvers used to treat CPP, but as a stand-alone procedure it may
result in failure for many women not properly evaluated for the likely
cause of pain. Endometriosis-associated pain, refractory to conservative
surgical measures, pain associated with menstrual bleeding, and pain
suspected to be of uterine origin may provide women relief from their
symptoms. If performed hastily, hysterectomy has the potential to
worsen or induce new pain symptoms as a result of surgical trauma.
Prior to considering hysterectomy, alternatives as discussed above
should first be considered.
Vaginal Cuff Pain

Just as neuropathic pain can develop following an abdominal inci-
sion [30], the vaginal cuff can be a source of pain following hysterec-
tomy [31]. Vaginal cuff pain usually presents as new dyspareunia
following hysterectomy, whereas dyspareunia that was present before
and remains after surgery is more likely related to other factors such as
pelvic floor tension myalgia. The character of discomfort from vaginal
cuff pain is often burning, stinging, or simply sharp, radiating pain when
contact is made. Cuff pain is diagnosed by tenderness elicited with care-
ful cotton-swab palpation along the length of the cuff. In evaluating
post-hysterectomy dyspareunia, moving directly to a bimanual exam can
provide confusing information, as it can be difficult to distinguish if pain
is arising from the cuff itself or pathology beyond the cuff, such as an
adherent ovary. Treatment follows in-line with other neuropathic modal-
ities with systemic medications such as tricyclic antidepressants or
GABAergic agents, in addition to local anesthesia, either patient-admin-

istered or as an in-office injection. Vaginal apex revision can be consid-
ered in refractory cases, but patients should be advised that recurrence
of pain is common several years after such a reoperation [32].
Comorbid Pain Conditions

An understanding of chronic pain as a problem of central sensitiza-
tion, whereby hypersensitive responses to diverse stimuli are the reflec-
tion of abnormal processing of pain signals by the nervous system, may
explain why functional pain syndromes tend to cluster in patients.
Peripheral pain generators encountered in evaluating patients with
chronic pelvic pain are listed in Table 12.1, with gastrointestinal and
urologic symptoms being some of the most common adjacent-organ
contributors. Indeed, IBS has been documented in over one-third of
patients with CPP [33, 34], and nearly two-thirds of these women dem-
onstrate features of IC/PBS [35]. These conditions are defined by the
symptoms experienced by the patient (e.g., alternating constipation/
loose stool, urinary frequency, dysuria, nocturia). After more traditional
diagnoses are excluded (e.g., inflammatory bowel disease, celiac dis-
ease, urinary tract infection), tools such as the Rome Criteria [36] or the
Pelvic Pain and Urinary/Frequency (PUF) symptom scale can be help-
ful [37], although they are more sensitive than specific by design. For
IC, the bladder or urethra may be tender on unidigit exam, and a cys-
toscopy with hydrodistention can be useful. The bladder is filled to
capacity and then reexamined to look for subepithelial petechiae or
Hunners ulcers. If a low bladder capacity is observed, a therapeutic
distention for approximately 10 min can be helpful. Potassium sensitiv-
ity testing is rarely needed or helpful in patients with bladder pain.
Treatment of IC generally involves avoiding bladder irritants such as
tobacco or caffeine, administering tricyclic antidepressants (especially
amitriptyline, exploiting its anticholinergic activity), GABAergics
(e.g., gabapentin), pentosan polysulfate, bladder analgesics (e.g.,
phenazopyridine), and occasionally repeated bladder instillations with
a cocktail of lidocaine, dimethyl sulfoxide, and/or heparin. IBS is gen-
erally managed with dietary modification and medications to either
slow (e.g., loperamide) or speed (e.g., lubiprostone) transit time,
together with agents to change the character of stool to a more favor-
able consistency (e.g., polyethylene glycol 3350). It is common for
bladder symptoms, nausea, or diarrhea to accompany severe dysmenor-

rhea, and treating the latter hormonally may also improve urologic or
gastrointestinal symptoms.
Psychological Factors
Mood disorders, a history of sexual abuse, and sexual dysfunction
are all commonly encountered in patients with pelvic pain [3841]. The
careful clinician cannot ignore these important influences, but must also
tread lightly. Patients with pelvic pain are frequently accustomed to
being made to feel their symptoms lie on the first side of an artificial
psychiatric/organic divide. Asking too soon about depression, anxiety,
or whether a patient has seen a therapist can create a barrier difficult to
overcome. By its nature, sexual abuse or current sexual dysfunction may
be difficult to talk about freely in a traditional medical setting. After
establishing patientclinician trustnot necessarily on the first visit
the clinician can preempt apprehension with an explanation of psycho-
logical factors having a symbiotic, rather than causal, relationship with
pelvic pain. For example, although a history of sexual abuse is more
common in patients with CPP than without, clearly not all abuse victims
develop chronic pain, and there are many women with pain and no his-
tory of abuse. With depression, pain thresholds are lowered even in
people without chronic pain. It makes intuitive sense that struggling
with daily pain could easily lead to a depressed disposition.
Determining the cause is less important than simply treating pain and
mood symptoms to the degree that they are present. Sensitively suggest-
ing consideration of enlisting a therapists help can be presented as
augmenting treatment of pain symptoms instead of conveying that a
womans discomforts are simply supratentorial.
Recognizing catastrophization, the belief that things are as bad as
they can be and are unlikely to improve, is likewise important. This trait
is often seen in patients with CPP [42] and presents one of the more
refractory obstacles in treating these women. Catastrophizing is often
supported by well-meaning family members and spouses who reinforce
the sick role with kind attention and devoted attempts to help. These
situations especially are best served with a multidisciplinary approach
to treatment.
Discussion
Nonacute pelvic pain represents a spectrum of disorders not unlike
many others, whereby the diagnosis remains elusive and the treatment is
fraught with episodes of trial and error. In recent years, our fundamental
understanding of pain mechanisms has helped to provide not only a bet-
ter awareness among providers who care for women, but an improved
capacity to have a positive impact on these patients who are indeed suf-
fering. Salient features of the historical intake along with a focused
exam, without the need for expansive diagnostic studies, often direct us
to treatment options that are typically nonsurgical and can be applied
readily. When addressing elective surgery, not all clinicians will be able
to offer each option, and so knowing when to operate and when to refer
will only enable her care. Ultimately, an honest discussion with a patient
in painlistening to her concerns and allowing her to be active in her
carebecomes our obligation and may be therapeutic in and of itself.
Key Points
A complete medical and psychosocial history, as well as a pain-
oriented physical examination, should be completed before
diagnostic laparoscopy is performed.
Neuropathic and musculoskeletal components of chronic pelvic
pain often require treatment both before and after appropriate
pelvic surgery.
A minimally invasive surgical approach is particularly appropri-
ate for chronic pain patients.
Laparoscopic treatment of endometriosis is more effective than
diagnostic exploration alone.
Resection of deeply infiltrating endometriosis is effective treat-
ment of organ-specific symptoms.
Improvement in pain symptoms following GnRHa treatment
does not prove the existence of endometriosis. Many painful
conditions (e.g., irritable bowel, inguinal hernia) vary with the
menstrual cycle, and elimination of hormonal variation can
change symptom profile, regardless of the presence of
endometriosis.
Complete skeletonization of the infundibulopelvic vessels,
especially in difficult oophorectomy, reduces the risk of adja-
cent-organ injury and ORS. Ovarian remnants should be

removed with careful opening of avascular spaces and identifi-
cation of retroperitoneal structures.
Though not a cure for all components of a womans CPP, and in
some cases a causative agent of pain, hysterectomy can be an
effective treatment. A comprehensive evaluation must first be
conducted prior to considering hysterectomy.
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13. Imaging for Evaluation
of Groin Pain
Joseph M. Miller, Shane D. Smith, David N. Ishimitsu,

and Rola Saouaf
While inguinal hernias can typically be diagnosed with a history

and physical examination alone, patients who present with atypical
symptoms or subtle examination findings may require one or more
imaging studies to determine the true cause of their pain. The high
prevalence of inguinal hernia among the general populace implies the
possibility that coincident pathologywhether musculoskeletal, neuro-
logic, urologic, or gynecologicmust be entertained as the true cause of
groin pain. Moreover, it is important to understand that patients with
classic symptoms of an inguinal hernia may have such a small defect as
to be practically undetectable on physical exam. Imaging diagnosis of
the so-called occult or hidden hernia is difficult, and is therefore given
focused attention at the end of this chapter. The radiologic evaluation of
patients with groin pain after herniorrhaphy presents unique challenges
and is detailed in a separate chapter.
Imaging Modalities
The four modern branches of imaging consist of computed tomogra-
phy (CT)/radiography (X-ray), magnetic resonance (MR), ultrasound
(US), and nuclear imaging. Each has their own strengths and weak-
nesses with respect to the kinds of pathologies they can discriminate.

DOI 10.1007/978-3-319-21587-7_13
174 J.M. Miller et al.
Knowing the limitations of a given study in advance can improve diag-

nostic accuracy and help set patient expectations accordingly, thus pre-
venting the frustration elicited by unanticipated follow-up exams.
Regardless of the modality chosen, the more information provided to the
radiologist, the more specific the interpretation can be: while pain is a
valid indication, lateralizing and characterizing the pain (e.g., sharp left
groin pain with defecation) can assist with selection of proper image
acquisition protocols and winnow down the list of potential pathologies
that may present with similar appearances.
Computed Tomography/Radiography (X-ray)

An X-ray tube generates radiation by smashing high-energy electrons
into a durable piece of metal that can resist melting from the consequent
heat exchange. The process is known as the photoelectric effect, and
underlies a number of modern technologies like solar panels and digital
cameras. X-rays passing through the body have a probability of being
scattered or absorbed that is related to tissue density; that probability of
being attenuated by tissue allows for the discrimination of fluid, fat, soft
tissue, and bone. The amount of attenuation can be quantified on a rela-
tive scale quantified by the Hounsfield Unit, where air is arbitrarily
defined as 1000 HU and water as 0 HU, with the implication of an
upper bound of +1000 HU for bone. While these values are only explic-
itly measured for CT, they are still an important factor in conventional
radiography.
On conventional radiographs, the differentiation of two structures
relies on a sufficient discrepancy between their attenuations: air-filled
bowel can be easily seen against the background of the peritoneum,
while fluid-filled bowel is too similar to distinguish. Musculoskeletal
abnormalities that may cause groin pain, such as femoral acetabular
impingement (FAI), spondylosis/spondylolisthesis of the lumbosacral
spine, sacroiliitis, slipped-cap femoral epiphysis, hip osteoarthritis, cal-
cific tendonitis, and fracture, can all be reasonably eliminated from a
differential diagnosis on the basis of radiography, provided that the
proper views are acquired and that technical factors (such as patients
body habitus) allow (Figs. 13.1, 13.2, and 13.3). The gold standard in the
evaluation of inguinal hernia, i.e., herniographythe injection of con-
trast material into the peritoneal cavity followed by radiography of the
groinsis rarely performed these days outside of a few specialized
13. Imaging for Evaluation of Groin Pain 175
Fig. 13.1. Anteroposterior (AP) view of the pelvis is acquired with internal rota-
tion of the legs, laying out the femoral necks to evaluate for possible fracture.
There is severe osteoarthritic change about the right hip with preferential loss of
the superior, weight-bearing portion of the joint space (black arrow) and osteo-
phytosis (curved black arrow) and relative preservation of the medial space. In
contrast, the left hip is normal in appearance (white arrow). Chronic superior and
inferior pubic rami fractures are seen on the right (thick black arrows) with inter-
ruption of the smooth cortical line and callus formation. Significant degenerative
changes of the lumbar spine are partially visualized (asterisk).
centers, though it is frequently referenced in the radiologic literature. In

addition to the drawbacks of its invasiveness, it has been obviated by
dramatic technical advances in dynamic CT and MR acquisition.
CT relies on the same principles as plain film radiography. Instead of
acquiring a single image with a set amount of radiation, a CT scanner
acquires many images from many angles, each of which requires much
less radiation than a single conventional radiograph because they are not
meant to stand alone. A sophisticated processing algorithm then inte-
grates these individual projections into a three-dimensional attenua-
tion map that can be viewed in the axial coronal or sagittal plane, or
some oblique combination thereof. The advance of technology is such
that current generation CT scanners can produce diagnostic images in
any conceivable plane without appreciable loss of resolution. Pathologies
Fig. 13.2. A four view series of the lumbar spine combines the traditional two
view series (anteroposterior and lateral) with left and right oblique views.
While the AP and lateral views are sufficient for evaluating for vertebral body
height and alignment, oblique views reveal the scotty dog appearance of the
posterior structures, allowing for evaluation of the pedicle (arrow), lamina
(asterisk), pars articularis (curved arrow), and facets (circle). Spondylolysis,
or interruption of the pars articularis, may predispose to neuroforaminal steno-
sis and subsequent neurogenic groin pain.
such as appendicitis and degenerative spine disease in particular benefit

from modern high-resolution multiplanar imaging (Fig. 13.4). Other less
common causes of groin pain such as diverticulitis, abdominal aortic
aneurysm, myositis ossificans, adductor tendonitis, prostatitis, and pel-
vic inflammatory disease are well visualized by computed tomography,
although full characterization may require follow-up evaluation with
contrast or another imaging modality.
The overall radiation dose of a CT study is a function of the dose
associated with each acquisition, and the total number of acquisitions
needed to generate the three-dimensional attenuation map. Patient fac-
tors such as body width, lean muscle mass, and the presence of interven-
ing hardware (e.g., spinal fusion, hip arthrodesis, etc.) influence total
dose. Modern technologies such as exposure control and iterative recon-
struction can automatically reduce dose to minimally necessary levels.
For comparisons sake, the American College of Radiology (ACR)
maintains a set of Appropriateness Criteria. Their most recent Radiation
Dose Assessment lists a typical abdominal CT as the rough equivalent
Fig. 13.3. Two views of the right hip demonstrating the findings of mixed-type
femoroacetabular impingement. Pincer-type deformity can be diagnosed on the
anteroposterior view if there is evidence of acetabular overcoverage: in this case
the anterior acetabular wall is somewhat more lateral than the posterior wall,
forming a figure-of-eight. The modified Dunn view (patient lying supine with
feet flat on the table) allows for the evaluation of cam-type deformity, which is
due to asphericity of the femoral head. A circle is drawn within the confines of
the femoral head and an alpha angle measured between the axis of the femoral
neck and the point where the cortex of the neck first meets the head. This alpha
angle measured 65, while normal is considered less than or equal to 50.
of ten single view radiographs [1]. This is in comparison to natural back-

ground levels of radiation, which averages an equivalent of about three
radiographs per year in the United States [2]. The significant drop in
radiation associated with CT has allowed for the application of dynamic
acquisition in some diagnostic circumstances.
Intravenous iodinated contrast material has also advanced substan-
tially since its early uses. Recent research suggests that the nonionic, low
osmolarity contrast formulations currently employed in CT are not a
causative factor in the development of nephropathy, particularly among
patients with normal renal function at baseline [3, 4]. Rather, baseline
Fig. 13.4. Axial and coronal CT images displaying a case of perforated appen-
dicitis. The tubular shape of the appendix (asterisks) is clearly seen in the coro-
nal view with a high-density fecalith (black arrow) best seen on the axial view.
Gas (curved black arrow) within the surrounding fluid collection (surrounded
by white arrows) is consistent with peri-appendiceal abscess formation.
glomerular filtration rate appears to be the primary determinant of acute

kidney injury. Current iodinated contrast materials have been found to
not represent an independent risk factor for AKI even among patients
with impaired GFR (below 30 mL/min/1.73 m2) [5]. It bears mentioning
that this research is relatively recent and requires independent confirma-
tion before current practice guidelines will change [6]. The suggestion,
however, is that the administration of iodinated contrast material should
not be avoided in otherwise healthy individuals. While intravenous con-
trast material is not required for most protocols, it increases the ability of
CT to evaluate for all manner of infectious, inflammatory, and neoplastic
processes (Figs. 13.5, 13.6, and 13.7). Likewise, abdominopelvic
evaluation by CT benefits substantially from routine oral contrast
administration (Fig. 13.8). While rectal contrast agents also have utility,
improvements in image resolution and multiplanar reformatting are lead-
ing to decreased reliance on such invasive administration.
CT contrast reactions are infrequent occurrences that are incompletely
understood. In the majority of patients, reactions to iodinated contrast are
not allergies in the traditional sense of IgE mediation, yet may present
with anaphylactoid airway edema or other severe physiologic conse-
quences all the same [7]. As per the above discussion of contrast-induced
nephropathy, the incidence of severe adverse reactions has decreased
substantially since the switch was made to low osmolarity contrast mate-
rial [8]. A history of asthma or prior contrast reaction increases the risk
of acute reaction. Pretreatment with oral corticosteroids is recommended
for at-risk patients [9]. Common pretreatment regimens for high-risk
individuals may involve oral administration of 50 mg prednisone at 13,
Fig. 13.5. Axial, sagittal, and coronal CT images with features of delayed onset
muscle soreness (DOMS), a form of exercise-induced muscular pain that, when
involving the abdominal wall or pelvic musculature, may result in groin pain.
With severe exertion, rhabdomyolysis and subsequent acute renal failure may
occur. The soft tissues and fascial planes of the abdominal wall are diffusely
edematous (white arrows) as compared to the unaffected tissues (curved white
arrow) found more superiorly. Findings must be differentiated from fasciitis on
the basis of clinical presentation and laboratory results.
Fig. 13.6. Axial and coronal CT images of Fourniers necrotizing fasciitis.

Diffuse abdominal wall edema is again seen (white arrows), primarily involving
the scrotum. Although subcutaneous air is sensitive for fasciitis, as in this case
it is not always present. In contrast to prior patient, the clinical presentation
here was that of sepsis secondary to pelvic infection.
7, and 1 h before contrast administration, with or without oral administra-

tion of 50 mg diphenhydramine and 25 mg ephedrine at 1 h before con-
trast administration [10], though facility-specific variations abound.
Recent studies suggest that multiple exposures to contrast material may
be necessary for severe reaction to occur [11].
Fig. 13.7. Axial CT of the pelvis demonstrates bony erosions of the bilateral
iliac wings (black arrows) with sparing of the sacrum (white arrows), consistent
with sacroiliitis. Ferguson view of the pelvis (pelvic outlet radiograph not
shown) will accentuate the sacroiliac joints and may reveal sacroiliitis without
the need for CT.
Fig. 13.8. Axial, sagittal, and coronal CT reveal loop of bowel (asterisks) exit-
ing the peritoneal cavity below the inguinal ligament and medial to the femoral
vessels (black arrows), diagnostic of femoral hernia.
Magnetic Resonance
Magnetic resonance scanners utilize low-energy light to interact with
the hydrogen atoms found throughout most organic tissues. The electro-
magnet inside an MR scanner is always on, and typically operating at
1.5 T of field strength (roughly 10,000 times the strength of the Earths
natural field) although 3 T scanners are becoming more widely available
in routine clinical imaging. This magnetic field provides energy to
hydrogen atoms, forcing them to line up along the direction of the mag-
net much in the way that a compass needle will line up with the Earth.
Once the hydrogen atoms line up, the machine can communicate with
them by sending out radio-frequency pulses that only specific atoms are
able to respond to, forcing them to change direction and oppose the
magnetic field. This opposition is relatively unstable and the flipped

hydrogen atoms will eventually switch back to their natively aligned
state, emitting their own radio-frequency pulse and communicating back
with the scanner as they do so. Since every tissue is different, the rate of
this process varies dramatically throughout the body and allows for tis-
sue discrimination. Foreknowledge of how fat, water, and other body
substances will behave under these conditions allows for the targeting
by specific sequences such as T1-weighted sequences for fat,
T2-weighted sequences for water, and short-tau inversion recovery
(STIR) for edema, among many others. Compare this to computed
tomography, where there is only one parameter (i.e., density) that sig-
nificantly impacts tissue discrimination.
MR excels at differentiating between many subtle soft tissue and
musculoskeletal pathologies responsible for groin pain, such as those
seen in iliopsoas tendinosis, bursitis, osteitis pubis, and athletic pubalgia
(Figs. 13.9, 13.10, and 13.11). Avascular necrosis of the femoral head in
particular is apparent on MR long before it is demonstrable by CT (Fig.
13.12). Yet MR is not always a definitive examination, particularly with
respect to certain musculoskeletal pathologies in which the relative lack
of hydrogen in bone can necessitate correlation with conventional radi-
ography or CT. While radiographically occult stress fractures are clearly
identified on MR, many other benign and malignant osseous lesions
may be indistinguishable from each other on the basis of MR alone.
Definitive evaluation of acetabular labral tears is via MR arthrography,
wherein contrast material is directly injected into the hip joint (Fig. 13.13).
Dynamic MR has become the primary evaluation of pelvic floor dys-
function now that most centers have stopped performing colpography
and defecography, which involve the respective administrations of vagi-
nal or rectal contrast agents followed by fluoroscopic visualization dur-
ing Valsalva maneuver (Fig. 13.14). Dynamic MR can demonstrate
ligamentous laxity and organ prolapse (rectocele, cystocele, enterocele),
as well as less conspicuous pathologies such as vesicovaginal and recto-
vaginal fistulae. Occult inguinal hernias also benefit from evaluation
with dynamic MR, as will be discussed later in this chapter. Other gyne-
cologic sources of groin pain such as endometriosis, uterine fibroids,
and ovarian masses/cysts are well evaluated on MR but can often be
more readily and economically demonstrated with ultrasound.
Intravenous MR contrast material is fundamentally different than the
iodinated material used for CT. The risk of contrast reaction is signifi-
cantly lower with gadolinium-based MR contrast agents, and there is no
Fig. 13.9. Coronal and axial T2-weighted MR through the pelvis show
increased fluid signal (white arrows) lateral to the greater trochanter, consistent
with greater trochanteric bursitis.
Fig. 13.10. Coronal and axial CT of the pelvis demonstrate diffuse subchondral
sclerosis (black arrows) of the pubic symphysis. Corresponding coronal and
axial T1-weighted MR demonstrate focal hypointensity (white arrows), consis-
tent with osteitis pubis.
Fig. 13.11. Axial T1- and T2-weighted MR through the pelvis demonstrating
significant edema (black arrow) and trace fluid within the adductor compart-
ment, consistent with low-grade adductor strain.
Fig. 13.12. Anteroposterior radiograph of the right hip reveals subtle sclerosis
(black arrow) representative of avascular necrosis. Coronal T1-weighted MR
demonstrates serpiginous hypointensity (white arrow), confirming the diagnosis.
Fig. 13.13. Coronal and axial T1-weighted MR arthrogram of the hip after
intracapsular injection of gadolinium-containing contrast agent. A hyperintense
fluid cleft (white arrows) is seen separating the labrum (large white arrows)
from the chondral surface of the acetabulum. Findings represent superior labral
tear in this patient with cam-type deformity and femoroacetabular impingement.
Fig. 13.14. Sagittal T2-weighted MR images. The pubococcygeal line (PCL)

extends from the pubic symphysis to the final coccygeal joint and roughly
demarcates the pelvic floor. The H-line is measured from the pubic symphysis
to the anorectal junctions posterior wall and should measure less than 5 cm; the
M-line is the perpendicular drawn to connect the PCL and the H-line, and should
measure less than 2 cm. All organs should remain above the PCL. As seen on the
leftmost image, even at rest there is pelvic floor relaxation with pathologic
H-line and M-line measurements. The bladder (black arrow) and uterus (curved
black arrow) are mostly above the PCL, although there is mild prolapse of the
urethra in particular (asterisk). With Valsalva, there is significant elongation of
both H-line and M-line beyond their already pathologic baselines, as well as
severe prolapse of the bladder (white arrow) and the uterus (curved white
arrow), both dropping below the H-line.
known cross-reactivity between MR and CT contrast agents, although

patients with atopic tendencies in general are at increased risk for either
[6]. The unique risk of the gadolinium contrast agents used for MR is a
condition known as nephrogenic systemic fibrosis, of which only a few
hundred cases have been identified. Patients with severe or end-stage
renal failure (GFR below 30 ml/min/1.73 m2) seem to be most at risk,
and risk appears to be dose dependent [12]. Inability to remove the gado-
linium chelates at a normal rate is theorized to lead to free gadolinium
accumulation in the blood, followed by precipitation within the skin,
retroperitoneum, heart, etc., with secondary sclerotic change [13]. While
protocols are facility specific, lower doses of contrast are often admin-
istered in patients with abnormal renal function (GFR below 60 ml/
min/1.73 m2) and contrast is withheld altogether in patients with severe
or end-stage renal disease. While intravenous contrast is useful for the
evaluation of neoplasms in particular, it is not required for most differ-
ential diagnoses related to groin pain, and the availability of diffusion-
weighted MR sequences may provide a useful alternative in patients
with contraindications to gadolinium-based agents.
Unlike CT, there are contraindications to undergoing MR itself with
respect to implanted medical devices. Even MR safe devices can create
the sensation of tugging, particularly when entering or exiting the
machine [14]. Devices with functional circuitry (e.g., pacemakers, infu-
sion pumps, etc.) may be disrupted by the oscillating magnetic fields
[15, 16]. MR safe devices without circuitry (e.g., orthopedic implants)
may heat up during the application of certain sequences [17, 18].
Patients with anxiety or claustrophobia may be unable to undergo MR
imaging without sedation, and may even require general anesthesia.
Ultrasound
Ultrasound technology is based on a property known as piezoelectric-
ity, wherein mechanical deformation of a material results in the genera-
tion of an electrical current and vice versa. In the typical US transducer,
multiple piezoelectric crystals are placed in a shaped array and a voltage
applied, causing the crystals to vibrate. The specific characteristics of
the voltage, the crystal structure, and the configuration of the array
determine such technical factors as the frequency of vibration, as well as
its coherence, depth of penetration, and field of view. Sound waves
travel at different speeds in different materials, and so the interface
between two different body tissues often results in reflection of at least
some aspect of the sound wave. The US transducer probe rapidly
switches back and forth between generating sound waves and then lis-
tening for the eventual echoes. In regard to evaluation of groin pain, US
is most readily used for the evaluation of intra-pelvic organs (Fig.
13.15). The use of Doppler US allows for the additional evaluation of
vascularity within visualized tissues (Fig. 13.16). There have been
recent papers documenting frictional heat deposition by Doppler US,
with the suggestion of a theoretical risk to the developing fetus with the
use of this modality [19]. The ACR currently lists no contraindications
Fig. 13.15. Axial CT of the pelvis with corresponding sagittal Doppler and
coronal US images of the left adnexa. While CT is able to show a multiloculated
low-density fluid collection (black arrows) within the pelvis, further character-
ization is difficult. Follow-up US images demonstrate that the fluid is contained
within tubular structures (white arrows) in continuity with a dilated, heteroge-
nous appearing ovary (curved white arrows), allowing for diagnosis of tubo-
ovarian abscess.
Fig. 13.16. Sagittal Doppler US of the ovary demonstrating normal arterial

waveform on the left; normal venous waveform on the right. Morphologically,
typical ovaries are of homogenous echotexture with hypoechoic follicles (white
arrows) scattered throughout. Normal ovarian size varies significantly from
patient to patient, and asymmetry between the left and right ovaries is often
more diagnostically useful. Arterial waveform (curved white arrow) should have
rapid systolic rise and gradual diastolic fall without inversion below the base-
line. Likewise, venous flow (large white arrow) should remain uniform without
inversion below the baseline.
to US in pregnancy, but does suggest limited fetal exposure [20, 21]. As

a result, many radiology practices will avoid imaging the fetus when
examining the mother for a complaint such as groin pain.
The primary limitations of US are its operator dependence and inabil-
ity to image the pelvis completely: a negative US examination does not
necessarily confirm the absence of disease. Additionally, technical fac-
tors such as bowel gas and body habitus can make an US examination
completely nondiagnostic, whereas CT and MR evaluations are rarely so.
Yet, US is a widely available and cost-effective way to evaluate for com-
Fig. 13.17. Transverse US and Doppler US of a complex ovarian cyst with

large central septation (large white arrow), an ovary with numerous large thin-
walled theca lutein cysts (white arrows) in follicular hyperstimulation, and a
normal corpus luteum cyst surrounded by its pathognomic ring of fire
(curved white arrow) of peripheral increased vascularity.
Fig. 13.18. Sagittal Doppler US images. Normal testicle has homogenous

echotexture and scattered vascularity (white arrows). By contrast, testicular lym-
phoma presents as an ill-defined, hypoechoic focus (large white arrow) with sig-
nificant hypervascularity (curved white arrows). Scrotal hematoma can also
appear irregular and heterogenous, but should not demonstrate internal vascularity.
Fig. 13.19. Bilateral sagittal US and Doppler US images through the epididymis
comparing the enlarged, hypoechoic, and hypervascular (curved white arrows)
appearance of epididymitis with the normal contralateral anatomy.
mon causes of groin pain, which often elevates it as a first-line mode of

evaluation, particularly when genitourinary pathologies are suspected.
US is often a definitive examination for groin pain due to ovarian and
testicular masses or torsion, ectopic pregnancy, uterine fibroids,
epididymo-orchitis, pelvic inflammatory disease, hydrocele, varicocele,
and pelvic congestion (Figs. 13.17, 13.18, and 13.19).
US also has numerous applications in the initial evaluation of muscu-
loskeletal pathologies, though it may not be definitive. Pathologies such
Fig. 13.20. Normal bone scan.

as tendinosis and tendinopathy, bursitis, and intramuscular contusions of

the abdominal wall are easily and rapidly evaluated with US.
Nuclear
Nuclear imaginginvolves the intravenous administration of radionu-
clides bound to target-specific chemicals that are known to accumulate in
a given organ or at the site of a presumed pathology such as infection. The
studies most applicable to groin pain include the indium-111 white blood
cell and gallium-67 scans typically utilized for the evaluation of pelvic
abscess/inflammation and osteomyelitis, respectively. Technetium-99m
bone scans are also utilized to evaluate for osseous pathology (Fig. 13.20).
Imaging Evaluation of Occult Hernias

Occult hernia is defined as a clinically symptomatic defect in the
abdominal wall (whether direct, indirect, or femoral) that presents with-
out clear physical examination finding [22]. Surgical exploration of all
patients with groin pain would result in an unacceptably high negative
rate; as such, evaluation for an occult hernia is primarily reliant on imag-
ing for diagnosis. There has been controversy however about the most
appropriate way to engage in radiologic workup, and no standards have
been established.
Studies have highlighted the positive predictive value of US in the
diagnosis of inguinal hernia [23, 24]; however, few have offered surgical
exploration in the setting of negative US evaluation, preventing the esti-
Fig. 13.21. Axial and sagittal CT images acquired through the pelvis in a patient
with a pair of unilateral direct hernias (white arrows). While these hernias were
clearly palpable on physical exam, smaller defects may require MR for detection.
Fig. 13.22. Static axial and sagittal T2-weighted MR, and dynamic axial and
sagittal T2-weighted MR of occult femoral hernia not detected on CT or
US. Valsalva maneuver forces a small amount of fat (black arrows) through the
femoral triangle on the left.
mation of true negative predictive values. Dynamic examination of the

groin with Valsalva maneuver further strengthens the ability of US to
find small defects, but there is reason to believe that physically undetect-
able hernias would be equally difficult to demonstrate with the limited
resolution of US. While it is certainly reasonable to begin radiologic
assessment of suspected occult inguinal hernia with US, the test should
not be considered definitive on account of its operator dependence and
inability to ensure visualization of the entire pelvis [25].
CT of the pelvis solves this visualization problem and can often elu-
cidate unconsidered pathologies as the source of groin pain. Yet while
CT is often considered a definitive test for occult inguinal hernia
(Fig. 13.21), [26], the common focus of study design on the hernias that
require surgeryindicative of hernias more prone to complication
likely biases results toward detection of larger hernias. In a recent study
directly comparing all patients operated on for uncomplicated groin
pain, CT was found to be substantially weaker than MR in the evaluation
of occult hernia, with MR correctly identifying 91 % of the hernias
overlooked by CT (Fig. 13.22) [27].
The recommendation is that MR be considered the definitive nonop-
erative test for inguinal hernia in patients with history strongly sugges-
tive of such pathology but lacking clear physical findings. US and CT
still have utility in the evaluation of groin pain due to occult inguinal
hernia; however, in light of negative US or CT result, further diagnostic
workup with MR is indicated as symptoms persist [27].
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14. Perioperative Pain Management:
Multi-modalities to Prevent
Postoperative Chronic Pain
Brian J. Dunkin
Introduction
Inguinal hernia surgery is the most common operation done by a
general surgeon with approximately 770,000 repairs performed in 2003.
Among the most feared complications of this common surgery is the
chronic pain that occurs in 11 % of patients, one-third of whom report
limitations in daily leisure activities [1]. One component of this problem
may be inadequate control of acute pain [2]. As a result, it is important
that surgeons employ excellent pain management strategies for their
hernia patients not only to ensure a good perioperative experience but
also to avoid long-term problems.
This chapter describes the concept of multimodal pain therapy and
provide examples of medications that can be used in this approach. It
will also provide recommendations for pain management in the pre-,
intra-, and postoperative periods.
Multimodal Pain Therapy

In order to understand how to use multiple modalities to treat postop-
erative pain, we must first understand how surgical pain is perceived. The
process begins when noxious stimuli activate specialized nerve cells (noci-
ceptors) at the site of surgery. Nociceptive pain is so intense that it elicits
an autonomic response resulting in a withdrawal reflex. There are four
types of nociceptive pain (heat, cold, intense mechanical force, chemical
irritants), but in surgery, it is the intense mechanical force pathway that is
activated (Fig. 14.1). The nociceptors transmit a signal along the nociceptive

DOI 10.1007/978-3-319-21587-7_14
194 B.J. Dunkin
Noxious peripheral stimuli

Heat Pain
Autonomic response
Withdrawal reflex
Cold
Intense
Mechanical
Force Nociceptor
sensory neuron
Chemical
Irriants
Spinal cord Brain
Fig. 14.1. Nociceptive pain pathway.
nerve fibers in the periphery to the dorsal horn of the spinal cord. The
signal then continues up the spinal cord and is transmitted to multiple parts
of the brain. There are also descending inhibitory or excitatory pathways
that travel down the brain and back to the dorsal horn of the spinal cord to
decrease or increase the pain signal via interneurons. Intense mechanical
force during surgery causes tissue damage as well, which initiates an
immune response that liberates inflammatory mediators. These mediators
also activate pain receptors that transmit signals via the nociceptive nerve
fibers. This inflammatory pathway is responsible for patients feeling pain
beyond the duration of the surgical event and results in a hypersensitivity
at the surgical site with allodynia (reduced pain threshold) and hyperalge-
sia (increased response to painful stimuli). Multimodal pain therapy uses
medications and local anesthetics to block or modulate pain signals along
the entire pain pathway (Fig. 14.2). This results in more effective therapy
while minimizing the side effects of any one drug.
Multimodal Analgesics for Acute

Pain Management
There are multiple analgesics that can be used to modulate the pain
pathway. Beginning in the periphery and working toward the central
nervous system, these include (Table 14.1):
Local Anesthetics
Local anesthetics are aminoamide or aminoester compounds that
temporarily block the sodium channels in the nociceptive nerves, pre-
venting conduction of the pain signal. They may be infiltrated into
Pain
Opioids
Brain Acetaminophen
Alpha2 agonists
Ketamine
Local anesthetics
Opioids
Alpha2 agonists
Gabapentinoids
Spinal cord
Peripheral
nerve
Local anesthetics
Trauma
Local anesthetics
NSAIDS
Corticosteroids
Tissue block
Fig. 14.2. Comprehensive view of pain pathway with multimodal points of

modulation.
196 B.J. Dunkin
Table 14.1. Summary of analgesics for multimodal pain therapy.

Agent Mode of Action Dose Safety
Local Nerve conduction Ropivacaine 0.2 % Neurotoxicity
anesthetics blockade infiltration and
Bupivacaine 0.10.25 % cardiotoxicity
infiltration
Bupivacaine liposome
injectable suspension
(EXPAREL) 1.3 %
infiltration
NSAIDs COX-2 inhibition IV: ketorolac Wound site and
1530 mg q6 h GI bleedinga,
PO: celecoxib 200 mg renal toxicityb
BID
Gabapentinoids 2 ion channel Gabapentin 600 mg po Sedationc
blockade TID
Pregabalin 100 mg po
BID
-agonists Enhanced Patch: 0.1 mg/24 h Hypotension and
(Clonidine) monoamine- bradycardia
mediated
analgesia
Acetaminophen GABA inhibition, PO: 650 mg q6 h Hepatotoxicity
(APAP) serotonergic IV: 1000 mg q6 h
interaction
Opioids -receptor agonist Varied depending on Sedation,
formulation hypotension,
respiratory
depression,
nausea
Ketamine Nonselective 1 mg/kg/h infusion Hallucinations,
NMDA confusion
antagonism
a
Ketorolac should not be administered preoperatively
b
More selective COX-2 inhibitors like celecoxib are associated with lower incidence
of these complications
c
Adjust carefully in renal failure patients
tissue to block nerves locally, regionally to block pain perception from

an area of the body, or around the spinal cord to block transmission of
pain signals to the brain. They may also be short acting (lidocaine:
12 h duration), intermediate acting (bupivacaine: 36 h duration), or
long acting (liposomal bupivacaine: 72 h duration). Local anesthetics
may also be continuously pumped into the surgical site using an elasto-
meric or electrical pump in an effort to prolong the duration of their
14. Perioperative Pain Management Multi-modalities to Prevent 197
effect. For hernia surgery, local anesthetics may be applied using four
different techniques: inguinal nerve block (discrete nerve block at the
site of the ilioinguinal, iliohypogastric, and/or genitofemoral nerve);
field block (infiltration into the superficial and deeper structures in the
field of surgery, which may result in a block of the ilioinguinal, iliohy-
pogastric, and/or genitofemoral nerve); infiltration (injection of local
anesthetic into the cutaneous/subcutaneous/deeper structures of the
surgical field); and instillation (local anesthetic application without
needles (e.g., spray) into the surgical site).
Techniques for Administration of Local Anesthetics

Inguinal Nerve Block
The ilioinguinal and iliohypogastric nerves can be blocked by a
directed administration of local anesthetic pre- or intraoperatively.
Beginning two fingerbreadths superior and medial to the anterior supe-
rior iliac spine, a 1.5 inch needle is introduced deep into the abdominal
wall, targeting the layers between the internal and external oblique fas-
cia (Fig. 14.3). Depth is estimated by feeling for the pop of the needle
across the external oblique fascial layer and 10 mL of long-acting local
anesthetic (bupivacaine or liposomal bupivacaine) is infiltrated.
Transversus Abdominis Plane Block

This procedure is done under ultrasound or laparoscopic guidance
and used to block T11L1 cutaneous, myofascial, and peritoneal nerves,
including the iliohypogastric and ilioinguinal nerves. It provides excellent
pain relief for surgeries involving the infra-umbilical abdominal wall.
Fig. 14.3. Landmarks for inguinal nerve block.

198 B.J. Dunkin
Rectus
abdominis
External
oblique
Internal oblique
Transversus
fascia
Transversus
abdominis plane
TAP block
Fig. 14.4. Transversus abdominis plane (TAP) block.
Under ultrasound guidance, a blunt-tipped 22-gauge needle is inserted

into the abdominal wall two fingerbreadths above the iliac crest along
the mid-axillary line and advanced into the plane between the transver-
sus abdominis and internal oblique muscles (Fig. 14.4). After aspirating
to exclude a vascular puncture, 5 mL of local anesthetic is infiltrated
while ultrasound imaging confirms separation of the two muscles and
infiltration into the correct plane. Once confirmed, an additional 15 mL
of anesthetic is infiltrated. The genital branch of the genitalfemoral
nerve runs on the posterior aspect of the spermatic cord and is most
commonly identified where the cord crosses the pubic tubercle. Some
surgeons infiltrate local anesthetic into the spermatic cord at this area in
an attempt to block this nerve.
During laparoscopic surgery, the transversus abdominis plane (TAP)
block can be done without ultrasound, using intra-abdominal visualiza-
tion. The needle is passed using the same external landmarks and
advanced under laparoscopic monitoring into the plane just above the
transversus abdominis muscle. A test injection should demonstrate an
obvious bulge without elevation of the peritoneum.
Field Block
Local anesthetic is infiltrated into the surgical field. This begins with
infiltration of the dermal layer of the skin beyond the planned area of
incision. Each layer encountered is then infiltrated with additional anes-
thetic. The subcutaneous layer is infiltrated using a fanning technique
extending both superiorly and inferiorly from the wound. The external
oblique aponeurosis, internal oblique fascia, and transversus abdominis
fascia are also injected.
Instillation
Local anesthetic may be applied to the surgical area by simple instil-
lation, without the use of a needle. The surgeon essentially bathes the
field in local anesthetic. This is done at the time of closure in open
inguinal surgery and prior to port removal for TEP or just after perito-
neal closure in TAPP (needle puncture of peritoneum required).
Nonsteroidal Anti-Inflammatory Drugs

Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) play a key role in
multimodal analgesia as adjuncts or alternatives to opioids. They modu-
late the inflammatory pain pathway by blocking cyclo-oxygenase
(COX) enzymes. When cells die or are damaged, arachidonic acid is
released from the cell walls and acted upon by one of two COX
enzymes. The COX-1 enzyme is normally expressed in the body and is
considered a homeostatic isoform that converts arachidonic acid to
prostaglandins that are used to promote platelet aggregation, renal blood
flow, and gastric mucosal protection. The COX-2 enzyme is minimally
expressed normally, but greatly upregulated following trauma or sur-
gery. It promotes conversion of arachidonic acid to prostaglandin E2
(PGE2), which activates nociceptors and initiates the inflammatory cas-
cade. NSAIDs are classified based on their effect on COX-1 versus
COX-2. For pain control, it is ideal to have selective COX-2 inhibition
without interfering with COX-1, which can increase the risk of bleeding,
gastric ulceration, or renal damage. Figure 14.5 details the COX-2 ver-
sus COX-1 inhibition of common NSAIDS used in the USA.
200 B.J. Dunkin
COX-1 COX-2
Celecpxib
ibuprofen
naproxen
ketorolac
300 250 200 150 100 50 0 50 100
Fig. 14.5. Inhibition of COX-2 relative to COX-1.
Corticosteroids
Corticosteroids are potent anti-inflammatory drugs that can reduce
the intensity of postsurgical pain. They stabilize lysosomal membranes
in injured cells, decreasing the release of arachidonic acid, which in turn
reduces the production of prostaglandins and leukotrienes. The clinical
analgesic effect of corticosteroids is delayed in comparison to NSAIDs,
taking up to 4 h. However, the duration of analgesia provided by a single
dose can last up to 3 days [3]. In low doses, corticosteroids are also
potent antiemetics.
Gabapentinoids
Gabapentin and pregabalin are anticonvulsant analgesics approved
by the FDA for the treatment of neuropathic pain such as fibromyalgia
or post-herpetic neuralgia. However, they are increasingly being used
for acute surgical pain management. Both drugs have a high affinity for
presynaptic calcium channels, which decreases the influx of calcium and
decreases the release of excitatory neurotransmitters in the spinal and
supraspinal pain pathways. They also decrease the excitability of periph-
eral nociceptive nerves.
Clonidine
Alpha-2 receptor agonists (e.g., clonidine) provide sedation,
anxiolysis, and analgesia through central actions in the dorsal horn of
the spinal cord and the brainstem. Coadministration of clonidine and an
opioid produces more effective analgesia and reduction of adverse
events than higher doses of either drug alone. The ability of clonidine to
potentiate opioid-mediated analgesia is particularly useful in patients
with opioid tolerance. In the USA, it is available in oral, transdermal,
and epidural formulations. Administration of clonidine can cause altera-
tions in a patients hemodynamics, including an initial hypertensive
phase followed by hypotention and bradycardia.
Acetaminophen
Acetaminophen (APAP) is a synthetic, centrally acting analgesic for
mild to moderate pain. Contrary to popular belief, it does not act as an
NSAID and has negligible COX inhibition peripherally. The exact
mechanism of action is unknown, but it is believed to activate serotoner-
gic descending inhibitory pain pathways. Oral APAP has been available
in the USA since the 1950s. An IV formulation (Ofirmev) was approved
by the FDA in 2010. Intravenous APAP achieves maximal plasma con-
centration more rapidly and predictably than oral or rectal, and the
magnitude of plasma concentration is much higher. For this reason, it is
often used in the perioperative setting. In clinical trials, IV APAP is
superior to oral APAP and equivalent to 30 mg of IV ketorolac for mod-
erate postsurgical pain [4]. The onset of analgesia for IV APAP is
510 min, with peak effect in 1 h. Duration of effect is 46 h. The effec-
tiveness of IV APAP for postsurgical pain seems to be best when given
preemptively before incision [5].
Opioids
Opioids are naturally occurring, semisynthetic, or synthetic com-
pounds that produce analgesic effects by binding to opioid receptors in
the central nervous system. They are classified as strong or weak,
depending on the strength of their clinical effect, which has histori-
cally been measured against the effect of morphine. Table 14.2 lists a
202 B.J. Dunkin
Table 14.2. Common opioids used in the USA.

Opioid Clinical strength
Morphine Strong
Oxycodone Strong
Hydromorphone Strong
Meperidine Strong
Fentanyl Strong
Methadone Strong
Hydrocodone Weak
Codeine Weak
Tramadol Weak
few common opioids used in the USA for surgical pain. It should be
noted that the most common weak opioid prescribed in the USA is
hydrocodone, which is available only in formulations that combine it
with APAP. This must be kept in mind when using IV or oral APAP as
part of a multimodal pain management strategy in order to avoid APAP
overdose.
Ketamine
Ketamine is a nonopioid, centrally acting dissociative anesthetic.
At subanesthetic doses, it provides rapid and highly potent analgesia
without many of the adverse effects observed with opioids. It binds
to and antagonizes the NMDA receptors in the central nervous sys-
tem. Ketamine is particularly useful in opioid-tolerant patients.
However, major complications can be associated with its use, includ-
ing hyperdynamic cardiovascular responses and psychomimetic
reactions.
Perioperative Pain Management Strategies

The choice of anesthetic technique as well as preoperative, intraop-
erative, and postoperative management of medications, affects postop-
erative pain. Proper management of all three phases of the perioperative
experience will lead to a better surgical experience for the patient. The
following is a summary of pain management strategies based on review
of the literature by the authors of this chapter and by consensus
recommendation by PROSPECT (PROcedure SPECific postoperative

pain management consortium; http://www.postoppain.org/) and the
Surgical Pain Consortium (http://surgicalpainconsortium.com/) [6, 7].
Preoperative Pain Management

Eighty-five percent of hernia surgery is done as outpatient. As a
result, coordination of preoperative preparation of patients for surgery
requires clear communication with the patient and all members of both
the preoperative care unit and the operative team.
Recommended Preoperative Strategies

Systemic analgesics
COX-2-selective NSAIDs. Preoperative administration of a
COX-2 inhibitor (celecoxib or meloxicam in the USA) 1 h
before incision is recommended for its analgesic efficacy
and minimal effect on platelet aggregation. Use must
include an assessment of individual patient risks (contrain-
dicated in patients with cardiovascular morbidity, actual or
recent gastroduodenal ulcer history, renal or hepatic dys-
function, or aspirin-sensitive asthma).
Acetaminophen (APAP). APAP may be given orally or
IV. Because of the rapid and more predictable achievement
of plasma concentrations, the IV formulation is often pre-
ferred in the perioperative setting. IV APAP seems to have
a better analgesic effect when given preemptively
3060 min before incision. Because many hernia surgery
patients receive a weak opioid combined with APAP orally
(e.g., Lortabhydrocodone plus APAP) for postoperative
pain control, the timing and use of APAP perioperatively
must be carefully considered to avoid overdosing.
Local anesthetics
Inguinal nerve block including TAP block/field block/infil-
tration. Studies of local anesthetic administration for ingui-
nal hernia repair do not clearly differentiate between
inguinal nerve block versus field block. As a result, either
can be used for anesthetic infiltration. Local anesthetics can
be injected preoperatively or intraoperatively with the same
control of early postoperative pain. Long-acting local anes-
thetics are recommended over short-acting.
204 B.J. Dunkin
Possible Preoperative Strategies in Select Patients

Gaba agonists. Patients with a history of tolerance to opioids
may be considered for the preoperative use of gabapentin or
pregabalin.
Gabapentin 600900 mg the night before surgery, followed
by 600900 mg TID for up to 72 h.
Pregabalin 75150 mg the night before surgery, followed
by 75150 mg BID for up to 72 h.
Nonrecommended Preoperative Strategies

NSAIDs with significant COX-1 inhibition. Ketorolac is an
extreme outlier in its inhibitory effect on COX-1 relative to
COX-2. As a result, the FDA warns against its use as a prophy-
lactic analgesic prior to any major surgery. Because pre- and/or
intraoperative infiltration of local anesthetics provides good
analgesia in the immediate postoperative period, ketorolac
should be administered immediately at the end of the procedure
when the risk of postoperative bleeding can be more accurately
assessed by the surgeon.
Local anesthetic plus epinephrine. Adding epinephrine to the
local anesthetic does not significantly decrease the risk of toxic-
ity in the dosages associated with inguinal hernia repair and
does not improve its analgesic effect. It may, however, result in
undesirable cardiovascular side effects.
Intraoperative Pain Management

Recommended Intraoperative Strategies
Anesthetic technique
Local anesthesia (inguinal nerve block or TAP block/field
block/infiltration techniques), with or without intravenous
sedation, is recommended because it is associated with less
postoperative pain and provides additional recovery bene-
fits (earlier ambulation, less urinary retention) compared
with spinal, epidural, or general anesthesia. Intraoperative
use of local anesthetic injection techniques post-incision is
as effective as preoperative administration.
General anesthesia. If general anesthesia is used, it should

be combined with local anesthetic techniques to reduce
postoperative pain.
Systemic analgesia
Ketorolac. If a COX-2 inhibitor is not used preoperatively,
then IV ketorolac may be administered intraoperatively at
the end of the procedure when the risk of postoperative
bleeding has been assessed to be low by the surgeon.
Acetaminophen (APAP). If APAP was not administered
preoperatively, then it may be given intravenously intraop-
eratively. Because of the same concerns listed for APAP in
the preoperative state, the timing and use of APAP periop-
eratively must be carefully considered to avoid APAP over-
dosing. In addition, because IV APAP costs more than
ketorolac, many centers prefer the latter if there is no con-
traindication to use of a NSAID for the patient.
Nonrecommended Intraoperative Strategies

Anesthetic technique
Spinal anesthesia. While this technique provides good
early postoperative analgesia, it is associated with factors
that can delay discharge, including delay in early ambula-
tion, hypotention, and urinary retention.
Epidural anesthesia. Similar issues to spinal anesthesia
with more technical challenges to administer.
Paravertebral nerve block. Has only marginal analgesic
benefit over local anesthetic techniques and is more com-
plex to perform.
Local anesthetic plus epinephrine. Adding epinephrine to
the local anesthetic does not significantly decrease the risk
of toxicity in the dosages associated with inguinal hernia
repair and does not improve its analgesic effect. It may,
however, result in undesirable cardiovascular side effects.
Local anesthetic instillation. Despite some evidence that
this technique decreases postoperative pain, the data are
currently limited.
Pre-peritoneal instillation of local anesthetic (laparoscopic
hernia repair). Current literature does not demonstrate
efficacy of this technique.
206 B.J. Dunkin
Postoperative Pain Management

Recommended Postoperative Strategies
NSAIDS. Conventional or COX-2-selective NSAIDs should be
used in the postoperative setting. If they have not been adminis-
tered pre- or intraoperatively, then they should be started as
early in the postoperative period as possible. Because of the
associated risks of bleeding and gastroduodenal ulcer with con-
ventional NSAIDs, many surgeons prefer using a COX-2-
selective formulation. NSAIDS are best taken on a scheduled
basis, not as needed, and may be continued for 12 weeks
postoperatively.
Acetaminophen (APAP). APAP is recommended for routine pain
therapy in combination with conventional NSAIDs/COX-2-
selective inhibitors or weak opioids. It may be taken on a sched-
uled basis if the patient is not taking any other APAP formulation,
or as needed if included in another formulation such as a weak
opioid (e.g., hydrocodone plus APAP).
Weak opioids. Weak opioids are recommended when conven-
tional NSAIDs or COX-2-selective inhibitors plus APAP are not
sufficient or contraindicated. The most commonly prescribed
weak opioid in the USA is hydrocodone, where it is only avail-
able in formulations that combine it with APAP. This must be
taken into consideration when using this weak opioid in combi-
nation with IV or oral APAP.
Strong opioids. Strong opioids are recommended as rescue anal-
gesia for severe pain in addition to the use of nonopioid agents.
They are not recommended for first-line analgesia because of
side effects that may delay early ambulation.
Nonrecommended Postoperative Strategies

Continuous wound infusion with local anesthetic. Continuous
infusion of an intermediate-acting local anesthetic using either
an elastomeric or electric pump has shown longer duration of
postoperative analgesia compared to infiltration alone. However,
in hernia surgery, it is unclear as to whether the infusion should
be in the subcutaneous or subfascial space and whether use of
this system is superior to TAP block or nerve/field block using
long-acting liposomal bupivacaine. The expense and inconve-

nience of the system are also a barrier to use.
Bolus wound infusion of local anesthetic. Some surgeons have
placed a catheter into the would during closure of the hernia
surgery site to enable a single bolus injection of local anesthetic
postoperatively. This has not been shown to be effective.
Transcutaneous electrical nerve stimulation (TENS). This tech-
nique involves placing electrodes on either side of the hernia
incision following the operation and stimulating with a rela-
tively low pulse amplitude in the recovery room. After dis-
charge, the pulse amplitude is adjusted to deliver the maximum
electrical current that is comfortably tolerated. Study of TENS
units for open inguinal hernia surgery has not demonstrated
efficacy.
Not Routinely Recommended Pre-, Intra-,

or Postoperatively
Corticosteroids. Not recommended due to limited procedure-
specific evidence and because herniorraphy per se is not associ-
ated with a high incidence of postoperative nausea and
vomiting.
Clonidine. Not recommended because there is no procedure-
specific evidence, and there are potential side effects, including
hypotension, sedation, dizziness, and bradycardia. It may delay
early ambulation.
Ketamine. Not recommended due to associated side effects that
may hinder early ambulation, despite some evidence of analge-
sic efficacy in other procedures. Ketamine is associated with a
risk of adverse effects on the central nervous system.
Magnesium. Magnesium is an antagonist of N-methyl-d-
aspartate glutamate receptors, which can alter the perception
and duration of pain. As a result, its use has been studied for
managing postoperative pain. Currently, there is no evidence
that magnesium administered preemptively before open hernia
incision and in conjunction with use of NSAIDs plus intraopera-
tive nerve block decreased postoperative pain [8].
Gabapentin/Pregabalin. Not recommended due to the lack of
procedure-specific evidence, despite analgesic efficacy in other
procedures.
208 B.J. Dunkin
Summary
Understanding how to employ multimodal pain management
strategies for hernia surgery patients will help to ensure a good periop-
erative experience and may decrease the potential for chronic pain long
term. Use of these strategies is an imperative for responsible surgeons
performing these common operations.
References
1. Nienhuijs S, Stall E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R. Chronic pain
after mesh repair of inguinal hernia: a systematic review. Am J Surg. 2007;194(3):
394400.
2. Aasvang EK, Gmaehle E, Hansen JB, Gmaehle B, Forman JL, Schwarz J, et al.
Predictive risk factors for persistent postherniotomy pain. Anesthesiology. 2010;
112(4):95769.
3. Raeder J, Dahl V. Clinical application of glucocorticoids, antineuropathics, and other
analgesic adjuvants for acute pain management. In: Sinatra R, de Leon-Casasola O,
Ginsberg B, Viscusi E, editors. Acute pain management. New York: Cambridge
University Press; 2009. p. 37790.
4. Gorocs TS, Lambert M, Rinne T, Krekler M, Modell S. Efficacy and tolerability of
ready-to-use intravenous paracetamol solution as monotherapy or as an adjunct analge-
sic therapy for postoperative pain in patients undergoing elective ambulatory surgery:
open, prospective study. Int J Clin Pract. 2009;63(1):11220.
5. Arici S, Gurbet A, Trker G, Yavacaolu B, Sahin S. Pre-emptive analgesic effects of
intravenous paracetamol in total abdominal hysterectomy. Agri. 2009;21(2):5461.
6. Joshi GP, Rawal N, Kehler H, PROSPECT collaboration, Bonnet F, Camu F, Fischer
HB, et al. Evidence-based management of postoperative pain in adults undergoing open
inguinal hernia surgery. Br J Surg. 2012;99(2):16885.
7. Sinatra RS, Larach S, Ramamoorthy S. Surgeons guide to postsurgical pain manage-
ment: colorectal and abdominal surgery. West Islip, NY: Professional Communications;
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104(6):13749.
Part II
Secondary Groin Pain
15. Chronic Groin Pain Following
Anterior Hernia Surgery
Jennifer S. Schwartz, David S. Strosberg,

and David B. Renton
Introduction
Inguinal herniorrhaphy is one of the most common general surgery
operations performed in the United States at nearly 600,000 repairs
annually. An anterior approach is the most common method for surgical
repair, and may be performed as either a tissue repair or tension-free
repair [1].
Tissue repairs were the first type of repair for inguinal hernias. Since
the creation of the Bassini repair in 1887, at least 70 tissue repairs have
been described in the literature. This type of repair uses the patients
native tissues to close the hernia defect. Types of tissue repairs include
the Shouldice, Bassini, and McVay repairs. The Shouldice repair is
based on a multilayer imbricated repair of the posterior wall of the ingui-
nal canal, and has the lowest recurrence of tissue-based repairs in highly
selected patient populations. In a Cochrane review, the rate of recurrence
in specialized centers for a Shouldice repair is cited between 0.4 and 1.6
%; however, in nonspecialist centers recurrence is as high as 10 % [2].
The Bassini repair, the most popular type of repair prior to the introduc-
tion of tension-free repairs, involves suturing the transversus abdominis
and internal oblique musculoaponeurotic arches to the inguinal liga-
ment. The McVay repair, or Coopers ligament repair, approximates the
transversus abdominis aproneurosis to Coopers ligament. This opera-
tion may also be used for femoral hernias, as the femoral space is closed
with this repair. Tissue repairs are rarely used due to higher recurrence

DOI 10.1007/978-3-319-21587-7_15
212 J.S. Schwartz et al.
rates, cited as high as 46 % [3], and prolonged postoperative pain and

recovery time. However, a tissue repair is useful when prosthetic mesh
is contraindicated, including situations of ischemic bowel where resec-
tion is necessary, in the presence of ascites, or following a Cesarean
section.
Mesh-Based Repairs
Tension-free, or mesh-based, repairs have been the gold standard
for inguinal hernia repairs since the early 1990s due to the lower recur-
rence rate. Tension is eliminated with the placement of a synthetic mesh
to bridge the defect, thereby reducing the rates of recurrence to less than
1 % compared to the 46 % recurrence rate with tissue repair [3]. Types
of tension-free repairs include the Lichtenstein repair, plug and patch,
and sandwich technique. The Lichtenstein repair encompasses the place-
ment of a prosthetic mesh in the inguinal canal and re-creation of a new
mesh internal inguinal ring. Of note, the ilioinguinal nerve and genital
branch of the genitofemoral nerve pass through this newly created ring,
and care must be taken to protect these nerves from entrapment during
the repair. The plug and patch technique, an extension of the Lichtenstein
repair, provides an additional cone-shaped plug of polypropylene mesh
that is placed in the hernia defect, which occludes the hernia with
Valsalva. This is currently the most common type of anterior hernior-
rhaphy performed. The sandwich technique utilizes an underlay patch, a
plug type connector, and an onlay patch that covers the posterior ingui-
nal floor (Fig. 15.1) [4].
Complications
Complications of inguinal herniorrhaphy are multifold. Intraoperative
complications are noted at less than 2 %. Postoperative complications
are as high as nearly 20 %, including urinary retention, urinary tract
infection, orchitis, surgical site infection, neuralgia, or (rarely) life-
threatening complications. Long-term complications are nearly 18 %,
and may include seroma formation, chronic orchitis, chronic infection,
chronic pain, or recurrence [5].
15. Chronic Groin Pain Following Anterior Hernia Surgery 213
Fig. 15.1. Borders of the inguinal canal (from Wagner et al. [4], with kind per-
mission McGraw-Hill Education).
Chronic Post-herniorrhaphy Groin Pain: Definition

Chronic post-herniorrhaphy groin pain is defined as pain lasting >3 months
following hernia repair. Studies show an incidence of chronic pain of 11 %
[6]. Inguinodynia can be neuropathic or non-neuropathic. Neuropathic pain can
be caused by nerve entrapment, stretching of nerves, and partial or complete
division of nerves with neuroma formation. The three nerves most commonly
involved are the iliohypogastric nerve, the ilioinguinal nerve, and the genital
branch of the genitofemoral nerve. Non-neuropathic causes include periosteal
reaction and mechanical pressure caused by folded mesh [7].
Treatments
Treatments for chronic groin pain include nonoperative interven-
tions such as pain control with or without narcotic pain medications, and
injection-based therapies such as nerve blocks and radiofrequency
neurolysis. Additionally, operative intervention has been used for

refractory chronic groin pain. Surgical treatments include single nerve
resection, triple neurectomy, and mesh removal.
Nonsteroidal anti-inflammatory agents are often first-line therapy
for chronic groin pain. NSAIDs are nonselective COX inhibitors that
decrease inflammation. These are particularly helpful in the postopera-
tive period. Scheduled NSAIDs for 2 weeks improved pain symptoms
in 25 % of patients with chronic groin pain after inguinal hernia repair
in one study [7]. For moderate to severe chronic groin pain, opioid
analgesia may be required. Treatment with this regimen is recom-
mended for a minority of patients and in conjunction with a pain
specialist. Antidepressants are another first-line therapy used for
chronic neuropathic pain. At low doses, antidepressants work by
blocking neurotransmitter uptake at the presynaptic terminal and func-
tion as an analgesic. Tricyclic antidepressants followed by SSRIs are
the most commonly used antidepressants. Antiepileptic drugs such as
pregabalin, gabapentin, and topiramate have been used for neuropathic
pain. The mechanism of action is by modulation of calcium and sodium
channels that stabilize neurons involved in rapid firing, thus affecting
the intensity of neuropathic pain [8]. However, there are few studies
that investigate the efficacy of these treatment modalities for inguino-
dynia following hernia repair.
Injection-based therapies are another treatment alternative for
chronic groin pain following inguinal hernia repair. Multiple studies
have been performed looking at the effect of nerve blocks with local
anesthetics, often under ultrasound guidance. In a single study, 43 sub-
jects were evaluated for chronic moderate to severe inguinal pain status
post open hernia repair. Each was given an ilioinguinal and/or iliohypo-
gastric nerve block with a long-acting local anesthetic (bupivacaine) and
a corticosteroid (triamcinolonacetonide). There was an average of two
injections per subject. Post-procedure, 3255 % of subjects reported
resolution of their moderate to severe neuropathic pain after 20 months
[9]. Other studies have demonstrated patients receiving at least tempo-
rary relief from nerve blocks with local anesthetic. Ilioinguinal or ilio-
hypogastric nerve blocks can be an effective treatment modality for
chronic groin pain, though multiple treatments may be required. Long-
term success of injection-based therapies is still unclear. This treatment
is often used for diagnosis of affected nerve and prior to surgical
intervention.
Radiofrequency neurolysis (RFN) has become a more common proce-

dure in interventional pain management used for chronic inguinodynia. It
has been shown to have some longer lasting pain relief in patients with
refractory inguinal neuralgia. Although evidence is limited, one small
retrospective review evaluated 42 patients and compared radiofrequency
ablation to local infiltrative therapy. RFN showed longer lasting pain
relief, with the mean duration of pain relief 12.5 months versus 1.6 months
compared to an injection-based therapy control group. Patients required
from 1 to 3 radiofrequency neurolysis procedures. Local nerve infiltration
may be used to aid the identification of inguinal neuralgia and which
nerve is affected prior to RFN treatments. The use of this therapy has been
limited secondary to the need for extensive knowledge of the inguinal
anatomy and expertise in the technology required to perform this proce-
dure, found predominantly in pain management specialists and radiolo-
gists (Fig. 15.2) [4, 10, 11].
Surgical interventions have been reserved for patients with severe
chronic inguinal neuropathic pain who have been refractory to nonopera-
tive management. Identification of the involved nerve is often performed
using local infiltration. There is no gold standard operative intervention
for chronic inguinal pain. Mesh and suture removal, resection of a single
nerve, and triple neurectomy have all been proposed as potential treat-
Fig. 15.2. Left Retroperitoneal neuroanatomy (from Chen et al. [11] with kind
permission Springer Science + Business Media); Right corresponding dermato-
mal sensory distribution of the lumbar plexus (from Wagner et al. [4], with kind
ments. Some studies even advocate routine preventive resection of the

ilioinguinal nerve at the time of the original hernia repair.
Mesh and suture removal has been proposed as an option, alone or in
combination with neurectomy. Reoperative surgery and mesh removal
can be very challenging. Identification of the ilioinguinal, iliohypogas-
tric, and genitofemoral nerve and removal of any sutures through the
nerve or freeing it from entrapment of mesh can completely or partially
relieve chronic neuropathic pain. Additionally, if the nerve can be identi-
fied preoperatively, it can be resected and ligated with or without mesh
removal. It is essential to ligate the nerve in order to prevent neuroma
formation. Although mesh removal can be effective for pain, it causes a
high hernia recurrence rate [12].
Triple Neurectomy
Triple neurectomy has become a promising surgical technique for
chronic inguinal neuropathic pain after inguinal hernia repair. It involves
ligation of the ilioinguinal, iliohypogastric, and genitofemoral nerve.
The incision is made through the previous hernia repair, and the external
oblique aponeurosis is divided. First, the ilioinguinal nerve is identified
between the lateral border of the prosthetic mesh and the anterior supe-
rior iliac spine. It may easily be hidden if attached to the inguinal liga-
ment, upper external oblique aponeurosis, within the fat-filled grooves
of the internal oblique muscle, or simply under the retractor. The nerve
is sharply transected, and the proximal end is buried within the internal
oblique muscle to prevent future scarring. Next, the iliohypogastric is
identified between the external and internal oblique aponeurosis. The
intramuscular segment is followed lateral to the internal ring and divided
proximal to the surgical field of the original hernia repair. The iliohypo-
gastric nerve is the most vulnerable to injury due to the inability to
visualize it during the hernia repair. The inguinal segment of the genital
branch of the genitofemoral nerve can be identified by entering the inter-
nal ring through its inferior crus. After transection, the proximal ligated
cut end is allowed to retract into the preperitoneal space [13]. In a study
of 415 patients, 85 % had complete resolution of pain, with the remain-
ing 15 % having significant improvement of pain after the triple neurec-
tomy performed [14]. Other studies, although smaller, show success
rates of this procedure of 8095 %. Triple neurectomy appears to be a
Fig. 15.3. Injuries to the IM segment of the iliohypogastric nerve, left groin,
after inguinal hernia repair. (a). Nerve entrapped during a tissue repair. (b).
Nerve sutured to mesh plug. (c). Nerve trapped by staple (arrow) adherent to
upper edge of mesh patch held within forceps (Lichtenstein repair). PT, pubic
tubercle (from Amid and Hiatt [14]).
very effective treatment for chronic neuropathic pain after inguinal her-
nia repair, although this procedure can be quite technically challenging
(Fig. 15.3) [14].
Laparoscopic triple neurectomy is performed using a retroperito-
neal approach, as described by Santos and Towfigh at Cedars Sinai
Medical Center. It is typically performed for patients with inguino-
dynia following laparoscopic inguinal hernia repair or open posterior
inguinal hernia repair. The patient is positioned supine if bilateral
neurectomy is performed, or in the lateral decubitus position if unilat-
eral. The ports are placed in the same fashion as a laparoscopic adre-
nalectomy, with a supraumbilical Hasson and two to three subcostal
ports. The retroperitoneum is accessed following detachment of the
colon at the white line of Toldt. Once accessed, the 12th rib is identi-
fied superiorly, femoral nerve inferiorly, iliac crest laterally, and ureter
and medial half of the psoas muscle medially. The iliohypogastric and
ilioinguinal nerves arise from the posterolateral border of the psoas
muscle caudal to the 12th rib. Care must be taken not to mistake the
12th intercostal nerve for the iliohypogastric nerve, or the lateral
femoral cutaneous nerve for the ilioinguinal nerve. The genitofemoral
nerve exists from the mid-psoas muscle and branches distally, with the
ureter lateral. The nerves are transected at their exit from the psoas,
and proximal ends implanted into the muscle, while the distal end is
cut 5 cm distally to prevent communication [15].
Conclusion
While treatment modalities vary widely and include medication,
injection-based therapy, radiofrequency ablation, and surgical inter-
vention, the most effective treatment for chronic neuropathic pain is
prevention. Meticulous identification of all three nerves with care-
ful preservation is essential in preventing the development of
chronic pain following inguinal hernia repair.
References
1. Malangoni MA, Rosen MJ. Hernia. In: Townsend Jr CM, Beauchamp RD, Evers BM,
Mattox KL, editors. Sabiston textbook of surgery: the biological basis of modern
surgical practice. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012. p. 111440.
2. Amato B, Moja L, Panico S, Persico G, Rispoli C, Rocco N, Moschetti I. Shouldice
technique versus other open techniques for inguinal hernia repair. Cochrane Database
Syst Rev. 2012;4:CD001543.
3. Amid P. Groin hernia repair: open techniques. World J Surg. 2005;29(8):
104651.
Schwartzs principles of surgery. 10th ed. New York, NY: McGraw Hill Medical;
2014. p. 1495521.
5. Neumayer L, Giobbie-Hurder A, Jonassen O, Fitzgibbons Jr R, Dunlop D, Gibbs J,
et al, Veterans Affairs Cooperative Studies Program 456 Investigators. Open mesh
versus laparoscopic mesh repair of inguinal hernias. N Engl J Med.
2004;350(18):181927.
6. Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R. Chronic
pain after mesh repair of inguinal hernia: a systematic review. Am J Surg.
2007;194(3):394400.
7. Palumbo P, Minicucci A, Nasti AG, Simonelli I, Vietri F, Angelici AM. Treatment for
persistent chronic neuralgia after inguinal hernioplasty. Hernia. 2007;11(6):52731.
8. Hansen MB, Andersen KG, Crawford ME. Pain following the repair of an abdominal
hernia. Surg Today. 2010;40(1):821.
9. Thomassen I, van Suijlekom JA, van de Gaag A, Ponten JE, Neinhuijs SW. Ultrasound-
guided ilioinguinal/iliohypogastric nerve blocks for chronic pain after inguinal hernia
repair. Hernia. 2013;17(3):32932.
10. Kastler A, Aubry S, Piccand V, Hadjidekov G, Tiberghien F, Kastler B. Radiofrequency
neurolysis versus local nerve infiltration in 42 patients with refractory chronic inguinal
neuralgia. Pain Physician. 2012;15(3):23744.
11. Chen DC, Amid PK. Technique: lichtenstein. In: Jacob BP, Ramshaw B, editors. The
SAGES manual of hernia repair. New York, NY: Springer; 2013. p. 4154.
12. Ferzli G, Edwards E, Khoury G. Chronic pain after inguinal herniorrhaphy. J Am Coll
Surg. 2007;205(2):33341.
13. Amid PK, Chen DC. Inguinal neurectomy for nerve entrapment: triple neurectomy. In:
Jones DB, editor. Master techniques in surgery: Hernia. Philadelphia, PA: Lippincott
Williams and Wilkins/Wolters Kluwer; 2013. p. 1418.
14. Amid P, Hiatt J. New understanding of the causes and surgical treatment of postherni-
orrhaphy inguinodynia and orchalgia. J Am Coll Surg. 2007;205(2):3815.
15. Santos D, Towfigh S. Laparoscopic retroperitoneal triple neurectomy: a new technique
for persistent herniorraphy neuralgia (abstract). SAGES 2011, 30 Mar-2 Apr 2011,
San Antonio, Texas. P336. abstract archive. http://www.sages.org/meetings/annual-
meeting/abstracts-archive/laparoscopic-retroperitoneal-triple-neurectomy-a-new-
technique-for-post-herniorraphy-neuralgia/. Accessed 5 Mar 2015.
16. Chronic Groin Pain Following
Posterior Hernia Surgery
Edward L. Felix
Introduction
Today most posterior inguinal hernia repairs are performed laparo-
scopically, but the origin of this approach dates back to Annandale [1]
in 1876 with the first published report of an open posterior approach to
the hernia sac. The approach was slow to gather attention until Cheatle
(1921) [2] and later Henry (1936) [3] suggested it might be used for both
femoral and inguinal hernias. It was not until 1959, however, that Nyhus
[4] began to popularize an open posterior primary repair of hernia
defects. Mesh soon became a staple of the repair as patch reinforcement,
but with further refinements by Rignault [5], Stoppa [6], and later Wantz
[7], the patch was replaced by a large or sometimes giant mesh covering
the entire posterior floor.
Using the principles of the open posterior approach, a laparoscopic
approach was born in the early 1990s with the birth of advanced lapa-
roscopic techniques [810]. Two distinct approaches were successfully
developed, the transabdominal preperitoneal (TAPP) and the totally
extraperitoneal (TEP). Both approaches utilize a large mesh covering
all three potential defects. The techniques have been modified over
time, and the use of fixation and mesh type continue to be debated and
will be discussed later in the chapter.
Results of laparoscopic approaches have now been extensively stud-
ied in both retrospective and prospective randomized reports [1114]. In
the hands of experienced laparoscopic surgeons, recurrence rates are
equal or lower than open anterior approaches, but long-term chronic
pain is reduced by the laparoscopic approach when compared to anterior
open approaches [1517]. Whether (TAPP or TEP) approach is used does

DOI 10.1007/978-3-319-21587-7_16
222 E.L. Felix
not seem to alter the incidence of chronic pain. As will be discussed, fixa-
tion and mesh type may influence results.
Although the predominant posterior approach today is laparoscopic,
open posterior approaches are being performed [1820]. The mecha-
nisms by which these approaches cause chronic pain are in general simi-
lar to the laparoscopic approaches except in those cases where unique
meshes are utilized that may have their own problems.
Anatomy
Understanding the anatomy of the groin is integral in understanding
why patients develop chronic pain after posterior inguinal hernia repair.
The location of the nerves of the groin that puts them at risk and the
mechanisms by which they can be injured or irritated explain why
chronic pain develops, how it can be treated, and how it can be pre-
vented. One must first understand the conventional anatomy [21] (Fig.
16.1), and then accept that as many as 25 % of patients have some varia-
tion of the location of the named nerves [22] that puts them at jeopardy
for injury during the procedure or from irritation after the procedure is
completed.
The named nerves that are at risk for injury in the retroperitoneum
from dissection during a posterior hernia repair or after the repair are the
femoral nerve, genitofemoral nerve and its branches (femoral and geni-
tal), and the lateral cutaneous nerve. In most patients, the nerves run
below the iliopubic tract. How to avoid these nerves has been well
described by multiple authors [2325], but, unfortunately, as previously
mentioned, the location of the nerves is variable. In an excellent cadaver
study [22], in as many as 25 % patients, the nerves are not out of harms
way. They run above the iliopubic tract where they can be injured by
dissection and anchoring hardware such as staples or tacks. In addition,
anterior nerves that should not be at jeopardy for injury, on rare occa-
sion, present within reach of posterior fixation of mesh. Cases have been
reported of tacks penetrating the entire wall, injuring a superficial nerve.
Increasing the chance for chronic pain are idiopathic reactions to
mesh that can result in irritation of any of the posterior nerves, including
the obturator nerve, although it is well inferior but can be exposed dur-
ing placement of the mesh. If the mesh bunches up or wrinkles, it may
become thickened and hardened, acting as a potential pressure point on
any of the nerves. The result will be chronic pain aggravated by activity
or motion.
16. Chronic Groin Pain Following Posterior Hernia Surgery 223
Fig. 16.1. The anatomy of posterior floor as viewed through a laparoscope. (a)
Inferior epigastric vessels. (b) Genital branch of the genitalfemoral nerve. (c)
Genitalfemoral nerve. (d) Lateral cutaneous nerve. (e) Indirect hernia defect.
(f) Pubis with Cooper ligament. (g) Vas deferens. (h) Testicular vessels. (i)
Iliopubic tract. (j) External iliac vessels.
To summarize, nerve injury and chronic pain can be reduced by care-

ful dissection and by being aware of where nerve injuries are most likely
to occur. When mesh is fixed with anchors or mesh hardens, however,
chronic pain can develop even after taking the proper precautions.
Despite the potential for the development of chronic pain after posterior
hernia repair, the incidence is quite low and in fact less than that after
open inguinal hernia repair in randomized studies [15, 16].
Differential Diagnosis of Chronic Pain Following

Posterior Hernia Repair
Pain after posterior inguinal hernia repair can be divided into acute
and chronic, lasting more than 90 days. The etiology and treatment are
usually quite different, and therefore one must be able to differentiate
the two scenarios. Acute pain occurs from minutes to days after the
repair. Except for severe unrelenting pain in the distribution of the femo-
ral nerve, most pain arising within days after the surgery will slowly
decrease and disappear. It is usually due to minor irritation of the posterior
224 E.L. Felix
nerves from the surgical dissection, hematoma, or seroma. Anti-

inflammatory medications and watchful waiting are the treatments of
choice. If, however, pain is debilitating and in the distribution of a
named nerve, such as the femoral nerve, injury to that nerve from a tack
or staple should be suspected. Immediate re-exploration and removal of
the offending anchor are required. If pain persists more than 3 months,
it can be classified as chronic. Fortunately, this is uncommon, occurring
in less than 4 % [26, 27] of patients undergoing laparoscopic posterior
hernia repair.
Determining the etiology of a patients chronic pain after posterior
repair is essential to guiding the treatment. The nature, timing, and loca-
tion of the pain as well as inciting factors will help determine the cause
and possible management. Several questions are important when deter-
mining the cause.
1. When did the pain begin? Immediately after surgery, persist-
ing, essentially unchanged, or did it begin weeks or months after
the repair?
2. Where is the pain located? Is it pinpoint or diffuse? Is it in the
distribution of a single named nerve?
3. What is the character of the pain?
4. Is the pain elicited by any activity in particular?
Determining when and how the pain began helps determine the
cause. If it develops soon after the operation, the cause was something
that happened during the operation such as an injury of a nerve from a
staple; if it develops months after the procedure, it is most likely a reac-
tion to the mesh or even a recurrence of the hernia. If the offending agent
is a staple, the pain usually begins soon after the repair and persists or
worsens with time. Pain from a folded-up mesh begins much later and
has a new onset.
The location of the pain guides the observer toward the proper nerve
distribution. There is a fair amount of crossover, however, so location can
be misleading. If the patient has pinpoint tenderness, it is usually in the
location of the offending tack or staple used for fixation. This area should
be marked prior to any exploration and will guide the surgeon at reopera-
tion, as will be described later.
The type of pain may also help. Whether it is musculoskeletal or
neuropathic. Finally, questioning the patient about activities that elicit
or increase the pain may lead one to the correct location and precipitat-
ing event.
The workup should include a full history as just outlined and a com-
plete exam of the area, including a directed palpation looking for recur-
rence and trigger points. Again, if a single point is found, it should
marked prior to exploration. Ultrasounds, CT scans, and MRI have been
reported to be helpful in looking for occult recurrence [28].
Treatment of Chronic Pain following Posterior

Inguinal Hernia Repair
Unless postoperative pain is severe and occurring immediately after
the procedure in the distribution of a major nerve as previously outlined,
the patient should be observed and treated symptomatically. Because
most postoperative pain will decrease and disappear over time, it is
important that the surgeon explain that waiting 3090 days is essential
before more aggressive action is taken. The surgeon must explain that
acting too early or invasively may do more harm to the patient than
good. This time taken to talk with the patient to alleviate fears should
prevent the patient from losing trust in the surgeon and prematurely seek-
ing a second opinion. When the pain does not respond to conservative
measures and becomes chronic, the next step should be an attempt at
pain management with blocks by the surgeon or a pain management
clinic. The exception would be when the pain can be easily localized and
is most likely due to a single tack. Then laparoscopic exploration is
indicated. The trigger site is marked just prior to laparoscopic explora-
tion, and at laparoscopy the mark is palpated to guide removal of the
corresponding tack or staple.
If conservative measures, medications, and therapeutic injections
fail, laparoscopic re-exploration is the next step in treating chronic pain.
If CT or ultrasound suggests a recurrence or other pathology as the cause
of the pain, treatment is straightforward at the time of re-exploration.
Because a positive preoperative study may be the exception, a complete
laparoscopic exploration of the previous repair is necessary. The surgeon
should approach the previous repair using a transabdominal laparo-
scopic approach (TAPP). The first step is to look for intraperitoneal
pathology that might be causing the patients pain (Fig. 16.2). The next
step is to begin to open the peritoneum above the repair away from the
mesh in a virgin area. If the mesh is flat and in the proper position, it
should be left alone. Tacks or staples should be removed if they are loose
or appear to correspond to the distribution of pain. If the surgeon finds
226 E.L. Felix
Fig. 16.2. Lateral fold-up of mesh with an indirect recurrent hernia in a patient
with groin pain.
mesh rolled up or folded in on itself, it should be removed. Pressure on

sensory nerves from hardened mesh can result in chronic groin pain,
especially related to activity and change in position. Removal, however,
can be difficult. In some cases, the careful use of cautery is required to
cut the mesh away from the wall. A careful search for recurrence of the
original hernia or a missed hernia completes the exploration (Fig. 16.3).
It is not unusual to find a defect that was missed by preoperative radio-
graphic studies. If a recurrence is found to be the cause, it should be
repaired with the addition of new mesh. If recurrence is associated with
bunched-up, hardened mesh (Fig. 16.4), the surgeon should consider
removing the mesh and delaying repair of the recurrence. A recurrent
hernia can be repaired from an anterior approach after the patient recov-
ers from the laparoscopic exploration. This staged approach better
defines the etiology of the pain and leads to fewer long-term problems
and less confusion.
When should all of the mesh be removed? is a frequently asked
question. There are those who believe it is best to remove all of the mesh
[29]. This has not been our approach. Unless the mesh has hardened into
a rock-like mass that is potentially irritating or compressing a nerve, it
has been our approach to leave it in place. The risk of damaging sur-
rounding structures by unnecessarily removing mesh far outweighs any
potential benefit.
Fig. 16.3. The dissected anatomy of the patient with rolled-up mesh demonstrat-
ing the indirect recurrence and the position of the genital branch of the genital
femoral nerve.
Fig. 16.4. The laparoscopic view in a patient with severe groin pain reveals two
hardened plugs with a recurrent indirect hernia. The plugs were removed using
cautery and a flat mesh was placed to repair the recurrence.
Preventing Chronic Pain after Posterior Hernia

Repair
Decreasing the incidence of chronic pain following posterior inguinal
hernia repair is as important as knowing how to treat it. Some approaches
have proved to be effective, while others are only potentially effective.
228 E.L. Felix
It has been established that using no fixation is an effective way to

potentially decrease the incidence of pain following laparoscopic ingui-
nal hernia repair without increasing the incidence of recurrence [30].
Other approaches such as glue fixation [31, 32] and self-adhering
meshes [33, 34] have the same potential of decreasing chronic pain by
eliminating penetrating fixation, but long-term randomized studies are
needed.
As previously discussed, the mesh itself can be the cause of chronic
pain following posterior inguinal hernia repair. By far the most common
cause of mesh-induced pain is from mesh that bunches or folds in on
itself, creating a hard noncompressible mass. The best way of preventing
this is to carefully flatten the mesh and make sure that it is not rolled up
as the CO2 is evacuated at the end of a TEP repair, or as the peritoneum
is closed at the end of the TAPP repair. Whether using lighter weight
larger pore meshes will decrease the incidence of chronic pain is still
questionable. Short-term studies have shown that utilizing lightweight
meshes decreases acute discomfort. One randomized study has shown a
decrease in chronic pain but an increase in recurrence with lightweight
mesh [35]. Others have so far failed to show a difference in chronic pain
when light and heavyweight meshes are compared [36, 37]. Whether
altering mesh composition or using less invasive forms of fixation of
mesh can reduce the incidence further is yet to be determined. By far the
most important way to decrease the incidence of chronic pain is through
the use of proper techniques as previously outlined in this chapter.
Chronic pain after posterior inguinal hernia repair can occur because
of improper technique, but also when everything is done perfectly. It is
therefore important that all surgeons be able to recognize the causes of
such pain, and to be able to reduce the incidence and to treat the pain
based upon its root cause. Remember that most postoperative pain will
respond to conservative management. Because patients become
extremely unhappy and discouraged when they develop chronic pain, it
is important to handle it appropriately. It is essential that the pain man-
agement plan be discussed with the patient so that they feel like they are
participating in their own care. This usually prevents patients from
reaching out for a second opinion and possibly making the situation
worse. When appropriate, however, an aggressive approach as outlined
in this chapter must be followed to eliminate chronic pain after posterior
inguinal hernia repair.
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17. The Orthopedic Perspective
on Groin Pain: The Native
and Prosthetic Hip
Calin Stefan Moucha

Patients often erroneously associate a complaint of groin pain with
the possibility of having an inguinal hernia, and will seek consultation
with their primary care physician or with a general surgeon for this
reason. It cannot be stated too strongly that even in the setting of finding
an obvious inguinal hernia on physical exam, if the chief complaint is
groin pain, it is paramount to complete a thorough pain history and
exam to assure that the pain itself is not from other etiologies. Often an
MRI will help rule out these other etiologies, but the history and physi-
cal can help direct the surgeon to order the correct MRI. As this chapter
points out, there are a large number of orthopedic injuries that can pres-
ent as groin pain, and these complaints can lead both the patient and
untrained surgeon to incorrectly diagnose an inguinal hernia and pos-
sibly even mistreat the complaint with an inguinal hernia repair. All
general surgeons who see patients who complain of groin pain should be
familiar with the detailed information provided in this excellent chapter
written by a distinguished and experienced orthopedic surgeon.
Introduction
Orthopedic and general surgeons commonly see patients with groin
pain. As in any other specialty, obtaining an appropriate history from the
patient is vital. Young patients generally have completely different
causes of groin pain than elderly ones. A history of acute or repetitive

DOI 10.1007/978-3-319-21587-7_17
234 C.S. Moucha
trauma, often seen in younger athletes, will guide the workup differently
than pain not associated with a specific injury. A past medical history of
extensive alcohol abuse, steroid usage, and certain conditions such as
sickle cell anemia or lupus will guide the workup toward specific diag-
noses. Duration of symptoms, progression, and alleviating and exacer-
bating factors need to be properly identified. Exact location and
radiating patterns of pain help distinguish intra-articular from extra-
articular musculoskeletal causes. Associated symptoms such as weak-
ness, numbness, and paresthesias are also important to identify, as they
can be associated with pathology of the spine.
This chapter reviews musculoskeletal causes of groin pain by divid-
ing them into three categories: intra-articular, extra-articular, and groin
pain after hip replacement. The focus will be predominantly on diagno-
sis. Treatment of these conditions will not be discussed in much detail
as it is beyond the scope of this manual.
Extra-articular Causes of Groin Pain

A large majority of patients who present with hip pain do not actually
have intra-articular hip pathology. Determining whether the cause of
pain is intra-articular or extra-articular early on will help streamline the
diagnostic process. Patients with extra-articular causes of groin pain will
usually complain of pain on the side of the hip and/or in the buttock that
radiates into the groin.
Greater Trochanteric Pain Syndrome Greater trochanteric pain synd-
rome (GTPS) encompasses several diagnoses that include trochanteric
bursitis and tendinosis (or even a degenerative tear) of the gluteus medius
or minimus muscles. While the direct source of pain is extra-articular, it
is not uncommon for patients to present with groin pain. Patients usually
have pain while driving or lying down on the affected side.
Gait examination may reveal a Trendelenburg gait, indicative of weak
abductor muscles, which should not be confused with an antalgic gait
(painful gait). A Trendelenburg gait is characterized by downward tilting
of the contralateral pelvis during stance on the weakened side. On physical
examination, we usually see direct tenderness to palpation over the greater
trochanter or just proximal to it. The Trendelenburg sign is found in
patients with weak or paralyzed hip abductor muscles (medius and/or
minimus). A positive Trendelenburg sign means that the affected hemipel-
vis sags during one-legged stance. Most importantly, however, intra-
17. The Orthopedic Perspective on Groin Pain 235
Fig. 17.1. Intra-articular

hip pathology is excluded
by painless hip rotation
and a negative
Stinchfield test.
articular hip pathology is excluded by painless hip rotation and a negative

Stinchfield test (Fig. 17.1). The Stinchfield test is done with the patient in
a supine position and the examiner applying downward pressure on the
thigh as the patient actively elevates the leg as high as possible; pain dur-
ing this maneuver signifies a positive test and is indicative of likely intra-
articular pathology. An injection with steroid into the trochanteric bursa
region is both diagnostic and often therapeutic. On rare occasions, open or
endoscopic bursectomy may be considered, but results are not very pre-
dictable. Refractory cases warrant obtaining an MRI or an ultrasound to
rule out more significant abductor tears or an intra-articular process [1].
Lastly, coxa saltans externa, a less common cause of GTPS, refers to
snapping of the iliotibial band or the anterior border of the gluteus maxi-
mus muscle over the greater trochanter when the hip is brought from a
flexed position to an extended position. While it less commonly causes
pain, when it does, the pain may radiate from the side of the hip into the
groin. After physical therapy trials, surgical treatment consists of a variety
of iliotibial band release procedures [2, 3].
236 C.S. Moucha
Lumbar Spine Disease Spine diseases, such as thoracolumbar disco-

genic pain at multiple levels or L2L4 nerve root impingement, can all
cause groin and thigh pain, with or without associated back pain [4]. The
mechanism is sometimes complex, as the pain can be radicular pain from
nerve root compression or pain from nerve endings on the herniated disc
itself. The existence of sensory nerve endings in the annulus fibrosus of
the human lumbar intervertebral disc has been described and well docu-
mented [5]. Patients sometimes find it hard to understand how their groin
pain is originating from their back when they do not present with back
pain. Physical exam of the hip is usually normal. Limited spine flexion,
extension, and/or lateral bending are sometimes seen. Many of these
patients have very weak core musculature. The femoral nerve traction test
is done with the patient in a prone position with the knee flexed to 90 and
the hip fully extended; pain in the anterior thigh suggests a L2L4 nerve
root impingement. One of the most common findings, however, appears
to be tight hamstring musculature. Tight hamstrings lead to hip flexion
contractures, a subtle crouched gait, and compensatory pressure on the
spine. Physical therapy focusing on core strengthening, hamstring stretch-
ing, and lumbar stabilization is the first line of treatment. MRI of the spine
is sometimes needed, followed by selective spinal diagnostic and thera-
peutic injections.
Osteitis Pubis Osteitis pubis is a noninfectious inflammatory pro-
cess of the pubic symphysis commonly seen in runners and in athletes
involved in cutting sports such as soccer and hockey. Previous trauma,
overuse, and vaginal delivery are all risk factors. Patients often present
with groin pain that is activity related. On physical exam they usually
have normal hip range of motion, nontender abductor muscles laterally,
and focal tenderness to palpation over the pubic symphysis. Weak core
musculature is often noted; pain with resisted hip adduction or passive
hip abduction may also be found. These latter physical exam findings
are often confirmed by tendinosis of the rectus abdominis and adductor
longus insertions on an MRI. Plain radiographs of the pelvis are usually
helpful as well, as they typically show widening of the symphysis with
blurring of the cortical margins and sometimes cysts. Physical therapy is
the first line of treatment followed by steroid injections. Surgical bony
resection with preservation of the rectus and pubic ligaments is rarely
done [6].
Pubic Ramus Fractures Fractures of the superior and/or inferior
pubic rami are commonly seen in elderly patients who have sustained a
low-energy fall. These patients present with acute groin pain that was
not present prior to trauma. They usually have painless hip rotation
but focal tenderness over the bony pelvis lateral to the pubic symphysis.
It is common for these patients to report having had recent hip radio-
graphs that were normal. Unfortunately, the pelvis has rarely been
evaluated. Hip radiographs often do not show rami fractures; it is
imperative to obtain an AP of the pelvis when evaluating groin pain.
Treatment of these fractures is most commonly nonoperative with unre-
stricted weight bearing.
Iliopsoas Pathology The two most common iliopsoas pathologies
seen by orthopedic surgeons are snapping (coxa saltans interna) and
tendinitis. Internal snapping of the iliopsoas tendon is actually an extra-
articular process. Patients usually present with an audible snap and
anterior groin pain. As the hip is extended, the iliopsoas tendon travels
from lateral to medial catches at the iliopectineal eminence or on the
femoral head. On occasion, the snapping can be palpated directly in
the groin. Dynamic ultrasound may be useful in the diagnosis. MRI is
sometimes indicated, as it can show resultant hip labral tea [7]. Iliopsoas
tendinitis is a relatively rare entity in patients with native hips and seen
most commonly in patients involved in activities that require repetitive
hip flexion (rowing, uphill running, and ballet). Patients generally pres-
ent with anterior hip pain that radiates to the knee and sometimes with
knee pain alone. The most common physical exam findings are painless
hip rotation, pain with resisted hip flexion, and pain with passive hip
extension. Initial treatment of both coxa saltans interna and iliopsoas
tendinitis is always stretching (best done in a luge position) and, when
necessary, steroid injections [8]. Open and arthroscopic releases of the
iliopsoas tendon have been reported, but complications such as sympto-
matic intra-abdominal fluid extravasation [9] and anterior hip instability
[10] have been reported. Exclusion of the other potentially life-threaten-
ing pathologies with which abdominal surgeons are very familiar, such
as an iliopsoas abscess, is clearly important.
Intra-articular Causes of Groin Pain

Anterior groin pain that radiates deep into the hip and sometimes radi-
ates into the groin should always raise the suspicion of an intra-articular
process. In the now classic C sign (Fig. 17.2) suggestive of intra-articular
hip pathology, patients will place their hand over the affected hip with the
238 C.S. Moucha
Fig. 17.2. The classic

C sign suggestive
of intra-articular
hip pathology.
index finger in the groin and the thumb placed proximal to the greater
trochanter in the shape of the letter C [11, 12]. Patients will also com-
monly have a positive Stinchfield test, described earlier in this chapter.
Lastly, an active straight leg raise with the supine patient actively raising
the heel of the leg by flexing the hip about 30 is also suggestive of intra-
articular pathology: during this test, hip flexors produce joint reactive
forces up to two times the patients body weight across the hip joint itself.
Arthritis and Avascular Necrosis More than 21 % of the US popu-
lation aged 18 or older have arthritis or other rheumatic conditions, and
that percentage increases as people age. The number of people in the
USA who have arthritis is projected to increase to 67 million, or 25 %
of the adult population, by the year 2030. Osteoarthritis is the most
common form and the hip is commonly affected. Patients present with
pain in the groin, diminished hip motion, difficulty putting on their
shoes or socks, and inability to ambulate extensively. Physical exam
reveals a positive Stinchfield test and C sign. Nonoperative treatment
consists of intra-articular steroid or hyaluronate injections [13].
Surgical intervention is a total hip arthroplasty. Avascular necrosis,
commonly seen in the femoral head, is also a common reason for groin
pain, especially in patients with risk factors such as steroid use, alcohol
abuse, coagulopathies, sickle cell disease, Gauchers disease, and
decompression sickness. When radiographs are normal and suspicion
is high, patients should undergo an MRI of the hip. Depending on the
stage of avascular necrosis, treatment includes protected weight
bearing, bisphosphonate treatment, electrical stimulation, electromag-
netic fields, core decompression, bone grafting, autologous mesenchy-
mal cells, osteotomies, and arthroplasty procedures [14].
Hip Synovitis and Septic Arthritis Transient synovitis of the hip is a
short-lived acute inflammatory process usually seen in boys aged 210
following an upper respiratory tract infection. Generally a diagnosis of
exclusion, it must be differentiated from a septic hip, which is also
commonly seen in this patient population. Patients present with groin
pain and sometimes difficulty putting weight on the limb. In addition to
the aforementioned tests for intra-articular pathology, these patients will
have pain with log rolling of the hip while in extension. Kocher et al.
have provided useful ways of differentiating between these two entities
[15]. Patients with transient synovitis require close observation, while
those with septic arthritis most commonly require arthroscopic or open
irrigation and debridement of the hip joint.
Femoroacetabular Impingement Femoroacetabular impingement (FAI)
occurs when anatomic variations in hip anatomy lead to impingement
between the acetabulum and the femoral headneck junction. FAI is
believed by many to be a common pathway to hip arthritis, especially in
younger patients. Impingement is generally classified into Cam impinge-
ment and Pincer impingement. CAM impingement is due to prominence of
the anterosuperior headneck junction or diminished headneck offset.
Pincer impingement is secondary to acetabular overcoverage of the
femoral head for a variety of reasons such as coxa profunda or acetabular
retroversion. FAI may lead to chronic groin pain, especially in younger
adults who often go on to have symptomatic arthritis. FAI is also a probable
predisposing factor to labral tears, most of which, even in the face of
trauma, would probably rarely occur otherwise. Patients with FAI may
have some of the classic signs of intra-articular hip pathology and
also report pain with tests such as the anterior impingement test or
FADIR (flexion adduction internal rotation). Sophisticated radiographs
and MR arthrography are some of the methods of choice in further
240 C.S. Moucha
studying these conditions [16]. Diagnostic hip injections, when positive,

may lead to a variety of arthroscopic and/or open joint preserving
procedures [17].
Femoral Neck Stress Fractures Athletes, especially runners, and
military recruits are two groups of patients at risk of femoral neck stress
fractures. Delay in diagnosis can be devastating [18]. Female athletes
with anorexia and amenorrhea with groin pain and difficulty weight
bearing should be aggressively worked up with either a bone scan or an
MRI. Concomitant osteoporosis workup and evaluation for vitamin D
deficiency are important as well. Fractures on the compression side of
the femoral neck may be treated nonoperatively, while those on the
tension side generally require surgical fixation.
Hip Instability Chronic groin pain in hyperlax patients, especially
female athletes, can be a sign of hip instability. Many of these patients
have underlying acetabular dysplasia with decreased femoral head
coverage [19]. The exact mechanism of pain in these patients is unclear,
but may be due to early cartilage degeneration, labral tears, or synovitis.
MRI in patients who have associated dysplasia may show a hypertrophied
iliocapsularis muscle in the anterior aspect of the hip [20]. Physical
therapy focusing on strengthening hip musculature is the first line of
treatment. Refractory cases in patients without dysplasia may require
open or arthroscopic capsular plication procedures [21]. When dysplasia
is present, correction of bony abnormalities is critical [22].
Groin Pain after Total Hip Replacement

The demand for primary total hip arthroplasties during the period
20052030 is estimated to grow by at least 174 % to 572,000 [23, 24].
While this operation is extremely successful, there are still some patients
who continue to have pain. Patients who do not have a pain-free interval
after surgery and experience pain that is different than they did
preoperatively need an infection workup: abnormal C-reactive protein
and sedimentation rate should prompt a hip aspiration. Persistence of
preoperative pain should raise the question of an improper indication for
the hip replacement. Pain in the groin after hip replacement is usually
related to the area of the acetabulum; thigh pain often relates to the
femoral component. Iliopsoas tendinitis is not uncommon and often
missed. Acetabular component malpositioning into retroversion
(Fig. 17.3) is usually the cause, and treatment begins with a steroid injec-
tion and sometimes leads to component revision [25]. More recently,
Fig. 17.3. Acetabular component malpositioning into retroversion.
Fig. 17.4. (a, b) Metal corrosion from metal-on-metal hip implant or modular
components can lead to painful adverse local tissue response (ALTR) and so-
called pseudotumors.
cases done through an anterior approach show transient irritation of the

iliopsoas tendon that often subsides without aggressive intervention.
Stress fractures around cementless acetabular component, hematomas,
impingement, loosening, or leg length discrepancy that aggravates
preexisting spinal disease can all lead to groin pain. Metal corrosion
from metal-on-metal hip implants or modular components can lead to
painful effusions and so-called pseudotumors (Fig. 17.4) [26, 27].
Lastly, groin pain in a patient with a previous hip fracture treated with a
hip replacement may in fact have a partial hip replacement, also known
as a hemiarthroplasty. A good number of these patients, deemed low
demand and given this type of implant, go on to have groin pain due to
acetabular degeneration, either preexisting or progressive since surgery.
242 C.S. Moucha
Conversion to a total hip replacement during which the acetabulum is

resurfaced is often curative. Referral to a revision joint replacement
surgeon should be considered when the primary surgeon cannot identify
the cause of pain after a hip replacement.
Conclusion
Multiple musculoskeletal causes of groin pain exist. While this chap-
ter discussed common and some rare diagnoses, it was not all-inclusive.
Oncological causes of musculoskeletal groin pain in particular were not
discussed, as the topic is quite broad and beyond the scope of this
manual. Orthopedic surgeons evaluate groin pain using a slightly differ-
ent perspective. Only by cross-pollinating knowledge between different
specialties will we gain a better understanding of our own.
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18. Algorithmic Approach
to the Workup and Management
of Chronic Postoperative Inguinal Pain
Johan F.M. Lange Jr.
With the success of tension-free mesh-based inguinal repair, the inci-

dence of chronic postoperative inguinal pain (CPIP) has surpassed that
of recurrence after open and laparoscopic herniorrhaphy. Due to differ-
ent definitions of CPIP, the reported incidence of CPIP ranges from 1 to
63 % [17]. Significant CPIP affects daily life for 510 % of patients [8,
9]. As quality of life has become the most relevant outcome of inguinal
hernia repair, and considering the high prevalence of CPIP, a systematic
approach is needed for optimal management.
Etiology of CPIP
CPIP can have several causes. Literature of the past decade has put
focus on the possible role of the three inguinal nerves (ilioinguinal, ilio-
hypogastric, and genitofemoral). Although there is no substantial evi-
dence that the inguinal nerves should be identified to preserve them or
to cut them purposely, there is consensus that inguinal hernia surgery
should be performed with nerve-awareness. Besides the assumption
that iatrogenic nerve damage or interference of the mesh with the nerves
plays a key role in the pathogenesis of CPIP, other potential risk factors
have been defined: a mesh that is sutured too tight instead of floppy,
medial fixation of the mesh to the periosteal rim of the pubic bone, a too
narrow neo-annulus, and herniotomy (obsolete) with a twisted perito-
neal sac have all been described as potential causes for CPIP [10]. It is
also known that preoperative pain is a risk factor for CPIP [11, 12]. In
this respect, one should be alert when a patient presents with a sharp
groin pain without an obvious inguinal hernia found during physical

DOI 10.1007/978-3-319-21587-7_18
246 J.F.M. Lange Jr.
examination and only a small hernia detected by ultrasonography. This

represents the type of at-risk patient having a predisposition for the
development of CPIP. Finally, a wrinkled mesh, also known as meshoma,
is a rare but infamous cause for CPIP [13].
Algorithmic Approach
Surgical literature has already paid much attention to risk factors,
etiology, and prevention of CPIP. On the other hand, there is only little
known about the management of CPIP. What to do when the damage has
already been done? What is the policy to follow when a patient presents
himself with possible CPIP? It is very hard to answer this question with
regard to the heterogenic causes of CPIP, different operation techniques,
and lack of scientific evidence. Certainly, there are indications that triple
neurectomy can be successful in some cases of patients with CPIP, but
it is not the remedy for all patients, and the challenge remains to select
the right patient with CPIP for the right treatment. This chapter tries to
capture the elements of how to deal with this complex diagnosis in an
algorithm (Fig. 18.1).
Pain after repair of inguinal hernia
Pain 3 months: Pain >3-6 months Excruciating pain

expectative with not responding to
basic analgetics analgetics
No clinical Clinical recurrence Surgical

recurrence re-exploration
Ultrasonography
Meshoma No recurrence Recurrence
Painteam MRI scan Preoperative

abdominal wall consult painteam
Persisting pain Cured No recurrence

Operative
correction*
Removal Painteam
meshoma, repair,
!
triple neurectomy
by herniologist
# Insufficient effect Cured
Triple neurectomy!
by herniologist#
Cured Therapy resistant Cured
!
Including proximal genitofemoral nerve-neurectomy in case of chronic pain after open or laparoscopic preperitoneal mesh technique
#
Open or endoscopic procedure
* In case of neuropathic pain anterior correction in combination with triple neurectomy is optional
Fig. 18.1. Consensus algorithm for the management and treatment of CPIP (from
Lange et al. [14], with kind permission Springer Science + Business Media).
18. Algorithmic Approach to the Workup and Management 247
Until recently no such algorithm has existed and current practices

were mainly guided by personal opinion and expertise. While it was
impossible to include every perspective and address every subtlety in
dealing with this complex diagnosis, the proposed algorithm involved
many dedicated inguinal hernia surgeons and addressed the general
issues that are important in the diagnosis and management. This algo-
rithm approach is not intended as a solid law or rigid guideline, but
hopefully will serve as a guide for practicing surgeons, pain physicians,
primary doctors and the multidisciplinary services that assist in treating
this important group of patients [14].
Timing
The algorithm starts with the two categories of patients after inguinal
hernia surgery requiring medical attention: patients with pain immedi-
ately after surgery (acute pain) and patients who develop pain later dur-
ing the postoperative course. This second group is also subdivided in
two categories: patients who only complain in the early postoperative
phase and those who have persistent pain or develop pain after some
months. Acute, excruciating pain is considered an indication for early
re-exploration. If postoperative pain develops later during the postopera-
tive course, or if pain persists beyond the normal postoperative recovery
period, an expectative phase of 3 months is indicated. During this time,
analgesics and other conservative measures are recommended.
Diagnostics
If pain persists after 3 months, inguinal hernia recurrence should be
excluded based on physical examination. In case of clinical recurrence,
operative correction is indicated, with or without triple neurectomy,
depending on the type of pain (neuropathic or nociceptive). If physical
examination does not demonstrate recurrence, ultrasonography is recom-
mended as the initial diagnostic procedure to exclude occult recurrence
or meshoma. If ultrasonography is unrevealing, cross-sectional imaging
with MRI might detect recurrence, meshoma, or other pathologies.
If recurrence is identified and associated with pain, open anterior
repair is recommended in conjunction with triple neurectomy if accom-
panied by neuropathic pain. From the perspective of pain management
and remedial surgery for inguinodynia, if the initial hernia operation was
an anterior repair (Lichtenstein, Shouldice, Bassini, McVay), laparo-
scopic correction does not represent the primary recommended modality
because positioning of mesh in the preperitoneal space may lead to
additional neuropathy (main trunk of genitofemoral nerve and preperi-
toneal segment of its genital branch). This is contrary to the recommen-
dations for simple recurrence without neuropathic pain, which would
favor a laparoscopic approach. If laparoscopic repair of recurrence fails
to address the pain, it would not be possible to differentiate whether the
source of pain is from neuropathy of nerves in front or behind the trans-
versalis fascia. If the initial hernia operation was a posterior repair (TEP,
TAP, PHS, TIPP, or other preperitoneal repair), anterior repair is recom-
mended with open extended triple neurectomy, including the genito-
femoral nerve trunk if needed. Laparoscopic repair for recurrence may
be performed, but neuropathic pain if present must be addressed with
retroperitoneal triple neurectomy proximally to the site of neuropathy.
If no anatomical pathology is identified, the surgeon should refer the
patient to a pain management team familiar with CPIP. In addition to
pharmacologic and behavioral treatment, interventions play a major role
in the diagnosis and treatment of CPIP. Nerve blocks of the ilioinguinal,
iliohypogastric and genitofemoral nerves are of significant importance,
as they serve both a diagnostic and therapeutic role. If conservative or
interventional modalities are unsuccessful or not durable, surgical inter-
vention should be offered. If the original operation involves mesh in the
preperitoneal space from open or laparoscopic repair, open extended
triple neurectomy to resect the genitofemoral trunk or laparoscopic ret-
roperitoneal triple neurectomy is indicated [15].
The International Association for the Study of Pain (IASP) broadly
classifies postherniorrhaphy inguinodynia into nociceptive and neuro-
pathic pain [16]. Nociceptive pain is caused by activation of nociceptors
by nociceptive molecules. It is caused by tissue injury or inflammatory
reaction. Neuropathic pain is caused by direct nerve injury. It is charac-
terized by inguinodynia with radiation to the scrotum/femoral triangle,
paresthesia, allodynia, hyperpathia, hyperalgesia, hyperesthesia, hypo-
esthesia, and positive Tinels sign. There is no precise demarcation
between nociceptive and neuropathic pain and the complexity of diag-
nosis is increased by social, genetic, patient, and psychological factors.
In-depth knowledge of groin neuroanatomy is of paramount impor-
tance to prevent and treat CPIP. Knowledge of the original operative
technique and detailed evaluation of the original operative report will
help to determine the likely etiologies of CPIP and the nerves at risk.
The diagnosis is also very much dependent on a detailed history and

physical examination. Physical exam findings are dependent on the neu-
roanatomic course of the three inguinal nerves, their respective derma-
tomes, and the presence of mesh or recurrence. Tools including
preoperative dermatomal mapping, quantitative sensory testing, imaging
and diagnostic interventions (nerve blocks) help to characterize the eti-
ology and direct treatment [15].
Open and Endoscopic Treatment

of Neuropathic Pain
Treatment of the patient with CPIP remains a challenge and several
different therapeutic strategies have been proposed. Conservative treat-
ment with pharmacologic, topical, behavioral and expectant measures is
advocated in all patients. Interventional techniques, including nerve infil-
tration, blockade, neuromodulation, and ablative techniques, have all been
used in the management of CPIP. Results of selective or triple neurectomy
of one or more of the three inguinal nerves and resection of meshoma have
been published with practical efficacy. Despite this high volume of infor-
mation, no consensus on the management of CPIP has been published and
high-level evidence on the management of CPIP is lacking. Triple neurec-
tomy described by Amid et al. in 1995 is currently an accepted surgical
treatment for neuropathic pain refractory to conservative measures [17].
While some surgeons have had success with selective neurectomy, tri-
ple neurectomy is generally recommended due to neuroanatomic and
technical considerations [15, 18]. There is significant cross-innervation
between the inguinal nerves and reoperating in the scarred field becomes
increasingly more difficult and morbid for subsequent remedial
operations.
Extensive study of the anatomical variation of these nerves from the
retroperitoneum to its terminal branches in the inguinal canal demon-
strates significant variation in the number, location, and cross-innerva-
tion of these three nerves [19]. Additionally, visual identification of the
nerve at the time of reoperation cannot adequately exclude injury.
Electron micrography of grossly normal nerves resected at the time of
triple neurectomy often demonstrates ultrastructural nerve damage. It is
often challenging to identify nerves in the scarred field. Reoperation,
especially with concurrent mesh removal, carries the added risk of
recurrence, vascular injury, testicular compromise and visceral injury.
Best available evidence suggests that triple neurectomy has higher effi-
cacy than selective neurectomy [15].
Open or endoscopic methods are available to perform triple
neurectomy, depending on the type of prior repair, the presence of recur-
rence or meshoma, and if orchialgia is present. Open triple neurectomy
involves re-exploration through the prior operative field and is indicated
when recurrence or meshoma are present or for the treatment of patients
who originally underwent , anterior repair without preperitoneal place-
ment of mesh. The ilioinguinal nerve is identified laterally to the internal
ring, between the ring and the anterior superior iliac spine. The iliohy-
pogastric nerve is identified within the anatomical cleavage between the
external and internal oblique aponeurosis. The nerve is then traced
proximally within the fibers of the internal oblique muscle to a point
laterally to the field of the original hernia repair. Failure to do so may
leave the injured intramuscular segment of the nerve behind. The ingui-
nal segment of the genital branch of the genitofemoral nerve can be
identified adjacent to the external spermatic vein between the cord and
the inguinal ligament and traced proximally to the internal ring where it
is severed. Alternatively, the nerve may be visualized within the internal
ring through the lateral crus of the ring. Standard triple neurectomy does
not address neuropathy of the preperitoneal nerves (main trunk of geni-
tofemoral nerve and preperitoneal segment of its genital branch) after
open or laparoscopic preperitoneal repair. In these cases, an extended
triple neurectomy may be performed, dividing the floor of the inguinal
canal to access the genitofemoral trunk in the retroperitoneum directly
over the psoas muscle.
Nerves should be resected proximally to the field of the original her-
nia repair. Although there are no specific data available, ligation of the
cut ends ,of the nerves to avoid sprouting and neuroma formation and
intramuscular insertion of the proximal cut end to keep the nerve stump
away from scarring within the operative field are recommended [17].
Neurolysis, which does not address ultrastructural changes of nerve
fibers, is not recommended. Simple removal of entrapping sutures or
fixating devices while leaving the injured nerves behind is also not rec-
ommended and does not address irreversible damage to the nerve.
Endoscopic retroperitoneal triple neurectomy allows for access proxi-
mally to all potential sites of peripheral neuropathy, overcoming many
of the limitations of open triple neurectomy after laparoscopic or open
preperitoneal repair [15, 20, 21]. Prior preperitoneal laparoscopic or
open procedures may damage or entrap the nerve in the preperitoneal
position, rendering proximal access to the three nerves a challenge.

Endoscopic access to these three nerves in the retroperitoneum allows
for definitive identification of the ilioinguinal and iliohypogastric nerves
at the L1 nerve root overlying the quadratus lumborum muscle and the
genital and femoral branches of the genitofemoral nerve exiting from the
psoas muscle. The operative technique is safe and proximal to the field
of scarring from all prior inguinal hernia repairs. Complications includ-
ing deafferentation hypersensitivity are a significant concern. In addition
to numbness in the groin region and flank, patients undergoing proximal
neurectomy may develop bulging of the lateral abdominal wall because
of the additional loss of motor function of the iliohypogastric and ilioin-
guinal nerve (innervation of transversus abdominus and oblique mus-
cles). In the absence of recurrence or meshoma, endoscopic management
may be the preferred technique for definitive operative management of
CPIP. Selection of appropriate patients is most important and manage-
ment is best deferred to experienced hernia specialists.
The consensus recommendation is that reoperation for CPIP should
be performed only by experienced surgeons [17].
CPIP caused by recurrence is a less common etiology in these pre-
dominantly neuropathic pain syndromes. However, it still represents a
cause of CPIP ,largely to be excluded by physical examination and imag-
ing. This contrasts with neuropathic pain, for which there are no reliable
tests and can be considered a diagnosis per exclusionem. Ultrasound
is recommended as the first diagnostic test for recurrence (and meshoma)
because of costs and facility. It becomes more complicated if there is a
possible combined origin for pain: recurrence and neuropathic pain. In
case of the combination of recurrence and neuropathic pain, it is impor-
tant to consider the prior technique of hernia repair and the location of
the mesh, as this will dictate the ideal approach for neurectomy and the
subsequent repair (Fig. 18.2). In case of initial anterior repair anteriorly
to the transversalis fascia (i.e., Lichtenstein procedure, Shouldice, tissue
repairs), a standard open triple neurectomy including resection of the
intramuscular segment of the iliohypogastric nerve should be performed
[22]. Laparoscopic repair of the recurrence can potentially lead to neu-
ropathy of the preperitoneal nerves (main trunk of genitofemoral nerve
and preperitoneal segment of its genital branch), and when combined
with open triple neurectomy, it would not be possible to differentiate
between neuropathy of nerves in front and behind the fascia transversalis
as source of pain after this second operation. An alternative is to perform
an endoscopic hernia repair and an endoscopic triple neurectomy. In case
Neuropathic pain without recurrence Recurrence with signs of neuropathic pain
After anterior After TEP, After anterior After TEP,

tension-free or Pelissier or tension-free or Pelissier or
tissue repair TAPP tissue repair TAPP
Open anterior triple neurectomy Anterior correction +

OR Preperitoneal (endoscopic) triple open anterior triple neurectomy Anterior correction +
preperitoneal (endoscopic) triple neurectomy OR preperitoneal (endoscopic) triple
neurectomy Endoscopic correction + neurectomy
preperitoneal endoscopic triple
neurectomy
Fig. 18.2. Consensus recommendations for operative approach of CPIP (from

Lange et al. [14], with kind permission Springer Science + Business Media).
of recurrence and neuropathic pain after preperitoneal mesh repair [i.e.,

totally extraperitoneal repair (TEP), transinguinal preperitoneal (TIPP),
transabdominal preperitoneal repair (TAPP)], the recurrence should be
corrected with an anterior technique (preferably, Lichtenstein procedure)
to avoid the prior scarred field. However, a triple neurectomy via this
approach would not be useful, as the potentially damaged nerves are
located behind the fascia transversalis. As a result, the anterior correc-
tion should ideally be combined with an endoscopic triple neurectomy
in the untouched plane proximally to the preperitoneal mesh. A reme-
dial laparoscopic operation is an alternative approach with proximal
neurectomy if indicated.
Mesh Removal
Partial or complete mesh removal is indicated in case of meshoma
pain refractory to conservative management. Meshoma as a pathologic
entity can present in different gradations from mass-like density to more
subtle effects of mesh wrinkling or fibrosis. While meshoma will require
surgical intervention if persistent and severe, occasionally patients
whose overall pain levels improve can manage without re-exploration
and removal. If the pain team is able to decrease the pain with pharma-
cologic, behavioral, and interventional treatment, this would be prefer-
able. The greatest morbidity in these reoperative surgeries is from
removal of the mesh given its apposition to vital structures with the
potential for bleeding, testicular loss, visceral injury, and creation of a
new hernia. Any potential to spare a patient from surgery is advisable.
Instead of removal of meshoma only or removal of the nerves

entrapped by meshoma only, systematic triple neurectomy is recom-
mended because of neuronanatomic and technical considerations [20].
From a neuroanatomic perspective, there is significant cross-innervation
of the nerves within the inguinal canal and within the preperitoneal
space. Any neuropathic pain cannot be isolated to one specific nerve,
and if neurectomy is performed, all potentially damaged nerves within
an operative field should be taken. From a technical perspective, reop-
erative surgery to remove the mesh will likely damage the nerves within
the operative field, and the panel advised neurectomy.
Orchialgia
Chronic testicular pain (orchialgia) has been left out of the scope of
this algorithm, focusing primarily on inguinal pain. In most cases of
orchialgia, the etiology is neuroanatomically and causatively distinct
from CPIP. Accordingly, triple neurectomy is typically ineffective for
this indication. The management of orchialgia after inguinal hernior-
rhaphy remains challenging, and it is important to note that it can arise
after all variants of inguinal repair. Resection of the paravasal fibers or
spermatic cord denervation might be an option for patients with neuro-
pathic testicular pain but must be performed proximally to the level of
pathology. Orchiectomy remains an option, but should be reserved only
for refractory cases with evidence of nociceptive pain and parenchymal
testicular compromise [23].
Conclusion
Since the nature of this algorithm is expert opinion, it should not be
considered as a strict guideline. Rather, it should serve as a practical tool
for surgeons and clinicians treating the complex problem of CPIP. The
algorithm can help direct appropriate management based upon the stan-
dard practice of an international group of surgeons considered expert on
inguinal hernia surgery. It will also serve as a standard for further
research representing the starting point for a developing dynamic
algorithm.
In conclusion, with the frequency of inguinal hernia correction as one
of the most performed operations worldwide and the high incidence of
CPIP, there is need for guidelines with regard to the management of CPIP.
This algorithm will hopefully serve as a guide to the management of

these patients and help to improve clinical outcomes. If an expectative
phase of a few months has passed without any amelioration of CPIP, a
multidisciplinary approach is indicated and a pain management team
should be consulted. If conservative measures fail and surgery is
considered, triple neurectomy or correction for recurrence with or with-
out neurectomy should be performed. Surgeons less experienced with
remedial operations for CPIP should not hesitate to refer their patients to
dedicated hernia-surgeons.
Acknowledgements Special thanks to the following colleagues involved in the

emergence of this algorithm:
M.E. Arregui, C.R. Berney, F. Berrevoet, G. Campanelli, D.C. Chen,
R.J. Fitzgibbons Jr., D. van Geldere, C. de Gheldere, H. van Goor, J. Jeekel,
A.N. Kingsnorth, J.F. Lange Sr., R. Kauffman, M. Miserez, O. Mjaland,
A. Montgommery, S. Morales-Conde, F.E. Muysoms, E.P. Pellisier, J.P.E.N. Pierie,
R.J. Ploeg, W.M. Reinpold, M.P. Simons, R.K.J. Simmermacher, F. Ugahary,
A.R. Wijsmuller
This chapter is based on an article published in Hernia (Lange JF, Kaufmann R,
Wijsmuller AR, Pierie JP, Ploeg RJ, Chen DC, Amid PK. An international consensus
algorithm for management of chronic postoperative inguinal pain. Hernia.
2015;19(1):3343), with the kind permission of the editor and Springer
Science + Business Media.
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19. Radiologic Evaluation
for Postoperative Groin Pain
Joseph M. Miller, David N. Ishimitsu,

and Rola Saouaf
The use of mesh in inguinal hernia repair has substantially decreased

hernia recurrence; however, the trade-off appears to have been an
increase in the incidence of inguinodynia, or chronic inguinal pain [1].
While pain-generating complications like hematoma or abscess forma-
tion are likely to be visible with any modality (ultrasound, computed
tomography, magnetic resonance), most other complications are subtle
in nature. Barring frank recurrence, mesh abnormalities such as migra-
tion, meshoma, or mesh reaction are outside the scope of ultrasound
(US) evaluation, and may be of indeterminate significance on computed
tomography (CT). Inappropriate nerve division, in particular, requires
magnetic resonance (MR) imaging, as neuroma is currently beyond
the capability of CT. As such, MR should be considered both the defini-
tive and first-line modality for the most specific evaluation of the post-
operative groin.
Fluid Collections
Fluid collections may form anywhere along the path of surgical inter-
vention in the days following herniorrhaphy. They can cause pain and
discomfort or lead to subsequent complications. In the case of early
postoperative bulge, US can be used to quickly evaluate for bowel con-
tent versus the presence of fluid collection. On US imaging, mesh
appears isoechoic to surrounding tissues once incorporated [2]. Seromas
consist of simple fluid and appear hypoechoic with bright posterior mar-
gins, a property known as posterior acoustic enhancement. Hematomas

DOI 10.1007/978-3-319-21587-7_19
and abscesses may be indistinguishable by US, as it is impossible to

exclude whether a hematoma has been secondarily infected. Traditional
ultrasound characteristics of hematoma include a lacy, reticular pattern
indicative of clot with the preservation of posterior acoustic enhance-
ment. Definitive abscess reveals thickened walls with posterior acoustic
enhancement and complex echotexture; unlike the linear features of
organizing hematoma, an abscess may have a mixed appearance of
irregular bright and dark foci. All three collections may reveal fluiditic
motion when compressed by US probe or on Valsalva, and Doppler US
should demonstrate no internal flow pattern in any case.
The primary distinguishing feature of the various fluid collections on
CT is attenuation, or density, as measured in Hounsfield Units. On mod-
ern multidetector CT machines, simple fluid such as that found in a
seroma is considered to range from 0 to 20 HU, though typically in the
lower range [3]. Hematoma and abscess both appear more complex than
simple fluid; the presence of gas is a strong feature of infected fluid,
though no CT feature can guarantee sterility [4]. While the appearance
of a thick rim and surrounding soft tissue edema may help to identify
abscess, intravenous contrast may be needed for definitive characteriza-
tion, as abscess walls tend to enhance while hematomas do not.
MR allows for contrast-free characterization of fluid collection. The
fluid of a simple seroma should appear dark on T1 and bright on T2
without appreciable wall thickness. While abscess also appears dark on
T1 and bright on T2, its T2 signal may be more heterogeneous and its
wall thickened, with surrounding edema and tissue reaction apparent on
STIR (short tau inversion recovery) sequences, in particular (Fig. 19.1).
Fig. 19.1. Axial MR T1-weighted, T2-weighted, and fat-saturated T2-weighted

images of bilateral flat mesh repairs. The normal mesh on the left (white arrow)
appears smooth and linear, particularly on T1. Dark blooming artifacts
(curved white arrow) are commonly encountered in the postoperative groin and
are due to the presence of metal tacks or staples. In comparison, the mesh on the
right is distorted and difficult to visualize (black arrow) due to mesh infection.
There is a large fluid collection (curved black arrows) just posterior to mesh
material, best visualized on the fluid-sensitive T2 sequences.
19 Radiologic Evaluation for Postoperative Groin Pain 259
Fig. 19.2. Axial MR T1-weighted, T2-weighted, and fat-saturated T2-weighted

images of bilateral flat mesh repairs. Both mesh are intact; however, large super-
ficial fluid collections are seen bilaterally (black arrows). While simple seroma
would appear bright on T2 sequences only, this fluid is also intermediately bright
on T1 sequences, suggesting the presence of significant blood products. Both
groins were percutaneously drained, demonstrating hematoma.
Subacute blood products should appear bright on T1, differentiating

between hematoma and abscess [5]. If uncertainty still exists, contrast
may be utilized to demonstrate peripheral enhancement in abscess.
Additionally, diffusion-weighted imaging (DWI) may be used to differ-
entiate the diffusion-restricting abscess (DWI bright, ADC dark) from
organizing hematoma, although early hematoma may restrict as well
(Fig. 19.2) [6].
Mesh Complications
Mesh complications often present with subtle imaging findings, and
may require knowledge of the operative technique utilized to diagnose
definitively. US does not reliably identify the mesh, especially if it is
folded, balled up, or otherwise complicated (Fig. 19.3). As such, US is
not recommended as a first-line imaging modality to evaluate the post-
operative groin after mesh implantation when the integrity of the mesh
itself is in question. Due to the combination of low material density and
minimal profile, normal mesh material is often indistinguishable from
surrounding tissue on CT [2], requiring the radiologist to discern a post-
operative state from the presence and location of the patients surgical
scars (Fig. 19.4). Even in states of chronic inflammation (e.g., mesh
reaction), it may be impossible to specifically identify pathology on the
basis of CT alone. On MR, flat mesh materials appear as dark linear
bands on T1 sequences, slightly thicker than normal fascial planes, but
may be more difficult to identify among their surrounding tissues on
fluid-sensitive sequences (Fig. 19.5).
Fig. 19.3. The flat mesh (white arrows) shown on this Doppler US is hardly
conspicuous, and would be even less so if not for the small fluid collection
(curved white arrow) overlying it.
Fig. 19.4. The bilateral flat mesh (white arrows) seen in this axial CT of the
pelvis look similar to scar tissue, making it difficult to differentiate subtle mesh
abnormalities.
Normal mesh should appear smooth, and wrinkling may represent

migration with subsequent focal recurrence or inflammatory response.
While mesh may be fixed in position with sutures, staples, or tacks,
shifting of mesh material may occur. If slippage does occur, even partial
mesh migration may result in gross recurrence of bowel protrusion, or
may present as subtle herniation of peritoneal or preperitoneal fat.
Interposition of even small amounts of fat between mesh material and
the abdominal wall may be a cause of significant pain. Dynamic MR
Fig. 19.5. Coronal MR T1-weighted, axial T1-weighted, and axial fat-satu-

rated T2-weighted images of flat mesh material (black arrows) closing an
indirect defect of the right inguinal canal (white arrow). Flat mesh materials
typically appear as a thick hypointense line. While there is some undulation of
this mesh, there is no inappropriate folding and no significant mass effect to
suggest meshoma or mesh reaction.
Fig. 19.6. Contrast-enhanced axial CT and corresponding contrast enhanced

T1-weighted axial MR images of mesh plug within the left direct space. Both
modalities reveal a large mass (white arrows) with similar density/intensity as
soft tissue. This appearance is due to incorporation of soft tissue within the mesh
plugs interstices. Though there is mild irregularity within the plug, the lack of
contrast enhancement and normal appearance of the surrounding fat confirms lack
of mesh pathology.
sequences are particularly capable of identifying such pathology, which

may be missed by CT.
Pain associated with more complex mesh materials such as plug or
sandwich designs are uniquely challenging to diagnose, as many radi-
ologists are not aware of the existence of such materials and may not be
able to recognize normal postoperative appearance without access to
detailed operative notes or direct communication by the referring physi-
cian. Volume-occupying materials utilized in repair of large, patulous
defects often incorporate significant biological material into their inter-
stices, appearing on imaging as large pseudomasses and resulting in
misdiagnosis (Fig. 19.6). As an example, our own personal case series
includes a post-herniorrhaphy patient with significant pain who under-

went percutaneous biopsy of bilateral inguinal masses that were in
fact mesh PerfixTM plugs that were impressing upon the contents of the
inguinal canal, resulting in testicular venous congestion and chronic
pain. Most plugs are found within the inguinal canal with a cone appear-
ance, and conversion to a different shape (especially a narrow needle-
like one) may be indicative of abnormality, suggesting migration as an
etiology of groin pain. When properly positioned, sandwich mesh, such
as the ProleneTM Hernia System, should be seen on MR as a T1 dark
band superficial to the internal inguinal ring or direct fascial defect, with
a second layer positioned preperitoneally: the presence of fat between
the layers represents normal appearance.
When part or all of the implanted mesh material migrates or folds
into a circumscribed ball and produces mass effect on surrounding tis-
sues, it is referred to as a meshoma and can result in significant pain and
discomfort [7]. Similar inflammatory response to mesh materials with-
out apparent deformity is called mesh reaction, and can be characterized
by soft tissue edema. Mild tissue reaction has been reported even years
after herniorrhaphy without evidence of infection [8]. The identification
of both pathologies has led to the development of at least partially bio-
absorbable mesh materials in an effort to limit tissue response, although
these materials may predispose to recurrent hernia [9]. This is because
bioabsorbable devices consist of decreased amounts of synthetic materi-
als that are instead interlaced with collagen for structural integrity. As
that collagen is broken down over time, less mesh is left in place.
Totally synthetic-free biologic mesh is also finding clinical appli-
cations and would be expected to be indistinguishable on imaging from
surrounding tissues without gross pathology present.
Neurologic Complications
The iliohypogastric, ilioinguinal, and genitofemoral nerves all tra-
verse the areas involved in surgical repair of inguinal hernia, and as such
are predisposed to injury during herniorrhaphy, depending on the tech-
nique used. As a quick review of the relevant neuroanatomy: [10] the
iliohypogastric nerve runs deep to the internal oblique muscle, its cuta-
neous branch emerging about a centimeter above the external ring of the
inguinal canal; the ilioinguinal nerve traverses the inguinal canal and
supplies the tissues around and overlying the external inguinal ring; the
genital branch of the genitofemoral nerve enters the inguinal canal at the
Fig. 19.7. Axial and coronal MR neurogram images. Mesh is present within the
right inguinal canal (white arrow), its inferior border in contact with the ilioin-
guinal nerve. An ilioinguinal neuroma (curved white arrows) has formed as a
result, and is found directly below the patients pain as indicated by the skin
fiducial marker (large white arrow).
internal inguinal ring and follows the spermatic cord/round ligament

into the scrotum/labia majora; and the femoral branch of the genito-
femoral nerve passes under the inguinal ligament alongside the external
iliac artery, innervating the femoral triangle.
Whether directly identified or merely implied by the course of the
meshs edge, the presence of sutures, tacks, or staples along the expected
path of these nerves should raise the suspicion of neuropathic etiology for
chronic post-herniorrhaphy pain. Entrapment, perineural fibrosis, and
neuroma are all readily apparent on MR, presenting as T2 hyperintensity
within the affected nerve (Fig. 19.7). MR neurograms are specifically pro-
tocoled non-contrast MR images that allow for high-resolution evaluation
of the peripheral nervous system, but suffer from low signal-to-noise
ratios and should ideally be performed with a 3T magnet if available.
Other Complications
The two most common laparoscopic approaches to inguinal hernia
repair are known as TAPP (transabdominal preperitoneal) and TEP
(totally extraperitoneal), where TAPP perforates the peritoneum twice
and TEP remains outside the peritoneal cavity altogether (Fig. 19.8) [11,
12]. The TAPP approach in particular can predispose to scarring and
adhesion formation. CT is the preferred method of evaluation for post-
operative bowel obstruction, or trocar-associated bowel injury.
Inflammatory response to mesh may involve nearby pelvic structures
such as the bladder, resulting in intermittent nonspecific pain syndromes
Fig. 19.8. Axial MR T1-weighted images of laparoscopic mesh (black arrows)

placed with a transabdominal preperitoneal (TAPP) approach.
Fig. 19.9. Pair of axial MR T1-weighted images show an example of abnormal

laparoscopic mesh (black arrow), with areas of irregular central contour (white
arrow) and numerous tacks. The margins of the mesh are curled and folded
(curved white arrows). The bladder is distorted (curved black arrow), suggestive
of local mass effect. Significant adhesions were present at surgical exploration.
that are temporally related to urination or defecation. It is important to

identify subtle findings on images related to these repairs, such as blad-
der asymmetry or its adhesion to a site or segment of the repair (Fig.
19.9). Regardless of approach, attachment of mesh to the pubic tubercle
by tack or staple may result in periosteal reaction, another source of
chronic pain.
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the human toll of inguinodynia? Am J Surg. 2013;206(4):61923.
2. Parra JA, Revuelta S, Gallego T, Bueno J, Berrio JI, Farias MC. Prosthetic mesh used
for inguinal and ventral hernia repair: normal appearance and complications in ultra-
sound and CT. Br J Radiol. 2004;77(915):2615.
3. Israel GM, Bosniak MA. How I do it: evaluating renal masses. Radiology.
2005;236(2):44150.
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puted tomography. Am Surg. 2012;78(2):1859.
5. Noone TC, Semelka RC, Worawattanakul S, Marcos HB. Intraperitoneal abscesses:

diagnostic accuracy of and appearances at MR imaging. Radiology. 1998;208(2):
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25368.
8. Baheci T, Nursal GN, Aydn M. Intense FDG uptake around the inguinal surgical
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ate absorbable mesh: a critical update of the long-term results. Hernia. 2013;17(1):
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pelvic painpart 1: clinical pathoanatomy and examination of the pelvic region. Pain
Pract. 2012;12(2):88110.
11. Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ. Laparoscopic transperitoneal
procedure for routine repair of groin hernia. Br J Surg. 2002;89(8):10626.
12. Faure JP, Doucet C, Rigouard P, Richer JP, Scpi M. Anatomical pitfalls in the tech-
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Anat. 2006;28(5):48693.
20. Management of Groin Pain:
Interventional and Pharmacologic
Approaches
Anuj Malhotra

Many hernia surgeons do not have a set algorithm for managing a
patient with the chief complaint of chronic groin pain. Thus when sur-
geons encounter a patient who is in distress from chronic groin pain, all
too often the ability to care appropriately for that patient can break
down and patient satisfaction can plummet. Written by a dedicated pain
management specialist, this chapter provides an amazing overview of
the management strategies for chronic groin pain and highlights the
importance of having a dedicated pain team to assist in what can some-
times be a very complicated management plan. It is a must read!
Introduction
Pain is defined by the International Association for the Study of Pain
as an unpleasant sensory and emotional experience associated with
actual or potential tissue damage [1]. Postoperative pain is a normal,
adaptive phenomenon which prevents further harm such as inadvertent
trauma and generally resolves with tissue healing. However, for some
individuals this pain persists and becomes chronic. The exact point at
which this transition occurs is unknown and, in fact, some patients expe-
rience a pain-free interval of weeks to months prior to onset of chronic
pain [2, 3]. Regardless, if the pain persists for more than 3 months, it is
often classified as chronic [1].
Pain can be further classified as nociceptive or neuropathic.
Nociceptive pain is often mediated by inflammation and can represent an

DOI 10.1007/978-3-319-21587-7_20
268 A. Malhotra
extended variant of normal tissue healing. It often presents with signs and
symptoms consistent with an inflammatory process, including localized
edema, erythema, excessive scar formation, and mechanical sensitivity
without radiation. It may represent a reaction to a foreign body such as
stitch, staple, or mesh. Neuropathic pain is more commonly character-
ized by shooting, burning, or electric pain; evidence of altered sensory
perception, often in the distribution of a particular nerve; and proximal
or distal pain relief with local anesthetic nerve block. It may result from
direct nerve injury, entrapment of a nerve in scar tissue, or neuroma for-
mation. Neuroplasticity of the central and peripheral nervous system
likely plays a role in the development of chronic pain, and thus appropri-
ate and timely diagnosis and treatment may influence overall outcome.
Risk Factors
Identifying patients at risk for postoperative groin pain can aid in
vigilant monitoring and early recognition of the transition from acute to
chronic pain. Studies have identified the following risk factors for the
development of persistent pain following groin hernia surgery: age
younger than 40 years, preoperative pain, prior groin surgery within 3
years, severe postoperative pain, postoperative complications, preopera-
tive dysesthesia, female gender, and anterior hernia repair [413]. In a
survey of 2500 Swedish patients 23 years removed from groin surgery,
30 % reported residual groin pain with 1114 % reporting pain severe
enough to interfere with daily activities [5].
First-Line Treatments
First-line treatment of postoperative groin pain is generally conserva-
tive, to allow for expected resolution and to avoid interventions that may
slow tissue healing. Initial treatment is generally with as-needed analge-
sic dosing with the goal of tapering off as pain improves. Opioids are
indicated in the acute postoperative period, exerting their effects in the
brain and dorsal horn of the spinal cord to inhibit ascending signals to the
somatosensory cortex. These are avoided in the long term, if possible,
due to development of tolerance, potential for opioid-induced hyperalge-
sia, and concerns for addiction or diversion. Nonsteroidal anti-inflamma-
tories inhibit cyclooxygenase, thereby decreasing inflammation and pain
related to local tissue injury. They inhibit platelet function to variable
20. Management of Groin Pain 269
degrees, and for this reason are sometimes contraindicated in the imme-
diate postoperative period. Acetaminophen and paracetamol are thought
to work centrally through inhibition of prostaglandin synthesis, and are
often used as adjuncts due to easy tolerability and good safety profile.
Second-Line Treatments
If pain does not improve or if escalating rather than tapering doses of
prn medications are observed, antineuropathic agents are often initi-
ated. These include topical agents such as lidocaine 5 % cream or patch,
which blocks sodium channels and produces a local anesthetic effect in
the underlying skin and superficial soft tissues. This can be of particular
use if a superficial injury is expected, such as scar neuroma.
Gabapentinoids are often second line due to minimal interaction with
other medications and acceptable safety profile. Gabapentin and prega-
balin act as modulators of calcium channels, found in abundance on
small nerve terminals and in the dorsal horn of the spinal cord. They are
dosed 23 times daily and require slow titration up to a therapeutic dose
to allow for tolerance of sedation side effects. Tricyclic antidepressants
(TCAs) are also of use in treating neuropathic pain, with a mechanism
of action at multiple sites, including serotonin and norepinephrine reup-
take inhibition, sodium channel blockade, and anticholinergic effects.
Second-generation TCAs such as nortriptyline and desipramine, the
active metabolites of first-generation amitriptyline and imipramine, are
often more easily tolerated due to fewer anticholinergic side effects.
Selective norepinephrine receptor inhibitors (SNRIs) such as venlafax-
ine and duloxetine have also been shown to improve neuropathic pain
and are more likely to be of benefit than selective serotonin reuptake
inhibitors (SSRIs). If these options are exhausted, anticonvulsants with
sodium or calcium channel blocking properties such as topiramate, leve-
tiracetam, and carbamazepine may be tried, though these agents require
closer monitoring due to potential for rare but serious adverse events.
Interventional Targets
Beyond temporary relief of symptoms, treatment of chronic postop-
erative groin pain often includes interventions designed to identify and
treat the affected area. From least to most invasive, these include diag-
nostic nerve blocks, selective nerve root blocks/transforaminal epidural
270 A. Malhotra
steroid injections, therapeutic nerve blocks, pulsed radiofrequency neu-

romodulation of peripheral nerves or dorsal root ganglia, cryoablation,
radiofrequency ablation, chemoneurolysis, and implantable peripheral
field stimulation. Identifying the nerve that is most likely to be injured
is the first step in pursuing an interventional approach. Groin pain by
definition occurs between the abdomen and thigh, and for this reason the
nerves supplying the skin and structures in this area are referred to as
border nerves [14]. These include the ilioinguinal, iliohypogastric,
genitofemoral, and lateral femoral cutaneous nerves arising from the
T12L3 anterior rami as they form the upper lumbar plexus.
1. Iliohypogastric nerveformed by L1 with contributions from
T12. Exits the lateral border of the psoas and runs in the retro-
peritoneum along the quadratus lumborum before emerging
through the transversus abdominis plane at the iliac crest. It
innervates the infraumbilical skin to the inguinal ligament.
2. Ilioinguinal nerveformed by L1 with contributions from T12.
Follows a similar course as the iliohypogastric nerve before
passing lateral to the internal inguinal ring, running anterior to
the spermatic cord to innervate the medial thigh, root of penis
and upper scrotum in men, and mons pubis and labia majora in
women.
3. Genitofemoral nerveformed by L1 and L2. Pierces the psoas
and runs along its anterior surface before splitting into a genital
and femoral branch. The femoral branch runs with the external
iliac artery under the inguinal ligament and innervates the antero-
lateral thigh. The genital branch passes through the inguinal canal
and runs along with the spermatic cord to innervate the testicle
and scrotum. It can run inside or outside the cord itself [14].
4. Lateral femoral cutaneous nerveformed by L2 and L3. Exits
the lateral border of the psoas and runs inferolaterally to the ante-
rior superior iliac spine (ASIS) and then passes under the inguinal
ligament and over the sartorius, located between the fascia lata
and iliaca, providing innervation to the lateral thigh.
It should be noted that there is significant overlap and communication
between nerves in the groin. In particular, the ilioinguinal nerve distribu-
tion may overlay that of the iliohypogastric, and, indeed, they are com-
monly inverse in size. Similarly, the ilioinguinal nerve has been shown to
share innervation of the genital branch of the genitofemoral nerve in up
to one-third of cadaver dissections [14]. Due to this anatomical variability,
landmark-based techniques for nerve blockade are unlikely to be
successful or specific, as they rely on large volumes of anesthetic

infiltrated over a large area to ensure spread to the involved nerves and
tissue planes. For example, four different landmark-based techniques
medial to the ASIS and above the inguinal ligament are commonly advo-
cated for ilioinguinal nerve block; however, high failure rates are reported,
even in children where the anatomy is generally superficial [15].
Localizing Options
Ultrasound guidance offers several advantages that make it highly
suited for diagnosing and treating groin pain. The machines are portable,
there is no radiation exposure, the superficial locations of the border
nerves can be easily visualized, and the lack of surrounding bony struc-
tures allows for in-plane needle advancement for accurate, safe, and
highly specific diagnostic and therapeutic interventions. Nerve stimula-
tion may be included to ensure close proximity to the involved nerves
and can also be of diagnostic value, as stimulating the injured nerve may
replicate the patients usual pain. An initial block of the affected nerve
using a low volume of local anesthetic can be performed with confirma-
tion of sensory block in the expected distribution. If this block relieves
the patients usual pain, then neuralgia in this distribution is the likely
diagnosis. If pain continues despite appropriate block, then another
source for pain should be investigated.
1. Iliohypogastric and ilioinguinal nerve blockA linear high-fre-
quency probe is placed with the lateral end at the ASIS and the
probe oriented in the transverse axis to visualize the three layers
of the abdominal wall. A needle is advanced in plane from medial
to lateral with the target between the transversus abdominis and
internal oblique layers, where the nerves can often be visualized
12 cm medial to the ASIS [16].
2. Genitofemoral nerve blockA linear high-frequency probe is
placed perpendicular to the inguinal ligament with the medial
end at the pubic tubercle. The spermatic cord and accompanying
nerve are visible in cross section within the inguinal canal, and a
needle can be advanced in plane from medial or lateral with the
target within the canal and outside the cord [16].
3. Lateral femoral cutaneous nerve blockA linear high-frequency
probe is placed with the lateral end at the ASIS and the probe
oriented along and inferior to the inguinal ligament. The nerve is
272 A. Malhotra
located just below the subcutaneous tissue, deep to the fascia lata
and supercial to the fascia iliaca above the sartorius muscle.
A needle can be advanced from medial to lateral in this
supercial plane.
If there is high suspicion of injury to one of these nerves but there is
no improvement with nerve block, neuralgia proximal to the site of
blockade should be considered. In this case, diagnostic selective nerve
root block/transforaminal epidural steroid injection can be performed.
During this procedure, a needle is positioned at the neural foramen of the
selected level using fluoroscopic guidance. Contrast is injected to ensure
specific spread to the nerve root alone. A small amount of local anes-
thetic is then injected, and blockade can be confirmed via dermatomal
skin testing. If anesthetizing the nerve roots that form the nerve sus-
pected to be injured transiently improves the pain, this can indicate
involvement of the nerve in a proximal location. However, it should be
noted that given overlapping nerve root innervation of the border
nerves, results may only indicate the presence of neuralgia and not the
specific nerve involved.
Therapeutic Options
Once the pain source is identified, several interventional options can
be tried for therapeutic benefit. Repeating the block with the addition of
a corticosteroid can extend the duration of the block and may also cause
mild local tissue or scar atrophy, which can lessen nerve entrapment.
Good prognostic signs for this approach include increasing duration and
intensity of benefit with subsequent blocks. If good relief is obtained but
no extended duration occurs with repeat intervention, pulsed radiofre-
quency (PRF) can be tried. PRF uses radiofrequency stimulation
through an insulated needle with an active 510 mm tip that is placed in
proximity to the nerve to be treated. Neuromodulation is believed to
occur due to inhibition of evoked synaptic activity [17, 18]. PRF has
advantages over traditional RF, including limited tissue damage and
ability to treat superficial structures due to less reliance on creation of a
thermal lesion. PRF can be applied to peripheral nerves or to the dorsal
root ganglia of involved nerve roots. Evidence is at the level of case
series, but results thus far have been promising [1921].
Alternatively, true ablation can be performed using a variety of tech-
niques. However, as these techniques cause neurolysis, additional con-
cerns must be considered. First, these techniques should not be performed
on any nerves with a significant motor component as weakness will

occur. Fortunately, the border nerves are primarily sensory, but given the
proximity of DRGs to the spinal nerve, these cannot be safely ablated.
Second, injury to adjacent structures may occur, such as to blood vessels
which may be coagulated by radiofrequency ablation. Finally, neurolysis
can create an area of desensitized skin, which can be bothersome for
certain patients and may progress to anesthesia dolorosa, a feared com-
plication manifested by pain in the area despite numbness to stimulation.
Nonetheless, these approaches may be of significant benefit in appropri-
ate cases and after full discussion of risks and benefits with the patient.
Ablation may be performed with injection of a chemical neurolytic such
as phenol or dehydrated alcohol. Radiofrequency ablation creates a ther-
mal lesion at 80 C along the active needle tip. Cryoablation creates a
supercooled 70 C ice ball around the neural sheath, which leads to
decreased transmission. Again, case reports have shown promising
results with decreased pain and analgesic requirements [22].
For patients refractory to percutaneous interventions, peripheral nerve
field stimulation may be attempted. During the trial, stimulating leads are
placed either in proximity to the affected nerve or more subcutaneously
in the painful area. The leads are then sutured at the skin, and the external
lead contacts connected to a patient-controlled pulse generator. The
patient can then vary the stimulation intensity and pattern to produce a
vibratory sensation that overlaps the affected area. After a trial of 35
days, the patient reports on any resulting benefit, and if there is evidence
of increased function and decreased need for analgesics, a permanent
device can be placed with an implantable pulse generator. Peripheral
stimulation is based on the gate control theory proposed by Wall and
Melzack, wherein activation of large fibers suppresses painful input from
small fibers. This varies from the traditional use of stimulating leads in
the dorsal column of the spinal cord and is considered an off-label use.
Several case series have shown significant and sustained benefit with
peripheral stimulation, which may hold particular promise long term, as
there is unlikely to be a recurrence of pain after a pain-free interval as can
occur with regeneration of ablated nerves following neurolysis [2326].
Conclusion
Several recent expert reviews have attempted to quantify the effect of
various interventions for chronic postsurgical groin pain [16, 27]. Many
promising modalities have been identified, as above; however, differences
274 A. Malhotra
Acute
Nociceptive Neuropathic
Medications NSAIDs Topicals

Opioids (short term) Gabapentinoids
Acetaminophen TCAs
SNRIs
Na+ channel blockers
Chronic
Diagnostic nerve blocks Ilioinguinal

Iliohypogastric
Genitofemoral
Lateral femoral cutaneous
Selective nerve roots (T12-L2)
Therapeutic options Corticosteroid injections

Pulsed radiofrequency
Cryoablation
Radiofrequency ablation
Chemoneurolysis
Peripheral field stimulation
Aid in surgical planning
Fig. 20.1. Management of groin pain: interventional and pharmacologic approaches.
in reporting and study methodologies make it difficult to compare outcomes

between interventions. In general, a stepwise approach is advocated, begin-
ning with appropriate pharmacotherapy, then progressing to diagnostic
nerve blocks, and finally to therapeutic interventions (Fig. 20.1) [27]. Early
referral to a pain management physician can help expedite this process and
possibly prevent the transition from acute to chronic pain. For certain
patients, despite the use of multiple modalities, pain will not improve sub-
stantially or for any prolonged duration. For these patients, information
from any interventions that at least temporarily lessen their usual pain may
be used to help inform more definitive surgical intervention.
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2. Poobalan AS, Bruce J, Smith WC, King PM, Kurkowski ZH, Chambers WA. A review
3. Smith WC, Bourne D, Squair J, Phillips DO, Chambers WA. A retrospective cohort
study of post mastectomy pain syndrome. Pain. 1999;83(1):915.
4. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and preven-
tion. Lancet. 2006;367(9522):161825.
5. Frnneby U, Sandblom G, Nordin P, Nyrn O, Gunnarsson U. Risk factors for long-
6. Reinpold WM, Nehls J, Eggert A. Nerve management and chronic pain after open
inguinal hernia repair: a prospective two phase study. Ann Surg. 2011;254(1):1638.
7. Kalliomki ML, Meyerson J, Gunnarsson U, Gordh T, Sandblom G. Long-term pain
after inguinal hernia repair in a population-based cohort; risk factors and interference
with daily activities. Eur J Pain. 2008;12(2):21425.
8. Nienhuijs SW, Boelens OB, Strobbe LJ. Pain after anterior mesh hernia repair. J Am
Coll Surg. 2005;200(6):8859.
9. Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WC. Chronic
pain and quality of life following open inguinal hernia repair. Br J Surg. 2001;88(8):
11226.
10. Liem MS, van Duyn EB, van der Graaf Y, van Vroonhoven TJ, Coala Trial Group.
Recurrences after conventional anterior and laparoscopic inguinal hernia repair:
a randomized comparison. Ann Surg. 2003;237(1):13641.
11. Gottrup H, Andersen J, Arendt-Nielsen L, Jensen TS. Psychophysical examination in
patients with post-mastectomy pain. Pain. 2000;87(3):27584.
12. Macrae W, Bruce J. Chronic pain after surgery. In: Wilson PR, Watson PJ,
Haythornthwaite JA, Jensen TS, editors. Clinical pain management: chronic pain.
London: Hodder Arnold; 2008. p. 405.
13. Aasvang EK, Mhl B, Bay-Nielsen M, Kehlet H. Pain related sexual dysfunction after
inguinal herniorrhaphy. Pain. 2006;122(3):25863.
14. Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemo-
ral nerve: implications for the treatment of groin pain. Plast Reconstr Surg. 2001;
108(6):161823.
15. van Schoor AN, Boon JM, Bosenberg AT, Abrahams PH, Meuring JH. Anatomical
considerations of the pediatric ilioinguinal/iliohypogastric nerve block. Paediatr
Anaesth. 2005;15(5):3717.
16. Peng P, Tumber P. Ultrasound-guided interventional procedures for patients with
chronic pelvic paina description of techniques and review of literature. Pain
Physician. 2008;11(2):21524.
17. Mitra R, Zeighami A, Mackey S. Pulsed radiofrequency for the treatment of chronic
ilioinguinal neuropathy. Hernia. 2007;11(4):36971.
18. Van Zundert J, Patijn J, Kessels A, Lam I, van Suijlekom H, van Kleef M. Pulsed
radiofrequency adjacent to the cervical dorsal root ganglion in chronic cervical radicular
pain: a double blind sham controlled randomized clinical trial. Pain. 2007;127(12):
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19. Cohen SP, Foster A. Pulsed radiofrequency as a treatment for groin pain and orchial-
gia. Urology. 2003;61(3):645.
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21. Dermatome Mapping: Preoperative
and Postoperative Assessment
Rigoberto lvarez
History
During the last two decades, there has been an important decrease in
recurrence rates after inguinal hernia repair [13]. Consequently, post-
operative chronic pain has become the more frequent and important
outcome that occupies our attention [4]. The proper study of chronic
postoperative pain both prior to its treatment and during subsequent
monitoring is of great significance, to the extent that the success or fail-
ure of our management depends on proper terminology, characteriza-
tion, description, and diagnosis. Unfortunately, at present there are no
radiological or electromyographic studies that show us with certainty the
real scenarios that we face in clinical practice. The available pain evalu-
ation questionnaires are more oriented to determine the degree of limi-
tation and disability than to provide us with reliable guidelines to
implement the proper therapies for each individual case [5, 6]. The sig-
nificance cannot be understated, given the importance of the labor and
legal concerns due to the implications and impact of disabling pain after
inguinal hernia repair. The generally accepted time frame for defining
chronic postoperative pain is after the third postoperative month [7, 8].
There are two main types of postoperative pain that contribute to post-
inguinal herniorrhaphy inguinodynia. The first is the nociceptive or
non-neuropathic pain, which is the most common and is caused by the
rupture of soft tissues such as skin, subcutaneous tissue, and muscles; as
a result of tissue trauma, cutting, or cauterization during surgery; as well
as pain caused by the presence of orchialgia, meshomas, or granulomas.
The second type of pain is neuropathic. It usually appears in the early
postoperative period and involves injury of one or several nerve
branches, mainly caused by two mechanisms: when these nerves are cut

DOI 10.1007/978-3-319-21587-7_21
278 R. lvarez
intentionally or incidentally, or due to entrapment of the nerve by a

suture or penetrated when fixating with tacks. This type of pain is the
most persistent and severe in intensity.
It is noteworthy that after more than 10 years evaluating patients with
chronic postoperative pain, we have not had a single case of lateral femo-
ral cutaneous nerve involvement. The most frequently affected nerve by
both open and laparoscopic approaches has been the ilioinguinal nerve,
followed by the genital branch in the open technique, especially in
patients in whom plugs were placed in the internal ring where this branch
emerges, or when the round ligament was severed. The femoral branch
of the genitofemoral nerve was involved mainly in the laparoscopic
approach [9]. We believe that the mechanism of injury of the femoral
branch is caused by traction, pulling, or rupture of this structure when
dissecting near to the iliac vessels. This is probably the reason why most
of these patients improve with conservative management, since the
mechanism of injury is not entrapment. Even so, the recommended treat-
ment for patients with persistent pain involving femoral branch derma-
tome after 3 months is the lumboscopic approach and truncal genitofemoral
nerve resection [10, 11]. The surgical management often involves
removal of the mesh [12, 13] and tacks with neuropathy addressed with
selective neurectomy [8, 9, 13], triple neurectomy [14, 15], or extended
or quadruple truncal neurectomy [10, 11].
Introduction
Dermatome Mapping
Clinical evaluation of the dermatomes involved with each nerve trunk
has been a routine part of our general medical practice due to our aca-
demic training in routine neurological assessment; therefore, to consider
dermatome mapping in a comprehensive evaluation of the patient with
chronic postoperative groin pain is of utmost significance when address-
ing such patients. For this reason, in 1998 we developed and implemented
the dermatome mapping test (DMT) as an integral tool in the evaluation
of our patients [11, 15]. Since then, DMT has shown us a high sensitivity
when matching mapped results with the surgical findings. More impor-
tantly, it has demonstrated high sensitivity with histological results [11]
and postsurgical evaluation and outcomes (see Clinical Cases below).
21. Dermatome Mapping: Preoperative and Postoperative Assessment 279
Subsequent analysis has allowed us to implement technical modifications

such as extending our evaluation to include the upper third of the thigh,
because we found a high frequency of injury or involvement of the
femoral branch, especially in patients approached laparoscopically. The
dermatome mapping aims to determine the specific source of pain with
regard to type and intensity in order to establish therapeutic guidelines.
Unlike the rest of the proposed assessments that primarily determine the
impact on quality of life in the patient [5, 6], we consider the two com-
pletely different evaluation techniques yet highly complementary to
each other.
The current diagnostic methods for the evaluation of chronic postop-
erative pain are primarily clinical. Electromyographical studies and
evoked potentials do not show a reliable sensitivity or specificity and are
difficult to implement and interpret. Imaging in general such as computer-
ized tomography (CT) magnetic resonance imaging (MRI) or ultrasound
(US) has demonstrated only limited utility in cases of granulomas or
meshomas; however, they are of no use in chronic pain of neuropathic
origin.
Technique Description
As a stimulator, a regular ballpoint pen is used to apply the pressure
needed to assess the deep sensation of the dermatome evaluated. Three
permanent markers black, red, and blue (Fig. 21.1) are used to mark and
delineate assessed areas.
In all patients with chronic postoperative pain, dermatome mapping
test (DMT) can be implemented using as reference a point one-inch lateral
to the umbilicus contralateral to the region to be evaluated. With respect
to this point, sequentially go from the superior iliac crest to the midline at
a distance of no more than one inch between each point radially, continu-
ing down to the upper third of the scrotum and penis for males, or the labia
for women. Continue inferiorly to reach and evaluate the upper third of
the thigh, including the anterior, lateral, and medial sides (Figs. 21.2, 21.3,
21.4, 21.5, 21.6, 21.7, 21.8, 21.9, 21.10, and 21.11).
Once the dermatome mapping is completed, proceed to photograph
the area and integrate this into the clinical record in order to have an
objective view of this event. We can follow up with subsequent mapping
to compare with previous DMTs in cases of vague pain scenarios or in
preoperative versus postneurectomy pain assessments after quadruple,
triple, or selective neurectomy.
Fig. 21.1. Material: A ballpoint pen and three permanent markers, black for nor-
mal sensation (isoesthesia), red for pain or tenderness (hyperesthesia), and blue
for anesthesia, numbness, or discomfort (hypoesthesia). Each point is evaluated
and marked as follows: (a) A circle in black for those who have a similar sensation
to the reference para-umbilical point. (b) A cross in red for those points where the
patient feels pain and/or hypersensitivity. (c) A minus in blue for those points of
anesthesia, hypoesthesia, or discomfort (superficial burning or numbness).
Fig. 21.2. Dermatome

mapping compatible with
postoperative pain due to
right ilioinguinal nerve
involvement. DMC
Dermatome Mapping
Classification.
left iliohypogastric nerve
involvement.

left genital branch involve-
ment. This injury occurs
mainly when the round lig-
ament is severed or plugs
are placed in the internal
ring where this branch
emerges.
left femoral branch
involvement. This injury
occurs mainly in patients
approached
laparoscopically.

postoperative pain due
to left ilioinguinal nerve
and left femoral branch
involvement. This injury
occurs mainly in patients
approached
laparoscopically.
postoperative denervation,
numbness, or discomfort
after a successful right tri-
ple neurectomy. As a fol-
low-up to chronic
postoperative pain
assessment.

postoperative denervation,
numbness, or discomfort
due to successful selective
neurectomy of the left
ilioinguinal nerve. As a
follow-up to chronic post-
operative pain assessment.
mapping compatible with a
non-neuropathic or noci-
ceptive VAGUE postopera-
tive etiology of pain
because it does not follow
the pattern of a dermatome.
This is probably the case of
a simulator due to malin-
gering, conversion, or other
non-anatomic pathology. In
these scenarios, dermatome
mapping may be repeated a
week later and photo-
graphed, with expectations
of a complete different
pattern.

mapping compatible
with a non-neuropathic
or nociceptive
postoperative PUBALGIA.

mapping compatible with a
non-neuropathic or noci-
ceptive postoperative right
ORCHIALGIA.
Dermatome Mapping Classification

Traditionally, in the era when recurrence was our main concern,
chronic postoperative inguinal pain had been referred to using the
general term inguinodynia for all possible types of inguinal pain
manifestations. However, the variation of clinical presentations and
etiologies necessitates that we broaden and deepen our understanding of
this complex condition [16]. Primarily, it is important to establish the
origin of the pain and to classify the location and type of pain that we are
dealing with: neuropathic (follows the pattern of a dermatome of specific
nerve trunks), nociceptive (non-neuropathic), or paresthesias (denerva-
tion or discomfort due to incidental or therapeutic neurectomy).
286 R. lvarez
Subsequently, we must determine the specific source of pain. That is,

to establish which nerve or multiple nerve trunks are involved, and at the
same time determine if the source of pain is non-neuropathic (meshomas,
orchialgia, pubalgia, or vague) or some other mechanism when the nerve
trunks are clearly preserved.
Finally, it is imperative to have a record of how the intensity of pain
is perceived by the patient. For this purpose, the visual analogue scale
(VAS) is used in conjunction with this classification system.
We reported the original Dermatome Mapping Classification in 2009
[9]; the updated 2015 DMC is presented in (Fig. 21.12) with respect to the
Location Type Source Intensity

VAS
R Right N Neuropathic 1 Ilio inguinal Nerve I-X
L Left 2 Ilio hypogastric Nerve I-X
C Central 3 Genital Branch I-X
4 Femoral Branch I-X
5 Lateral F Cutaneous Nerve I-X
T1-T12 Costal Nerves I-X
NN Non Neuropathic G Granuloma I-X

H Hernia I-X
L Lipoma I-X
M Meshoma I-X
O Orchialgia I-X
P Pubalgia I-X
S Sports Hernia I-X
V Vague I-X
D Denervation 1 Ilio inguinal Nerve I-X

Discomfort 2 Ilio hypogastric Nerve I-X
3 Genital Branch I-X
4 Femoral Branch I-X
5 Lateral F Cutaneous Nerve I-X
T1-T12 Costal Nerves I-X
Fig. 21.12. DMC (Dermatome Mapping Classification). Dermatome Mapping

Classification (DMC) is classified evaluating 4 aspects in chronic postoperative
pain: location, type, source, and intensity (updated version of the 1999 original [9]).
pre- and postoperative evaluations of patients with chronic postoperative

pain. Currently, we are updating the DMC regularly, expanding it, for
example, not only to evaluate the inguinal region but also to consider
thoracic nerves for cases when postoperative pain occurs in the abdominal
region due to injury or entrapment of thoracic nerves during an inguinal
laparoscopic surgery, or when using transfascial sutures, for instance, in
the Rives or laparoscopic techniques. We have also modified the DMC to
include Dr Chens contribution of the term vague for nonspecific situa-
tions, subjective inconsistencies, or patients simulating pain that had
previously been termed faking.
The Dermatome Mapping Test (DMT) results are presented and
sorted according to the authors classification (DMC), which takes into
account 4 main aspects:
1. Pain location
L: Pain or discomfort is located on the left side
R: Pain or discomfort is located on the right side
C: Pain or discomfort is located on the center
2. Type of pain or denervation discomfort
N: Neuropathic pain that follows the path of a nerve branch or
dermatome
NN: Non-neuropathic pain that does not follow the pattern of a nerve
branch or dermatome
D: Denervation incidental or secondary to neurectomy, manifested by
anesthesia, hypoesthesia, or numbness
3. Source of neuropathic pain or discomfort and denervation symptoms
Source of neuropathic pain or denervation symptoms
1. For the dermatome of the ilioinguinal nerve
2. For dermatome of the iliohypogastric nerve
3. For the dermatome of the genital branch
4. For the dermatome of the femoral branch
5. For the dermatome of the lateral femoral cutaneous nerve
T1 through T12 For each thoracic nerve dermatome
Source of non-neuropathic pain

Those symptoms that do not follow a nerve dermatome
pattern. The following nomenclature for the source of pain or
discomfort is assigned
288 R. lvarez
G: Granuloma
H: Hernia
L: Lipoma
M: Meshoma
O: Orchialgia
P: Pubalgia
S: Sports Hernia
V: Vague
4. Intensity of pain or discomfort
The Visual Analogue Scale (VAS) is reported with Roman numerals
(I through X). These data are integrated into the Dermatome Mapping
Classification (DMC) for chronic postoperative pain (see Fig. 21.12).
Clinical Cases
See Figs. 21.13, 21.14, and 21.15.
Conclusion
Dermatome Mapping Test (DMT) is a )simple and cost-effective
technique that requires only a ballpoint pen and three felt-tipped
markers.
This test can be performed in the surgeons office. A photograph is
taken that provides an objective record of a subjective situation such as
postoperative chronic pain.
The Dermatome Mapping Classification (DMC) establishes and
incorporates a broadened common language that names every specific
scenario encountered in post-inguinal herniorrhaphy pain. It allows us to
characterize and communicate the multifactorial pain that patients pres-
ent with and to discuss and form treatment plans in a logical fashion.
It additionally provides an excellent tool for postoperative assessment
and follow-up to document and communicate the efficacy of our
interventions.
Fig. 21.13. (a) Dermatome mapping compatible with LAPAROSCOPIC severe

neuropathic postoperative pain due to bilateral ilioinguinal nerve, right T12
nerve, and left femoral branch involvement. (b) X-ray shows 11 tackers on each
side and two hemoclips.
290 R. lvarez
Fig. 21.14. Same patient as Fig. 21.13 after successful bilateral triple neurec-
tomy and multiple tackers removal. The symptoms improved significantly after
1 year. Left femoral branch pain persists in 12 points of the femoral branch
dermatome although less intense compared to the preoperative assessment. This
patient would have been a candidate for truncal quadruple lumboscopic
neurectomy.
Fig. 21.15. (a) Dermatome mapping compatible with neuropathic postoperative

chronic pain due to right ilioinguinal nerve involvement after an open mesh plug
technique. (b) Dermatome mapping of the same patient that shows denervation
due to selective neurectomy of the right ilioinguinal nerve and genital branch
after plug removal with the iliohypogastric nerve dermatome seen intact.
Successful decrease on ilioinguinal pain intensity from X down to II in VAS
Visual Analog Scale.
References
1. The Swedish Hernia Register [Internet]. http://www.svensktbrackregister.se/.
Accessed 12 Jul 2014.
2. Danielsson P, Isacson S, Hansen MV. Randomised study of Lichtenstein compared
with Shouldice inguinal hernia repair by surgeons in training. Eur J Surg. 1999;
165(1):4953.
3. Beets GL, Oosterhuis KJ, Go PM, Baeten CG, Kootstra G. Longterm followup (1215
years) of a randomized controlled trial comparing Bassini-Stetten, Shouldice, and
high ligation with narrowing of the internal ring for primary inguinal hernia repair.
J Am Coll Surg. 1997;185(4):3527.
4. de Lange DH, Wijsmuller AR, Aufenacker TJ, Rauwerda JA, Simons MP. Neuralgic
pain, a significant complication after a Lichtenstein procedure for inguinal hernia
repair. Ned Tijdschr Geneeskd. 2008;152(41):22059 [Article in Dutch].
5. Staal E, Nienhuijs SW, Keemers-Gels ME, Rosman C, Strobbe LJ. The impact of pain on
daily activities following open mesh inguinal hernia repair. Hernia. 2008;12(2):1537.
292 R. lvarez
6. Lermite E, Arnaud JP. Prospective randomized study comparing quality of life after
shoudice or mesh plug repair for inguinal hernia: short-term results. Surg Technol Int.
2012;22:1016.
7. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions
of pain terms. Prepared by the International Association for the Study of Pain,
Subcommittee on Taxonomy. Pain Suppl. 1986;3:S1226.
8. Campanelli G, Bertocchi V, Cavalli M, Bombini G, Biondi A, Tentorio T, et al.
Surgical treatment of chronic pain after inguinal hernia repair. Hernia. 2013;17(3):
34753.
9. lvarez Quintero R, Mayagoitia Gonzlez JC. Chapter 37. Dolor inguinal crnico
posoperatorio o inguinodinia. In: Mayagoitia Gonzlez JC, editor. Hernias de la pared
abdominal: tratamiento actual. 3rd ed. Editorial Alfi: Mxico; 2015. p. 2939 [Book
in Spanish].
roscopic and open preperitoneal inguinal hernia repair. J Am Coll Surg. 2011;
213(4):5316.
9627.
12. Heise CP, Starling JR. Mesh inguinodynia: a new clinical syndrome after inguinal
herniorrhaphy? J Am Coll Surg. 1998;187(5):5148.
13. Bischoff JM, Enghuus C, Werner MU, Kehlet H. Long-term follow-up after mesh
removal and selective neurectomy for persistent inguinal postherniorrhaphy pain.
Hernia. 2013;17(3):33945.
14. Amid PK. Causes, prevention, and surgical treatment of postherniorrhaphy neuro-
pathic inguinodynia: triple neurectomy with proximal end implantation. Hernia.
2004;8(4):3439.
15. lvarez Qiomterp R, Anaya Prado R, Mal VE. Inguinodinia: Mapeo por dermatomas
como mtodo diagnstico. Cirujano General. 2004;26(4):2659 [Article in Spanish].
16. Turk DC, Rudy TE. IASP taxonomy of chronic pain syndromes: preliminary assess-
ment of reliability. Pain. 1987;30(2):17789.
22. Management of Inguinal Hernia
Recurrences (When Pain Is the Primary
Symptom)
Keri A. Seymour and Jin S. Yoo
Roughly 27 % of men and 3 % of women in industrialized countries

will undergo inguinal hernia repair [1]. Surgical repair of inguinal hernias
has progressed from primary repair to mesh repair and now includes mini-
mally invasive techniques. The most common postoperative complica-
tions of inguinal hernia repair include recurrence and chronic pain.
Incorporating the variety of repair techniques, recurrence is reported in
515 % of patients after inguinal hernia repair, and chronic pain is
reported in up to 63 % of patients depending on the definition used [26].
Management of recurrence and pain after inguinal hernia repair requires a
multimodal and multidisciplinary approach. Surgical planning requires a
familiarity with the anatomy, realistic patient expectations, understanding
of previous repair, and open and laparoscopic options for remedial repair.
Postoperative Pain
Postoperative pain affects quality of life, leads to decreased physical
activity, and results in additional medical care and surgical procedures
[5]. Postoperative pain is multifactorial; its origin includes visceral,
somatic, or neuropathic sources (Table 22.1). Pain experienced in the
early postoperative period is frequently nociceptive in origin [4, 7]. It
presents as tenderness along the incision, inguinal canal, scrotum, and
thigh, and is due to tissue inflammation or irritation from mesh or suture
material. Neuropathic pain presents as allodynia, hypoesthesia, pares-
thesia, or hyperesthesia [8]. The definitions of chronic pain may vary
among studies; however, it is frequently defined as pain 3 months after
surgery and lasting for more than 2 months.

DOI 10.1007/978-3-319-21587-7_22
294 K.A. Seymour and J.S. Yoo
Table 22.1. Origin of postoperative pain after inguinal hernia repair.

Visceral origin
Vascular injury
Infectious
Urologic, gastrointestinal, or gynecologic disorders
Somatic origin
Scar tissue
Meshoma
Hernia recurrence
Periosteal inflammation
Neuropathic origin
Nerve injury or entrapment
Scar tissue
Mesh or suture irritation
Anterior and Posterior Approach

Neuropathic pain involves damage or injury to the nerves of the
inguinal canal, particularly nerves running in the anterior (inguinal) and
posterior (preperitoneal) space. There are five sensory and somatic
nerves that are susceptible to injury during inguinal hernia repair. These
nerves are iliohypogastric, ilioinguinal, genital and femoral branch of
the genitofemoral, and the lateral femoral cutaneous nerve.
The anterior approach to repair of inguinal hernia includes the
Bassini, McVay, Shouldice, and Lichtenstein repairs. These repairs may
expose the nerves running in the inguinal canal (iliohypogastric, ilioin-
guinal, and genital branch of the genitofemoral) to injury or entrapment.
Recurrence after open (anterior) inguinal hernia repair occurs in up to
6 % of patients and pain is associated with 15 % of repairs [9].
Minimally invasive inguinal hernia repair, laparoscopic transabdomi-
nal preperitoneal (TAPP) and totally extraperitoneal repair (TEP), is
associated with a recurrence rate of 3 % and postoperative pain occurs
after 2 % of repairs [9]. These repairs place mesh posterior to the rectus
fascia, in the preperitoneal space. The triangle of pain is outlined as
inferior to the inguinal ligaments; the apex is the internal ring, and
anterolateral to the gonadal vessels [4]. The lateral femoral cutaneous
nerve, femoral nerve, and femoral and genital branch of the genitofemo-
ral nerves lie in this region [5]. Placement of tacks in the triangle of pain
can inadvertently entrap the nerves.
22. Management of Inguinal Hernia Recurrences 295
Risk Factors
Pain and recurrence after inguinal hernia repair are related to a com-
bination of patient-related risk factors, technical considerations, and
operative approach. Technical errors include inadequate mesh coverage,
mesh folding, and mesh migration. Burcarth et al. recommend that
females undergo laparoscopic repair of inguinal hernias in order to evalu-
ate an unappreciated femoral hernia. Smoking is associated with impaired
wound healing due to hypoxia and decreased collagen formation [10].
Table 22.2 lists the preoperative, perioperative, and postoperative risk
factors associated with pain after inguinal hernia repair [1, 4, 5, 11].
Evaluation
Evaluation of recurrence when pain is the presenting symptom after
inguinal hernia repair should begin with a thorough history and physical
exam. The history should include the frequency, location, and triggers of
pain. The physical exam should focus on a bulge, fascial defect, and
Table 22.2. Risk factors associated

with pain after inguinal hernia repair.
Preoperative risk factors
Young age
Female sex
Pain prior to surgery
Obesity
Recurrent hernia
Direct inguinal hernia
Smoking
Perioperative risk factors
Surgeon experience
Neurolysis
Fixation with suture or staples
Lightweight mesh
Local anesthesia
Excessive dissection
Postoperative risk factors
Recurrence
Hematoma
Wound infection
reproducible pain. The operative report from the previous surgery

should be reviewed, including the type of repair, size of the defect, size
and type of mesh, handling of nerves, and type of fixation. Diagnostic
imagingultrasound, computed tomography scan, or magnetic reso-
nance imagingsupplements the management, excludes recurrence or
meshoma, and assists in the diagnosis [4].
Supportive Treatment
Treatment of postoperative pain involves a multidisciplinary approach,
including medications, behavior modification, and therapeutic interven-
tion. Courtney et al. found that 30 % of patients have resolution of post-
operative inguinal hernia repair pain, 45 % have reduced pain, and 25 %
continue to have chronic pain [12]. A period of watchful waiting with
symptomatic treatment with a multimodal therapy that includes behavior
modification, NSAIDs, and opioid medications is recommended.
Additionally, a multidisciplinary group approach that consists of the
primary care provider and a dedicated pain specialist (anesthesiologist,
neurologist, psychiatrist) is recommended. Adjunctive modalities such
as nerve stimulators, steroid injections, or nerve blocks can be both diag-
nostic and therapeutic. Specific to this subgroup of patients with pain in
the presence of a known recurrence, it is important to characterize the
potential etiologies of pain so that all contributing factors can be
addressed at the time of remedial surgery for both recurrence and pain.
Surgical Options
Reoperation for a recurrent inguinal hernia is considered at the time
of identification either by physical exam or imaging studies. A trial of
conservative measures, careful diagnostic evaluation, and treatment for
the pain component is prudent to help delineate if the pain is primarily
due to the recurrence or if neuropathy, meshoma, or other anatomic
issues are causative. At the time of repair of a recurrent inguinal hernia,
surgery for pain management may include an operative neurectomy or
possible removal of mesh, depending on the presentation and suspected
etiology of pain.
Neuropathic pain refractory to conservative measures identified from
history, physical examination, and adjunctive testing may not improve
with recurrent hernia repair alone, and the inguinal and preperitoneal
nerves are placed at additional risk during remedial surgery. Neurectomy

is advisable at the time of reoperation in these cases. In 2002, Amid
described a one-stage, anterior triple neurectomy to treat posthernior-
rhaphy pain. Triple neurectomy resects the iliohypogastric, ilioinguinal,
and genital branch of the genitofemoral nerve. Triple neurectomy suc-
cessfully treated pain in 80 % of patients. Adequate dissection lateral to
the internal ring is necessary to identify the proximal portion of the
ilioinguinal nerve. The iliohypogastric is found between the external and
internal oblique, and the genital branch of the genitofemoral nerve is
identified near the external spermatic vein. The nerves, along with any
mesh that incorporates the nerves, are resected with the proximal nerve
ends placed in the internal oblique muscle or allowed to retract into the
inguinal ring [11]. Excessive scar tissue may distort the anatomy and
make a triple neurectomy difficult; however, the nerves have overlap-
ping sensory innervation and triple neurectomy is preferred [4, 7].
Complications include persistent numbness, vascular or bowel injury,
testicular atrophy, recurrence of the hernia, wound infection, and pain
[2, 7, 8]. Neurectomy must be performed proximal to the site of any
nerve injury in order to be effective. A retroperitoneal approach to triple
neurectomy is indicated for neuropathic pain after prior preperitoneal
posterior repair through either an extended anterior approach or laparo-
scopic approach.
Recurrence After Anterior Approach

There are different options to manage recurrence of an inguinal her-
nia combined with chronic pain after anterior repair. A standard open
reoperation allows for identification, repair, mesh removal if needed,
and neurectomy for neuropathic complaints. The operative repair is
more challenging due to reoperation within the scarred inguinal field.
Alternatively, Rosen et al. treated chronic neuralgia after anterior ingui-
nal hernia repair with a combined laparoscopic and open approach.
A diagnostic laparoscopy was the initial step to evaluate hernia recur-
rence, mesh contraction, incorporation of vas deferens, and pelvic
anatomy. Using a standard TAPP repair, mesh was placed in the preperi-
toneal space. Then the anterior incision exposed the mesh, which was
removed along with all sutures, including the tacking suture at the pubic
bone. The operation was completed after ilioinguinal and iliohypogas-
tric neurectomy was performed. Over 90 % of patients reported resolu-
tion of pain [2].
Recurrence After Posterior Approach

Chronic pain and recurrence after laparoscopic inguinal hernia repair
require additional consideration. Pain with recurrence after posterior
(preperitoneal) repair should be treated with anterior repair of the recur-
rence. A laparoscopic approach to remove tacks, staples, suture, mesh,
or a trapped nerve and the addition of an extended peritoneal triple
neurectomy may be required to treat chronic pain [7]. The extended
triple neurectomy involves dissection in the retroperitoneal space to the
psoas muscle to locate the genitofemoral trunk along with the ilioingui-
nal and iliohypogastric nerve adjacent to the quadratus lumborum.
Successful relief of pain with extended triple neurectomy is reported in
over 85 % of patients [13]. Laparoscopic repair of the recurrence
remains an option but carries the risks and challenges of reoperating in
the scarred preperitoneal field.
Conclusion
Inguinal hernia repair is a common surgery performed worldwide.
Prevention of recurrence and chronic pain rely on preoperative knowl-
edge of risk factors. Recurrence and chronic pain complicate 515 % of
inguinal hernia repairs. Multimodal intervention should begin 3 months
after the original hernia repair. Surgical management includes repair of
any recurrence, mesh removal, and/or neurectomy if indicated.
Successful treatment can resolve pain in up to 80 % of patients.
References
1. Bjurstrom MF, Nicol AL, Amid PK, Chen DC. Pain control following inguinal herni-
orrhaphy: current perspectives. J Pain Res. 2014;7:27790.
2. Rosen MJ, Novitsky YW, Cobb WS, Kercher KW, Heniford BT. Combined open and
laparoscopic approach to chronic pain following open inguinal hernia repair. Hernia.
2006;10(1):204.
3. Chatzimavroudis G, Papaziogas B, Koutelidakis I, Galanis I, Atmatzidis S,
Christopoulos P, et al. Lichtenstein technique for inguinal hernia repair using polypro-
pylene mesh fixed with sutures vs. self-fixating polypropylene mesh: a prospective
randomized comparative study. Hernia. 2014;18(2):1938.
4. Ferzli GS, Edwards ED, Khoury GE. Chronic pain after inguinal herniorrhaphy. J Am
Coll Surg. 2007;205(2):33341.
5. Nienhuijs SW, Rosman C, Strobbe LJ, Wolff A, Bleichrodt RP. An overview of the
features influencing pain after inguinal hernia repair. Int J Surg. 2008;6(4):3516.
6. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons Jr R, Dunlop D, Gibbs J,
et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med.
2004;350(18):181927.
pain. Hernia. 2015;19(1):3343.
8. Vuilleumier H, Hubner M, Demartines N. Neuropathy after herniorrhaphy: indication
for surgical treatment and outcome. World J Surg. 2009;33(4):8415.
9. Liem MS, van der Graaf Y, van Steensel CJ, Boelhouwer RU, Clevers GJ, Meijer WS,
et al. Comparison of conventional anterior surgery and laparoscopic surgery for
inguinal-hernia repair. N Engl J Med. 1997;336(22):15417.
10. Burcharth J, Pommergaard HC, Bisgaard T, Rosenberg J. Patient-related risk factors
for recurrence after inguinal hernia repair: a systematic review and meta-analysis of
observational studies. Surg Innov. 2015;22(3):30317. 2014 Sep 30. pii:
1553350614552731.
11. Amid PK. A 1-stage surgical treatment for postherniorrhaphy neuropathic pain: triple
neurectomy and proximal end implantation without mobilization of the cord. Arch
Surg. 2002;137(1):1004.
12. Courtney CA, Duffy K, Serpell MG, ODwyer PJ. Outcome of patients with severe
chronic pain following repair of groin hernia. Br J Surg. 2002;89(10):13104.
roscopic and open preperitoneal inguinal hernia repair. J Am Coll Surg. 2011;213(4):
5316.
23. Mesh Removal for Chronic Pain:
A Review of Laparoscopic and Open
Techniques
Lisa A. Cunningham and Bruce Ramshaw
Introduction
The incidence of chronic pain or discomfort after inguinal hernia
repair is much higher than previously thought, and studies suggest it
could be higher than 50 %. Although most of these patients have mild to
moderate pain, in a review by Bay-Nielsen et al., the rate of chronic pain
after repair that interfered with work or leisure activity was determined
to be 11 %, which has the potential to affect many individuals, as there
are approximately 800,000 repairs performed each year in the United
States [1, 2]. Regardless of the actual incidence, awareness of this prob-
lem is increasing in surgeons and other physicians caring for such
patients, some of whom are desperate for help.
Fortunately, the vast majority of patients who experience chronic
pain symptoms after hernia repair have mild to moderate symptoms and
do not require invasive intervention to maintain a good quality of life.
For patients in whom chronic pain negatively affects their quality of life,
it can threaten the ability to function independently and to work for a
living. This degree of chronic pain can also have detrimental effects on
family and social relationships. It is not uncommon for some patients
with severe chronic pain to verbalize a willingness to commit suicide if
their pain cannot be relieved.
Chronic groin pain after hernia repair is a complex problem involv-
ing many variables, making it difficult to fully understand and treat.
Chronic pain in this patient population can be a result of patient factors,
other diagnoses besides inguinal hernia, the surgical technique and
quality of the repair, the mesh and fixation materials used, and even the

DOI 10.1007/978-3-319-21587-7_23
302 L.A. Cunningham and B. Ramshaw
patients experience and environment in the pre-, peri-, and postopera-

tive period. One single factor may not be the sole cause for chronic pain,
and most often multiple factors play a role. Because of this complexity,
there are many treatment options available to patients, which range from
noninvasive medications and lifestyle modifications to invasive proce-
dures such as nerve blocks and reoperation. The same treatment option
may not benefit each patient, and in some patients, a multimodal
approach is necessary to achieve maximal pain relief.
This chapter will focus on the surgical approach for the management
of chronic groin pain, including mesh removal, although some other
treatment options will be discussed. We will also discuss a team-based
model for providing care that attempts to deal with complex problems
such as chronic groin pain after inguinal hernia repair.
Types of Pain
In general, pain following an inguinal hernia repair can be divided
into two groups, nociceptive and neuropathic [3]. Nociceptive pain is
caused by activation or sensitization of peripheral nociceptors, special-
ized nerve endings that respond to chemical, mechanical, or thermal
stimulus. Neuropathic pain is the consequence of injury to peripheral or
central nervous structures.
Acute pain from surgery is caused by noxious stimulation due to tis-
sue injury and is usually nociceptive. There are two subtypes of acute
pain, somatic and visceral. Visceral pain can occur in the groin when the
intestines become involved and may be due to mesh adherence and/or
erosion into the bowel. The somatic component of nociceptive pain fur-
ther subdivides into superficial or deep pain. Superficial pain is sensed
by unimodal nociceptors in the skin and subcutaneous tissues that evoke
a sharp, pricking type of pain, while deep somatic pain is sensed by
polymodal receptors in the muscles, tendons, joints, and bones that bring
about a long-lasting dull, aching, or burning pain that is typically less
well localized. The ability to localize pain is affected by the intensity
and duration of the painful stimulus. In addition, nociceptors display
sensitization following repeated stimulation that can manifest as an
enhanced response to noxious stimuli or an acquired responsiveness to
non-noxious stimuli. Sensitization of nociceptors is proposed as a key
component of peripheral pain disorders.
Neuropathic pain is due to partial or complete injury to the nerves.
This type of pain is characterized by partial or complete sensory loss or
23. Mesh Removal for Chronic Pain 303
changed sensory function due to damage of the afferent transmission

system. Neuropathic pain may be associated with hyperpathia, including
allodynia (a painful response to harmless stimuli), hyperalgesia (an
exaggerated response to harmful stimuli), and hyperesthesia (increased
response to mild stimulation). In contrast to nociceptive pain, neuro-
pathic pain may persist in the absence of noxious stimuli.
Pain that continues after the normal course of healing from injury or
surgery is termed chronic pain and varies in presentation in each indi-
vidual patient. Chronic pain may be purely nociceptive or neuropathic
or present on a spectrum between the two.
Chronic pain can cause long-term changes in the nervous system
signaling and processing pathways via neural plasticity. Neural plasticity
(or neuroplasticity) is a process in which modulations at the synaptic and
neurotransmitter level or relearning at the cortical level alters previously
established pathways. This mechanism of remodeling is helpful in situa-
tions where relearning is needed, such as when a right-hand-dominant
individual now has to become left-hand-dominant after amputation but
can also contribute to the development of chronic pain and the associated
hyperpathia. Neuroplasticity in conjunction with sensitization makes it
especially challenging to understand, manage, and treat chronic pain.
Causes of Groin Pain

As mentioned in the introduction, the cause(s) of chronic postopera-
tive pain after inguinal hernia repair are many and complex and may not
always be related to the repair itself. Many factors play a role in the
development of chronic groin pain after inguinal hernia repair. The
patient, the surgeon, and the materials used can all contribute to the
development of pain. In fact, preoperative groin pain predicts an
increased likelihood of postoperative chronic groin pain, which is sup-
ported by the findings of Aasvang et al., who also identified preoperative
pain response to heat as a contributing factor to the development of
postoperative pain [4]. In the 2014 update to the European Hernia
Society (EHS) guidelines, level one evidence showed that preoperative
pain and early postoperative pain are independent risk factors for
chronic pain and that postoperative chronic pain diminishes over time,
with the risk of chronic pain after hernia surgery decreasing in incidence
with age [5].
The surgeon may also contribute to the development of pain through
their chosen technique. In many studies, the laparoscopic approach has
been shown to have a decreased incidence of postoperative chronic

groin pain, although in some reports the incidence of chronic groin pain
after laparoscopic repair may still be as high as almost 30 %. In a meta-
analysis of data comparing the incidence of chronic groin pain after
open versus laparoscopic hernia repair, the EHS found no significant
difference; however, one small study found that the severity of the pain
present was less in the laparoscopic group at 10 years post-operation [6].
The sutures, fixation devices, and mesh may also play a significant
role. Chronic groin pain can occur after non-mesh, suture-only inguinal
hernia repair; however, when mesh is used, it can significantly contrib-
ute to the development of chronic groin pain through an inflammatory
response between the mesh and surrounding tissue. The inflammatory
reaction can cause nearby nerves to become entrapped in the mesh
directly or cause traction injury to nerves as tissues become scarred and
contract. The degree of inflammatory response in an individual patient
is impossible to predict at this time, although explanted mesh studies
that may help address this issue are in progress. In some patients, mesh
may be relatively inert, whereas in others it may migrate, fold, or erode
through local structures.
When mesh is used, fixation devices such as tacks and staples can
contribute to the development of pain, particularly if deployed near or
into nerves as they course through the operative field. Sometimes, after
surgical repair, a nerve injury is acutely painful and obvious, leading to
immediate, excruciating pain and paresthesia in the recovery room as
the patient awakens from anesthesia. This is often caused by direct
injury to the nerve from a mesh fixation device. In this case, it may be
appropriate to return to the operating room immediately to remove the
offending fixation device. Familiarities with the course of the nerves at
risk in open and laparoscopic inguinal hernia repair have decreased the
risk of this complication.
Treatment of Chronic Groin Pain After Inguinal

Hernia Repair
There are different levels of pain management that can be used to
help control pain after inguinal hernia repair. They range from noninva-
sive to invasive treatments and may be provided by the surgeon alone or
in conjunction with other care providers such as pain specialists.
Noninvasive Options
For nonsevere or acute pain following inguinal hernia repair, the
initial treatment is rest, ice, and/or heat to the groin, anti-inflammatory
medication, and sometimes a mild narcotic medication. This strategy is
appropriate to try for several weeks unless pain is severe or signifi-
cantly worsens within a short period of time, despite conservative
treatment.
Once chronic pain develops, other medications that may be consid-
ered include antidepressants, serotonin, and norepinephrine reuptake
inhibitors (SNRIs), neuroleptics, antispasmodics, muscle relaxants,
corticosteroids, anticonvulsants, topical local anesthetics, alpha-adrener-
gic agonists, and increased opioid narcotic doses. The use of these medi-
cations to attempt to treat chronic pain and allow a patient to return to
most normal activities may require activity restrictions while the patient
is experiencing chronic pain.
Other noninvasive options include physical therapy and transcutane-
ous electrical neural stimulation (TENS). A TENS unit works by stimu-
lating large epicritic afferent fibers that sense variations in temperature
and touch. Stimulation of these larger fibers outcompetes and potentially
causes complete conduction block of the afferent signal from smaller
pain fibers.
TENS is thought to produce analgesia by stimulating large afferent
fibers. It may have a role for patients with mild to moderate acute pain
and those with chronic low back pain, arthritis, and neuropathic pain.
The gate theory of pain processing suggests that the afferent input
from large epicritic fibers competes with that from the smaller pain
fibers.
Although evidence in support of complementary alternative medi-
cine (CAM) for treatment of chronic groin pain is not conclusive, it may
be a useful adjunct to traditional approaches in certain patients. CAM
may include acupuncture, spinal manipulation, massage therapy, relax-
ation techniques, tai chi, yoga, and herbal supplements.
To obtain optimal treatment success, psychological, emotional, spiri-
tual, and family counseling may also be required to address the psycho-
social factors that may have contributed to the development of chronic
pain or may be a result of the enormous toll that chronic pain can exact
on a persons life, especially when it has been present for a long period
of time.
Invasive Nonsurgical Options

For more severe pain and pain that worsens or persists for more than
a few weeks, it is appropriate to offer the patient more aggressive pain
management. This can include administering inguinal nerve blocks for
diagnostic and potentially therapeutic purposes. If results of the injec-
tion are good, but pain returns, additional nerve blocks may be appropri-
ate. Some patients will obtain sufficient pain relief to return to a full
quality of life after one or more nerve blocks.
Cryoablation and radiofrequency ablation can also be used and
involve placing specialized needles and probes near the affected nerve
and causing coagulation at very low or very high temperatures, respec-
tively. These methods work by destroying the nerves at the site of appli-
cation, thereby providing at least temporary pain relief. It is still possible
for nerve regeneration to occur; long-term studies with definitive evi-
dence is lacking.
Surgical Options
If the pain has persisted for more than 36 months, and/or the pain
is severe or worsening despite other nonsurgical therapies, it is appro-
priate to consider an operation in an attempt to relieve the pain. Prior to
surgery, it is very important to address preoperative, operative, and
potential postoperative complications and factors prior to proceeding
with surgery.
Preoperative Management
In the preoperative setting, it is important to address goals, to assess
the impact of chronic pain on the patients quality of life and for risk
factors for continued pain, and to consider alternatives. It is also impor-
tant to assess and address any comorbidities and to discuss previous
treatment modalities that the patient has tried, if any, as these may help
predict their response to operative intervention.
Not everyone will benefit from surgery, and it is important to convey
to patients that the pain may stay the same, improve only partially, or
could in fact get worse. If neurectomy is to be performed, it is also
important to address postoperative numbness in the distribution of the
affected nerves.
Operative Management
For surgeons who are experienced with pelvic and groin laparos-
copy, a diagnostic laparoscopy is an appropriate first step. A laparo-
scopic view will identify intra-abdominal adhesions and possibly
interstitial and/or recurrent hernias. An interstitial hernia can occur as a
defect through the deeper layers of the groin, but not completely through
all layers of the groin or through the mesh when placed in an open
Lichtenstein-type hernia repair. Sometimes, offending tacks or staples
can be viewed and removed without entering the preperitoneal space.
After intraperitoneal exploration, the preperitoneal space may be
explored laparoscopically to view the cord structures and nerves (genital
and femoral branches of the genitofemoral nerve and lateral femoral
cutaneous nerves) that course along the psoas muscle with and lateral to
the spermatic cord and internal ring and usually posterior to the iliopubic
tract. The location and course of the nerves in the preperitoneal space
can be variable, especially in patients with a previous groin operation(s).
Fixation devices such as sutures, tacks, and/or staples and mesh (placed
laparoscopically or through some open techniques) can be identified in
the preperitoneal space. The laparoscopic exploration of the preperito-
neal space may include repairing an interstitial or recurrent hernia and/
or removal of mesh (including plugs that may be visualized laparoscopi-
cally) and/or fixation devices. If a hernia is found and thought to be the
cause of the pain, the goal of the operation is to provide a durable hernia
repair. If there is no hernia, the goal is to eliminate any adhesions from
the groin and to clear the groin of all foreign materials (mesh and fixa-
tion devices), freeing up the cord structures and nerves. Neurolysis
(freeing up the nerves) is frequently possible with a laparoscopic
approach; however, a neurectomy may be indicated if a nerve is embed-
ded in scar and/or mesh and cannot be freed and/or if the patient chooses
a planned neurectomy during the preoperative shared decision process.
The laparoscopic removal of mesh from the preperitoneal space of
the groin can be a difficult and potentially dangerous procedure, espe-
cially if the previous mesh had been cut and passed behind the cord
structures. Injuries to the cord structures, the iliac vein and artery, the
obturator vessels, the inferior epigastric vessels, and the bladder are all
possible. Even inadvertent bowel injury is possible, especially if there
are bowel adhesions to the groin or mesh. Sometimes it is appropriate to
leave a portion of mesh on one or more of these structures to minimize
the risk of injury.
If the previous hernia repair was done laparoscopically or if an open

approach was performed, during which the mesh was placed completely
into the preperitoneal space, it is possible that a laparoscopic approach
alone will result in the maximal benefit from an operation. The reason
for this is that the nerves in the preperitoneal space are different from
those typically involved if the mesh is located in a more superficial tis-
sue plane (as in a Lichtenstein repair). It is important to note that the
nerves typically involved in neuropathic pain are different for these two
different mesh locations. An open triple neurectomy (addressing the
more superficial nerves) will not likely help relieve the pain from mesh
or fixation devices that are located in the preperitoneal space (potentially
causing neuropathic pain from the deeper nerves). Figures 23.1 and 23.2
illustrate the nerves in the groin and why mesh placed in different loca-
tions can result in different nerve injuries. This also explains why a tra-
ditional open triple neurectomy may not be effective when mesh is
located in the preperitoneal space.
For patients who have had an open inguinal hernia repair with a
technique including placing mesh in the preperitoneal space and in
more superficial locations (plug and patch, Prolene Hernia System,
Ultrapro Hernia System, etc.) or a technique where no mesh is placed
in the preperitoneal space, it is likely that an open groin exploration will
be required to achieve the maximal benefits from a surgical approach.
The open exploration includes removal of mesh and any other material
that may be causing pain. Nerves that course in the groin in the inter-
muscular location (the iliohypogastric, ilioinguinal, and genital branch
of the genitofemoral) may be divided and the distal ends implanted into
muscle. There is some debate about whether to search for and divide all
nerves or only the nerves involved in the scar tissue, mesh, or other
fixation devices. Because of the difficulty in finding nerves outside of
the field of dissection and the potential to cause complications, it has
been our practice to divide only the nerves (neurectomy) or free nerves
(neurolysis) that are involved in the scar tissue, mesh, and/or fixation
devices, but not to look for additional nerves in otherwise normal-
appearing tissue. After the open approach is completed, the groin is
closed with three layers of absorbable suture, and then the skin is closed
with a subcuticular stitch.
At this point in our experience, we have not placed a permanent
synthetic, absorbable synthetic, or biologic mesh after mesh removal for
pain, regardless of whether the procedure was laparoscopic only or a
laparoscopic and open combined procedure. We have not placed a mesh
during this operation in an attempt to minimize the potential of causing
Ilioinguinal nerve
Pain
Doom
Fig. 23.1. Nerves in the left groin (anterior view and laparoscopic view).
Preperitoneal Mesh:
Lateral femoral
cutaneous
Femoral branch of the Lichtenstein mesh
genitofemoral placement:
Genital branch of the Iliohypogastric
genitofemoral Ilioinguinal
Genital branch
of the genitofemoral
Fig. 23.2. Mesh placement (preperitoneal and Lichtenstein) and the nerves
potentially at risk for the left groin.
additional or new pain from a mesh and/or from mesh fixation, when the
goal of the operation is to relieve pain. The exception to this is when an
interstitial or recurrent hernia is found at laparoscopy. If a hernia defect
is identified after a laparoscopic mesh removal, a laparoscopic primary
suture repair is performed. For all procedures that include open mesh
removal, a three-layer groin reconstruction is performed using absorb-
able sutures.
Postoperative Management
The patient is often discharged the same day or within 2448 h of the
operation, unless there are complications. However, for patients on high
dosages of opioid agonists, a longer hospital stay for pain control and
monitoring may be required. In this early postoperative period, the ini-
tial treatment of pain is identical to the treatment of nonsevere or acute
groin pain and includes rest, ice, and/or heat to the groin, anti-
inflammatory medication, and a mild narcotic medication. A bowel
regimen to prevent constipation and bloating may also be helpful. It is

often helpful to provide the patient with a multitude of pain medication
options and then allow them to choose which works best for them, as
they may already know from previous experience. Pain control in the
immediate postoperative period is essential, as some studies have shown
an increased risk for developing chronic pain in patients whose postop-
erative pain scores are high. Perioperative multimodal pain management
inducing transversus abdominis plane (TAP) block and intra-op block
with long-acting local anesthetic may help to minimize pain control
issues in the immediate postoperative period.
Some patients will have continued difficulty with pain control fol-
lowing surgery, especially if they were taking high doses of opioid medi-
cations prior to the operation. All of the pain management techniques
previously discussed can be considered for use in the postoperative
course. Typically, as the pain and inflammation from the operation
resolve, the patient will become increasingly aware of the results from
the operation and will report that their improvement levels off 24
months after the operation. Following surgery, it is important to track a
patients progress for improvement. It may help to compare a patients
preoperative assessment of pain on a standardized questionnaire to their
postoperative pain to examine for objective changes.
Postoperative Complications
In the early postoperative period, complications include wound
infection, seroma, and hematoma. As mentioned, postoperative pain
control may be difficult.
The long-term complications pertinent to this procedure include
hernia recurrence and inadequate resolution of pain. Nonsurgical pain
management should be continued and adjusted accordingly for pain that
is not resolved in an attempt to improve a patients quality of life. A
continued search for factors that contribute to the development of
chronic groin pain after inguinal hernia repair is essential to predict
subpopulations at risk for this problem and to potentially alter treatment
options based on new knowledge when the concept of predictive analyt-
ics and complex systems data management is applied [see Chap. 45,
Value-Based Clinical Quality Improvement (CQI) for Chronic Groin
Pain after Inguinal Hernia Repair].
For the patient who has a hernia recurrence after an operation to

relieve pain from a prior hernia repair, the decision to undergo another
hernia repair may be a difficult one. If another repair is performed, con-
sideration should be given to the approach (open or laparoscopic) and to
the choice of mesh, including options that are not permanent, such as
resorbable synthetic and biologic meshes. In this situation, involving the
patient in a shared decision process to determine the technique and
materials to be used may be helpful to give the patient some control in
determining their choice for hernia repair.
Prevention of Chronic Groin Pain After Inguinal

Hernia Repair
There have been many attempts to minimize chronic pain over the
years, mostly aimed at altering surgical technique. Previous studies have
shown mixed results in attempting to prophylactically identify and
divide the ilioinguinal, iliohypogastric, and/or genital branch of the
genitofemoral nerves during open inguinal hernia repair. In a multi-
center prospective study by Alfieri et al., identification and preservation
of nerves are directly correlated to the development of chronic pain
postoperatively [7].
The laparoscopic approach compared to open inguinal hernia repair
has some of the strongest evidence showing a decrease in acute and
chronic pain based on several studies. However, some studies have
shown a minimal difference in pain after the first 2448 h, and some
studies show increased severity of pain with a laparoscopic repair.
The other most studied factors in the prevention of chronic pain are the
mesh and fixation devices used. Several studies have evaluated light-
weight mesh to look for a decreased incidence of chronic pain. Some older
studies showed inconclusive results or only slight improvement when
using lightweight mesh. However, many of these studies also showed a
slight increase in hernia recurrence in patients with a lightweight mesh.
In two recent studies comparing open and laparoscopic repair, light-
weight mesh was associated with a decreased risk of developing chronic
groin pain and for the development of other groin symptoms, including
stiffness and the sensation of a foreign body, and was not associated with
increased risk of hernia recurrence [8, 9]. Decreasing or eliminating tack,
staple, and suture fixation, or using glue, has also shown some potential to
decrease pain, but with a potential for an increase in recurrence rate.
One other aspect to consider is pain management in the postoperative

period as mentioned previously. Some texts suggest that good pain con-
trol initially may help to reduce the development of chronic pain by
preventing chronic pain pathways from developing through sensitization
and neuroplasticity. For this reason, we have developed a multimodal
pain treatment protocol in conjunction with our anesthesiologists that
includes TAP blocks and controlling nausea to prevent emesis immedi-
ately postoperative to reduce strain on newly reconstructed groins.
Improvements in preoperative preparation and maximizing bowel func-
tion can also help improve outcomes. A summary of perioperative mul-
timodal management strategies is presented in Table 23.1.
Incorporating Systems Science Solutions into

the Management of Chronic Groin Pain After
Inguinal Hernia Repair
The attempts to isolate and improve one variable and the limited suc-
cess with this strategy highlight the fact that chronic pain is a complex
problem that can rarely be solved with a simple solution. Complex
problems require a systems approach that includes identifying and defin-
ing processes and variables, including outcomes that measure value
(including quality and satisfaction measures as well as costs for the
entire cycle of care). It is important to remember that each person is dif-
ferent and that what works for one may have deleterious effects on
another; it may have no benefit or cause harm and therefore may be
wasteful.
In our approach to treatment using principles of systems and com-
plexity science, we have built a team around hernia disease, with the
ultimate goal of creating more teams around other definable patient
groups. This places all the focus on the patient process and value-based
outcomes generated by the process.
Currently, our hernia team includes surgeons, anesthesiologists,
nurses, a patient care manager, care coordinators, a clinical quality
improvement manager, a biologic/materials engineer, a mechanical
engineer, residents, and other team members. Former patients and their
family members participate and help provide care for current patients
Table 23.1. Options for multimodal perioperative management of patient who undergo surgery for the treatment of chronic groin pain
314
after inguinal hernia repair.

Pre-op Intra-op Post-op
Prep/medical/emotional Weight loss/exercise/nutrition General anesthesia Activity as tolerated
Anesthesia Smoking cessation Low pressure Many small meals
Counseling Pneumoperitoneum/AirSeal Ice/heat/support
(for lap cases)
GI function Bowel cleansing Colace
Liquids/Colace/magnesium Magnesium
Entereg Entereg
Medications (up to one week Lyrica Lyrica
pre-op and post-op 35 days) Neurontin Neurontin
Opioid agonist (IV/oral)
L.A. Cunningham and B. Ramshaw
Medications (immediately Ofirmev Toradol Toradol

pre-op and post-op in hospital) Ibuprofen Ibuprofen
Ofirmev Ofirmev
Nerve block TAP: Long-acting local anesthetic Additional local infiltration
Decadron with long-acting local
Buprenorphine Xylocaine gel for bladder
Consider epidural catheter
Antiemetic therapy H2-blocker, Reglan, Zofran Zofran in PACU

(prior to end of case), Emend
(for high-risk PONV)
TAP Transversus abdominis plane, PONV Postoperative nausea and vomiting, PACU Postanesthesia care unit
and their family members by providing support and sharing their experi-
ences. By including others outside of the core hernia team, we are able
to participate in hernia care communities through face-to-face meetings,
video and teleconferencing, and Internet social networking. The clinical
portion of our team cares for patients through their dynamic care process
and allows for shared decision making with the patient at multiple steps
in the care process.
The first step in our process involves interaction with the clinical
manager or care coordinator, who begins to develop a caring relation-
ship with the patient and his or her family. From this interaction, we get
to develop a sense of the person as well as gather relevant clinical data.
Prior to having a clinical visit, it may beneficial for the patient to see
other providers first if there are areas of concern identified by the patient
care manager. Also, allowing patients to speak with former patients who
have suffered with similar types of symptoms can be very beneficial.
After the initial clinic visit, more options may be considered or surgery
may be offered. The patients care is followed throughout the hospital
and for the entire length of recovery by team members until the patient
returns to a good quality of life.
The clinical quality improvement portion of the hernia team is
focused on objective outcome measures and identification of anomalies
to learn and improve. The analysis of explanted synthetic hernia mesh is
the largest clinical quality improvement project currently in progress for
our hernia team. Many of these meshes have been explanted from
patients who have suffered from chronic groin pain after inguinal hernia
repair. By defining dynamic care processes and identifying and measur-
ing quality, satisfaction, and financial outcome measures, the objective
of our hernia team is to generate clinical quality improvement data that
will help identify ways to improve the value of care delivered.
Summary
Chronic groin pain after inguinal hernia repair is a complex problem
that can cause significant impairment to those who are affected as well
as for their loved ones. It is a difficult problem to treat and takes a tre-
mendous toll on the individual who suffers. For patients with severe,
lasting groin pain or those whose quality of life is impacted despite
noninvasive or minimally invasive measures to control pain, it may be
appropriate to offer a surgical option for treatment. Surgical treatment
includes a diagnostic laparoscopy to look for intra-abdominal adhesions,
interstitial and recurrent hernias, and foreign body materials in the
preperitoneal space. For previous laparoscopic repairs and for those

open repairs that result in mesh placement in the preperitoneal space,
this may be all that is required to achieve maximal improvement from an
operation. For most open inguinal hernia repair techniques, an additional
open groin incision may be necessary to achieve maximal improvement
from an operation. Removal of all foreign body materials and division
and/or lysis of all involved nerves with a three-layer groin closure using
absorbable suture can be accomplished through the open groin incision.
Even when the original cause of the pain has been successfully elimi-
nated at operation, complete pain relief may not be achieved and addi-
tional pain management may be required. Because of the complexity of
this problem and the psychological and emotional impact that can occur,
this problem is best addressed by a multidisciplinary team.
References
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results of 10 year follow-up. Hernia. 2012;16(6):63540.
7. Alfieri S, Rotondi F, Di Giorgio A, Fumagalli U, Salzano A, Di Miceli D. Influence of
preservation versus division of ilioinguinal, iliohypogastric and genital nerves during
open mesh herniorrhaphy: prospective multicentric study of chronic pain. Ann Surg.
2006;243(4):5538.
8. Sajid MS, Leaver C, Baig MK, Sains P. Systematic review and meta-analysis of the use
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24. Open Triple Neurectomy
Ian T. MacQueen, David C. Chen,

and Parviz K. Amid
Background
Recurrence rates after inguinal hernia repair have improved since the
adoption of tension-free techniques and the routine use of mesh.
However, postherniorrhaphy chronic pain still represents a substantial
burden of morbidity for patients after inguinal hernia repair. Depending
upon definition, the rate of postherniorrhaphy chronic pain reported in
the literature varies widely, from 0 % to upward of 60 % [1, 2]. The
Swedish Hernia Registry reports that severe or debilitating posthernior-
rhaphy chronic pain occurs at a rate of between 5 and 7 % [3].
Development of inguinodynia is independent of the method of hernia
repair [46], but an in-depth understanding of the causes of pain, groin
neuroanatomy, and technical aspects of the initial operation is necessary
to successfully manage this complication [68]. These factors determine
the operative options available to address chronic pain after inguinal
hernia repair. Effective management is needed, given the person and
societal consequences of postherniorrhaphy chronic pain on quality of
life, disability, and healthcare utilization.
Pain Classification
Postherniorrhaphy inguinodynia is classically divided into two broad
categories, nociceptive pain and neuropathic pain. Nociceptive pain is
the result of tissue injury and local inflammatory reaction. It is mediated
by endogenous nociceptive molecules and their action on nociceptors.
Neuropathic pain, in contrast, results from direct nerve injury. In the
postherniorrhaphy patient, neuropathic pain symptoms may include

DOI 10.1007/978-3-319-21587-7_24
320 I.T. MacQueen et al.
inguinodynia radiating to the scrotum or femoral triangle, paresthesia,

allodynia, hyperpathia, hyperalgesia, hyperesthesia, hypoesthesia, or
positive Tinel sign. The mechanisms of nerve injury include indirect or
direct structural damage and entrapment injuries, caused by suture,
folded mesh or meshoma, or fixating devices. In practice, nociceptive
pain and neuropathic pain are not discrete categories but exist on a spec-
trum with significant overlap between the two. The complexity of diag-
nosis is increased by social, genetic, patient, and psychological factors.
Anatomy
The neuroanatomy of the groin is complex and highly variable from
the retroperitoneal lumbar plexus to the terminal branches exiting
through the inguinal canal [9, 10]. Familiarity with this anatomy is cen-
tral to avoiding nerve injury or entrapment. Evidence suggests that the
rate of postherniorrhaphy chronic pain can be reduced to less than 1 %
by careful identification and handling of the relevant nerves and by
preventing their injury or direct contact with mesh [5]. The three nerves
most commonly implicated in postherniorrhaphy chronic pain are the
ilioinguinal nerve (IIN), the genital branch of the genitofemoral nerve
(GFN), and the iliohypogastric nerve (IHN) (Fig. 24.1) [11]. Additionally,
the main trunk of the GFN, the femoral branch of the GFN, and the
lateral femoral cutaneous nerve (LFC) may be involved, especially if the
original repair was done via a laparoscopic or open preperitoneal
approach (Fig. 24.2) [12]. Understanding the potential location of nerve
injury based upon mechanism, subjective symptoms, and physical
examination (dermatomal mapping, quantitative sensory testing) is cru-
cial to successful operative remediation.
The IIN lies over the anterior surface of the spermatic cord and is
covered by the investing fascia of the internal oblique muscle. During
inguinal hernia repair, this fascia protects the nerve from direct contact
with the mesh and should not be disrupted. Contrary to prior teaching,
dissection of the IIN from the cord should be avoided because destruc-
tion of this protective fascia increases the risk of perineural scarring or
entrapment by the implanted mesh.
The genital branch of the GFN enters the deep inguinal ring and
traverses the inguinal canal within the spermatic cord. It is covered by
the deep cremasteric fascia, which protects it from contact with the
mesh. Its location is most easily identified by its close proximity to the
external spermatic vein, which appears as a blue line immediately adja-
24. Open Triple Neurectomy 321
Fig. 24.1. Inguinal neuroanatomy (From Chen et al. [11] with kind permis-
sion Springer Science + Business Media).
cent to the nerve. When isolating the cord, care must be taken to visual-
ize the nerve and maintain its position with the other cord structures as
the cord is separated from the inguinal floor. The deep cremasteric
fascia should be kept intact to avoid perineural scarring or contact
between the nerve and mesh.
The IHN lies between the internal and external oblique muscle lay-
ers of the abdominal wall. The investing fascia of the internal oblique
protects the nerve from contacting the mesh. The IHN can be identified
by opening the anatomic cleavage between the internal and oblique lay-
ers high enough to expose the internal oblique aponeurosis. This simple
maneuver allows for easy identification of the portion of the nerve that
lies superficial to the internal oblique aponeurosis. There is an addi-
tional, more proximal segment of the nerve that lies within the internal
oblique muscle. This intramuscular segment is commonly injured
because it is not visible during hernia repair. Suturing the internal
Fig. 24.2. Retroperitoneal neuroanatomy (From Wagner et al. [12], with kind
oblique muscle to the inguinal ligament or mesh implant can potentially

result in injury or entrapment of this segment. In approximately 5 % of
patients, the IHN runs deep to the internal oblique aponeurosis, passing
directly through the internal and external oblique layers simultaneously
and is not visible within the inguinal canal at the time of initial repair,
placing this nerve at risk [7]. This should be noted by the operating
surgeon at the visible point of its exit, and care should be taken to avoid
passing suture or fixation material through the internal oblique aponeu-
rosis in the anticipated course of this nerve, risking injury or entrap-
ment of the underlying nerve.
Surgical Management of Neuropathic Pain

Operative management for pain after inguinal surgery has been
reported as early as 1942 with Magee describing genitofemoral cau-
salgia as a source for post-inguinal surgery pain [13]. Selective IIN,
IHN, and GFN neurolysis or neurectomy, removal of mesh and fixa-

tion material, and revision of the prior herniorrhaphy are common but
less effective options for treatment [1416]. Neurolysis, which does
not address ultrastructural changes of nerve fibers, has limited effi-
cacy and is not recommended [5]. Simple removal of entrapping
sutures or fixating devices while leaving the injured nerves behind is
also inadequate [5]. Selective single or double neurectomy may be
effective for some patients, but does not address ultrastructural
changes or microscopic neuromas of seemingly normal-appearing
nerves during reoperation [1416]. For patients with high probability
of isolated neuropathy based on history, symptoms, mechanism (e.g.,
IHN entrapment in a Pfannenstiel incision, neuropathy from isolated
trocar site, or LFC injury from lateral tack placement), physical
examination including dermatomal mapping/distribution, and sensory
testing, selective neurectomy is reasonable in experienced hands.
However, for most anterior hernia repairs and posterior approaches
utilizing fixation, multiple nerves may be involved, and triple neurec-
tomy is more effective.
From a technical perspective, reoperation in the scarred field
increases difficulty and morbidity for subsequent remedial operations.
Anatomically, the significant variation and cross-innervation of the ingui-
nal nerves in the retroperitoneum and inguinal canal make selective
neurectomy less reliable [5]. A recent study by Bischoff et al. described
their experience with selective neurectomy in 54 patients with chronic
pain after open mesh repair [17]. The IIN, IHN, and GFN were identi-
fied in 40 (74 %), 20 (37 %), and 13 (24 %) patients, respectively, illus-
trating the challenge of reoperative nerve identification in experienced
hands. It is difficult to precisely isolate the inguinal nerves involved, and
frequently there is more than one nerve implicated in postherniorrhaphy
chronic neuropathic pain. Triple neurectomy of the IIN, IHN, and geni-
tal branch of the GFN, pioneered in our institute in 1995, is currently a
universally accepted surgical treatment for neuropathic pain refractory
to conservative measures and is arguably the most effective option [5,
18]. Our experience has included over 700 patients using an open
approach with a success rate of over 85 % and 50 selected cases using a
laparoscopic retroperitoneal approach with a 90 % success rate.
Operative neurectomy in conjunction with removal of meshoma, when
present, provides effective relief in the majority of well-selected patients
with refractory neuropathic inguinodynia [5].
Timing and Patient Selection
A systematic approach is imperative for proper identification of

patients suited for operative intervention. Recommended timing of sur-
gical intervention for postherniorrhaphy pain unresponsive to standard
nonsurgical modalities is 6 months to 1 year after the original hernia
repair [1, 5]. Failure of conservative measures, in of itself, is not an
indication for further surgery. Successful outcomes are entirely depen-
dent upon choosing patients with discrete neuroanatomic problems ame-
nable to surgical correction. A thorough preoperative evaluation should
include symptomatology, review of the prior operative report for tech-
nique (specifically, the type of repair, type of mesh used, position of the
mesh, method of fixation, and nerve handling), imaging to assess for
meshoma or other anatomic abnormalities, and response to prior interven-
tions [5, 19]. The patients most likely to benefit from operative neurectomy
are those with neuropathic pain isolated to the inguinal distribution that
was not present prior to the original operation and that showed improve-
ment with diagnostic and therapeutic nerve blocks.
Risks of Surgery
Operative remediation of inguinodynia carries risk of complications,
including refractory pain, exacerbation of underlying pain, deafferenta-
tion hypersensitivity, and anticipated permanent numbness involving
unilateral labial numbness and potential associated sexual dysfunction
in women. Risks related to reoperation in the scarred field include bleed-
ing, disruption of the prior hernia repair, recurrence, vascular injury, and
testicular loss. These risks should be discussed with the patient and
documented prior to proceeding to operation.
Technique
Triple neurectomy involves resecting segments of the IIN, the genital
branch of the GFN, and the IHN from a point proximal to the original
surgical field to the most distal accessible point. The main trunk of the
GFN over the psoas muscle may also be resected in the case of pain after
open or laparoscopic preperitoneal hernia repair, as described below
Fig. 24.3. Identification and neurectomy of ilioinguinal nerve.
[20]. This chapter focuses on open triple neurectomy with laparoscopic

triple neurectomy described separately. Exposure for open triple neurec-
tomy typically utilizes the same incision as the original anterior repair.
If the original repair was done laparoscopically, a standard inguinal inci-
sion is used. Extending the incision more cephalad and lateral than typi-
cal for a hernia repair facilitates the exposure of the proximal portions
of the IIN and IHN. Additionally, this allows for access to the inguinal
canal proximal to scarred mesh within the canal.
The IIN is typically identified lateral to the deep inguinal ring and
divided as proximally as possible (Fig. 24.3). The IHN is identified in
the plane between the internal and external oblique aponeurosis. It is
traced proximally to its intramuscular segment and divided proximal to
the field of the original repair. Including the intramuscular segment in
the resection avoids missing an occult injury in this segment. If the IHN
is noted to be one of the subaponeurotic variants described previously,
the internal oblique aponeurosis is split proximal to the point where the
nerve traverses both internal and external oblique aponeurosis, and this
hidden portion of the nerve is divided (Fig. 24.4). The genital branch of
the GFN is identified adjacent to the external spermatic vein under the
cord or through the lateral crus of the internal ring. In a standard triple
neurectomy for pain after anterior repairs, it is ligated and divided at the
internal ring (Fig. 24.5).
Fig. 24.4. Identification and neurectomy of iliohypogastric nerve.
Fig. 24.5. Identification and neurectomy of genital nerve in the inguinal canal.
While there is no scientific consensus for handling the cut ends of the
nerves, ligation of the cut nerve ends closes the neurilemma and may
reduce neuroma formation. Our standard practice includes burying the
proximal nerve stump into surrounding muscle to protect it from the
inflammation and scarring of the operative field.
Chronic Pain After Preperitoneal Hernia Repair

The preperitoneal nerves most commonly implicated in posthernior-
rhaphy neuropathy are the main trunk, femoral branch, and the preperi-
toneal segment of the genital branch of the GFN. These nerves lack a
fascial covering and are therefore at increased risk of injury if allowed
to contact mesh. Neuropathic injuries of these nerves can be addressed
by laparoscopic triple neurectomy (discussed in Chap. 25) or open
extended triple neurectomy, which includes segmental resection of the
main genitofemoral trunk in the retroperitoneum [20]. For open
extended triple neurectomy, the exposure utilizes the same split made in
the internal oblique muscle during resection of the intramuscular seg-
ment of the IHN. The underlying transversus abdominis muscle is simi-
larly split, and the parietal peritoneum is swept medially and cephalad
to expose the psoas muscle and the main trunk of the GFN as it courses
along the body of the muscle (Fig. 24.6). Resecting the GFN at this level
additionally addresses neuropathic pain due to injury of the main trunk,
the femoral branch, or the preperitoneal segment of the genital branch,
which are inaccessible during standard triple neurectomy.
Fig. 24.6. Identification and neurectomy of retroperitoneal genitofemoral nerve

trunk over psoas muscles (extended triple neurectomy).
Postherniorrhaphy Orchialgia
Occasionally, postherniorrhaphy orchialgiaaccompanies inguino-

dynia, and it is important to distinguish testicular pain from the scrotal
pain often associated with genital neuralgia in inguinodynia. If true
orchialgia exists, it will not respond to triple neurectomy alone.
Postherniorrhaphy orchialgia is complex and is likely caused by neu-
ropathy of the paravasal nerve fibers and the autonomic fibers that
accompany the cord structures. In patients identified preoperatively,
segmental resection of the lamina propria of the vas deferens, which
includes the paravasal nerves, may be performed at the time of triple
neurectomy. This procedure has been successful, but the results are
inconsistent [19]. In orchialgia after preperitoneal mesh repair, vas neu-
rolysis with open triple neurectomy is ineffective, as the injury is proxi-
mal to this intervention. Accessing the autonomic nerve plexus proximal
to the mesh may be accomplished laparoscopically or robotically in
these cases of preperitoneal repair (Fig. 24.7).
Results
Our experience includes over 700 patients who have undergone
open triple neurectomy. In patients whose original repair did not enter
the preperitoneal space, we now achieve satisfactory resolution of
Fig. 24.7. Vas deferens and autonomic nerve plexus.

postherniorrhaphy inguinodynia in 95 % of patients. These results rep-

resent patients whose triple neurectomy included resection of the intra-
muscular segment of the IHN, a technique we have employed since
2004. Prior to this modification, only the extramuscular portion of the
IHN was resected, with an associated success rate of 85 % [7].
We have performed open extended triple neurectomy including the
main trunk of the GFN in 40 patients with chronic inguinodynia follow-
ing preperitoneal mesh inguinal hernia repair, with over 90 % of these
patients experiencing significant improvement of their pain. We have
additionally combined paravasal neurectomy with triple neurectomy for
24 patients with postherniorrhaphy groin pain and orchialgia. The orchi-
algia was eliminated in 83 % of patients. These limited series suggest
that both procedures are safe and effective, though additional study is
indicated before they become standard practice.
Conclusion
There is no level 1 or 2 evidence regarding the operative management
of inguinodynia, and best available recommendations are derived from
case reports, case series, expert opinion, and expert consensus [5, 18].
Our experience with over 750 triple neurectomy operations (700+ open,
50+ laparoscopic) performed by two surgeons (PKA and DCC) is the
largest single-institution experience. Since the inception of the
Lichtenstein Hernia Institute in 1984, we have additionally evaluated
and treated thousands of patients without surgery, with mesh removal,
selective neurectomy, quadruple neurectomy, and all other variants of
therapy. Triple neurectomy, pioneered in our institute, remains the most
definitive and common remedial operation performed. The operative
principles of open triple neurectomy involve segmental resection of the
IIN, the genital branch of the GFN, and the IHN proximal to the site of
injury and resection of the intramuscular portion of the IHN. For
patients with a prior preperitoneal hernia repair, open triple neurectomy
must be extended to the retroperitoneum to include the main trunk of the
GFN, or this nerve can be addressed during laparoscopic triple neurec-
tomy. Patients with concurrent postherniorrhaphy orchialgia may benefit
from combining paravasal neurectomy with open triple neurectomy.
With success rates of over 90 %, triple neurectomy provides the greatest
chance of improving pain and symptoms and is the most definitive
option to remediate these problems in an operative field that will ideally
never be entered again. Outcomes are highly dependent upon patient

selection and experience, and a logical plan of care must be tailored for
each patient based upon mechanism, symptoms, anatomy, and technical
considerations. Prevention is by far the most important and effective
means of preventing inguinodynia and improving patient outcomes.
References
2. Hakeem A, Shanmugam V. Inguinodynia following Lichtenstein tension-free hernia
repair: a review. World J Gastroenterol. 2011;17(14):17916.
3. Franneby U, Sandblom G, Nordin O, Nyren O, Gunnarsson U. Risk factors for long-
4. Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after
inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg. 2001;233(1):
17.
Doglietto GB. International guidelines for prevention and management of post-operative
chronic pain following inguinal hernia surgery. Hernia. 2011;15(3):23949.
6. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. Cause and prevention of
postherniorrhaphy neuralgia: a proposed protocol for treatment. Am J Surg.
1988;155(6):78690.
7. Amid PK, Hiatt JR. New understanding of the causes and surgical treatment of posth-
8. Aavsang E, Kehlet H. Surgical management of chronic pain after inguinal hernia
repair. Br J Surg. 2005;92(7):795801.
9. Klaassen Z, Marshall E, Tubbs RS, Louis Jr RG, Wartmann CT, Loukas M. Anatomy
of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve
contributions. Clin Anat. 2011;24(4):45461.
10. Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemo-
ral nerve: implications for the treatment of groin pain. Plast Reconstr Surg.
2001;108(6):161823.
11. Chen DC, Amid PK. Technique: Lichtenstein. In: Jacob BP, Ramshaw B, editors. The
SAGES manual of hernia repair. New York: Springer; 2013. p. 4154.
p. 1495521.
13. Magee RK. Genitofemoral causalgia: (a new syndrome). Can Med Assoc
J. 1942;46(4):3269.
14. Aavsang E, Kehlet H. The effect of mesh removal and selective neurectomy on per-
sistent postherniotomy pain. Ann Surg. 2009;249(2):32734.
15. Zacest AC, Magill ST, Anderson VC, Burchiel KJ. Long-term outcome following ilioin-
guinal neurectomy for chronic pain. J Neurosurg. 2010;112(4):7849.
16. Loos MJ, Scheltinga MR, Roumen RM. Tailored neurectomy for treatment of posth-
erniorrhaphy inguinal neuralgia. Surgery. 2010;147(2):27581.
Hernia. 2013;17(3):33945.
pain. Hernia. 2015;19(1):3343.
roscopic and open preperitoneal inguinal hernia repair. J Am Coll Surg.
2011;213(4):5316.
25. Laparoscopic Triple Neurectomy
Stephanie A. Kingman, Parviz K. Amid,

and David C. Chen
Introduction
Inguinal hernia repair, with the use of mesh and tension-free tech-
niques, has seen significant improvements in outcomes and decreased
recurrence rate. However, postherniorrhaphy chronic pain remains a
considerable complication affecting as many as 63 % of patients after
surgery [13]. Such pain interferes with the physical activity, social
interactions, employment, and productivity of 68 % of patients after
herniorrhaphy, causing notable burden on the individual and society
[26].
In addition to pain from hernia recurrence, inguinodynia can be
caused by factors relating to nociceptive or neuropathic pain [712].
Nociceptive pain is induced by tissue injury and inflammation from
forceful tissue handling and retraction or from foreign material such as
meshoma. Neuropathic pain is provoked by direct nerve injury, perineu-
ral scarring, or entrapment injuries by suture, fixating devices, or mesh.
Classically, it presents as inguinodynia with radiation to the scrotum/
femoral triangle, hyperalgesia, allodynia, hyper- or hypoesthesia, and
paresthesias. There is no clear distinction between these two types of
pain, and the diagnosis is often complicated by genetic, psychological,
social, and economic factors [25, 9].
Nonsurgical management, including pharmacologic, interventional,
and behavioral therapies, is successful in many patients. Nonetheless,
operative intervention is necessary in some cases. The most definitive
and effective remedial surgery for refractory neuropathic inguinodynia
is triple neurectomy of the ilioinguinal, iliohypogastric, and genitofemo-
ral nerves. This technique, described by us in 1995 with further technical

DOI 10.1007/978-3-319-21587-7_25
334 S.A. Kingman et al.
modifications in recent years, has yielded response rates of 8597 %

[1315].
Triple neurectomy, whereby the three nerves are resected proximal to
the area of the initial hernia repair and as distal as possible, is conven-
tionally done via an open anterior approach [13, 16]. The open operation
has limitations, as it may be difficult to identify and access the three
inguinal nerves in the reoperative field, and there is considerable neuro-
anatomic variation especially distal to the retroperitoneum within the
inguinal canal. Operating in scarred tissues increases the risk of disrupt-
ing the previous hernia repair as well as injuring the spermatic cord and
testicle. In patients whose initial operation was a preperitoneal (open or
laparoscopic) repair, accessing the nerves proximal to the pathology is
not always possible from an inguinal approach. These challenges, in
addition to causing surgical pain in an already hypersensitive area, make
a minimally invasive retroperitoneal approach very desirable.
Preoperative Workup
The recommended timing of surgery for chronic postherniorrhaphy
pain not controlled with conservative treatments is 6 months to 1 year
after the initial inguinal hernia repair. Prior to surgery, a detailed and
methodical preoperative workup is recommended to define the potential
causes of a patients groin pain. This should involve characterization of
symptoms, assessment of prior conservative pain management with
pharmacologic and interventional therapies, as well as imaging to evalu-
ate for presence of meshoma or other anatomic abnormalities. Previous
operative reports should be analyzed for technique such as type of
repair, presence, type and position of mesh, method of fixation, and
identification and handling of nerves, as these factors would influence
the type of intervention and remedial surgery possible. Patients should
also have multidisciplinary treatment, including evaluation by a pain
specialist. All patients considered for surgery should undergo diagnostic
and therapeutic nerve blocks of the ilioinguinal, iliohypogastric, and
genitofemoral nerves.
Finally, it is imperative to thoroughly discuss and document possible
benefits and risks of remedial surgery with patients, including failure to
identify or resect all three nerves, persistent pain despite successful neu-
rectomy due to various etiologies of pain, permanent numbness in the
corresponding dermatomal distributions, abdominal wall laxity second-
ary to partial denervation of the oblique muscles, numbness in the labia
25. Laparoscopic Triple Neurectomy 335
in females that may alter sexual sensation, testicular atrophy, and loss of
the cremasteric reflex in males. The surgery may cause hypersensitivity
from deafferentation that is typically temporary, though its course is
unpredictable and may be permanent. This technique does not alter noci-
ceptive pain caused by tissue injury, meshoma, or testicular pain [16].
Surgical Approach
Laparoscopic retroperitoneal triple neurectomy is a 1-stage procedure
to access the main trunks of the ilioinguinal, iliohypogastric, and geni-
tofemoral nerves in the lumbar plexus [17]. This access allows the
nerves to be resected proximal to any potential site of peripheral neu-
ropathy from the previous surgical field.
The patient is positioned in lateral decubitus position, and the table is
flexed to open the space between the iliac crest and costal margin. A
12-mm transverse incision is made in the midaxillary line 34 cm above
the iliac crest (Fig. 25.1). The external oblique fascia is incised, and the
oblique muscles are separated until the retroperitoneum is accessed. An
oval dissecting balloon can be placed into this potential space and
inflated under direct visualization. This mobilizes the peritoneum in the
avascular plane, rotating the viscera medially, and exposes the retroperi-
toneal space. The dissecting balloon is then exchanged with a 12-mm
balloon trocar, and carbon dioxide is used to insufflate to a pressure of
15 mmHg. Another 5-mm port is inserted 2 cm medially under direct
visualization. The retroperitoneal fat pad is then dissected medially
using laparoscopic cautery or a vessel-sealing device to expose the psoas
and quadratus lumborum muscles.
The lumbar plexus should be defined before any neurectomy is per-
formed (Fig. 25.2) [18]. The subcostal nerve can first be identified at the
T12 costal margin (Fig. 25.3). The iliohypogastric and ilioinguinal
nerves, frequently sharing a common trunk, can then be seen overlying
the quadratus muscle at L1 (Fig. 25.4) [19, 20]. The lateral femoral cuta-
neous nerve originating at L3 is identified lateral to the psoas, crossing
the iliacus muscle below the iliac crest (Fig. 25.5). The femoral nerve can
also be found lateral and deep to the psoas muscle, but does not require
specific dissection. The dissection is then continued toward the groin
where the genitofemoral nerve trunk can be noted running over the psoas
muscle (Fig. 25.6). Similar to the iliohypogastric and ilioinguinal nerve
trunks, the genital and femoral nerve trunks have considerable variability
and often have separate trunks. If the dermatomal distribution of the
Fig. 25.1. Trocar placement and operative positioning.
Fig. 25.2. Retroperitoneal lumbar plexus (From Wagner et al. [18], with kind
femoral branch of the GFN is not affected, a separate femoral trunk

should be preserved when found. Of note, the ureter and iliac vessels
should be identified medial to the psoas and protected (Fig. 25.7).
After all structures have been clearly delineated, the iliohypogastric
and ilioinguinal nerves can be resected over the quadratus muscle. With
Fig. 25.3. Subcostal nerve trunks and 12th rib at T12 level (star). Ilioinguinal/
iliohypogastic nerve trunk caudal.
Fig. 25.4. Iliohypogastric and ilioinguinal nerve trunks over quadratus lum-
borum muscle at L1 level (star). Subcostal nerve and 12th rib cephalad.
regard to the cut nerve, our preference is to place a clip proximally and
distally to close the neurilemma. This theoretically helps to avoid neu-
roma formation and allows for radiographic identification of the cut
nerve if future proximal interventional blocks are needed. The genito-
femoral nerve trunk is subsequently clipped and resected over the psoas
muscle in a similar fashion. A transabdominal approach may alterna-
tively be used to access the same anatomic planes but requires medial
rotation of the viscera and more operative ports.
Fig. 25.5. Lateral femoral cutaneous nerve trunk at L3 level (star).
Fig. 25.6. Genitofemoral nerve trunk over psoas muscle (star). Femoral nerve
lateral to psoas muscle (arrow).
Outcomes
In our prospective series, 42 patients who presented with chronic
inguinodynia not controlled with conservative pain management thera-
pies underwent laparoscopic triple neurectomy (Fig. 25.8). The mean
numeric pain scores were significantly reduced (baseline score 8.4) on
postoperative days 1 (score, 3.4; p < 0.001), 7 (score, 2.8; p < 0.001), 30
(score, 2.4; p < 0.001), 90 (score, 2.1; p < 0.001), and 180 (score, 1.9;
p < 0.001 [17]. Thirty-four patients have been followed to 12 months (pain
score 1.5; p < 0.01), and 20 have been followed over 2 years (pain score
Fig. 25.7. Relationship between ureter (X), iliac artery (arrow), and genito-
femoral nerve trunk over psoas muscle (star).
10
7
* P < .05 vs preop
6
4 *
* (36) (35) (22)
3 *
*
* *
2
*
1
0
Pre-Op POD1 POD7 POD30 POD90 POD180 POD360 POD540
Fig. 25.8. Laparoscopic triple neurectomy outcomes: VAS scores.
1.1; p < 0.01). Narcotic dependence was seen to decrease and the activity
level of patients increased. All patients reported numbness as anticipated
in the distribution of neurectomy. Fourteen (33 %) had transient hyper-
sensitivity consistent with deafferentation, with four patients (9 %) hav-
ing persistent symptoms greater than 3 months. Seven experienced
residual meshoma pain with four of them undergoing a subsequent reop-
eration for mesh removal. Orchialgia was not improved as expected since
paravasal nerves need to be resected to address this problem [16].
Discussion
With the advances in technique of tension-free inguinal hernia repair,
chronic groin pain now surpasses recurrence as the most common long-
term postoperative complication. This debilitating condition is a result
of nociceptive and neuropathic factors. Given the lack of clear discrimi-
nation between the two types of pain, confounded with variables such as
excitatory coupling between sympathetic and afferent nociceptive
fibers, deafferentation hyperalgesia, pain centralization, and neuroplas-
ticity, as well as patient-related factors, prevention of this complication
is of key importance [9, 21].
Nociceptive pain can be minimized with gentle handling of tissues

and with the use of local anesthetic to decrease the formation of nocicep-
tive molecules. Neuropathic pain can be decreased by meticulous iden-
tification and protection of nerves to avoid injury and their direct contact
with mesh, which ultimately changes the structure of their fibers. Doing
so has been shown to reduce the rate of postherniorrhaphy chronic pain
from 5 to 8 % to a fraction of 1 % [20]. Understanding inguinal and
preperitoneal groin neuroanatomy as well as the pathophysiology of
inguinal pain helps to guide good operative technique in all methods of
inguinal hernia repair. Prevention and avoidance of injury at the time of
the original operation are of paramount importance.
Numerous operative techniques have been used to address chronic
inguinodynia such as revision of the original herniorrhaphy, removal of
mesh or fixation device, and selective neurolysis or neurectomy of the
ilioinguinal, iliohypogastric, and genitofemoral nerves. These tech-
niques, however, often leave behind injured nerves and do not affect the
ultrastructural changes of nerve fibers. Moreover, the considerable
variation in anatomy and cross-innervation of the inguinal nerves within
the retroperitoneum and inguinal canal can make such procedures unre-
liable [19, 20, 2225].
The current most effective therapy for the neuropathic component of
inguinal pain is triple neurectomy [1216, 2224]. In our ongoing series
of laparoscopic retroperitoneal triple neurectomy, we have had a 93 %
success rate in reducing numeric pain scores and narcotic dependence
and improving the quality of life and function in daily activities for
patients. Numerically, this demonstrates superior results of the laparo-
scopic retroperitoneal approach to standard open triple neurectomy (80
%) and extended open triple neurectomy, which includes the resection
of the genitofemoral nerve trunk (87.5 %). Importantly, it allows us to

more effectively treat inguinodynia following posterior repair (i.e., lapa-
roscopic TEP/TAPP), a subset of patients who do not respond as effec-
tively to open anterior triple neurectomy, as the pathology and site of
injury typically are proximal to the inguinal operative field.
With the minimally invasive approach, nerve identification, which is
often the cause for failure of open neurectomy, is uniformly successful;
the anatomy in the retroperitoneal lumbar plexus is less variable, and it
obviates the need to reoperate in a scarred field. Risks of remedial sur-
gery are reduced; morbidity and perioperative disability are minimized.
Thus, in the absence of recurrence or meshoma, this surgery is our pre-
ferred technique for definitive management of chronic postherniorrha-
phy inguinodynia due to neuropathic causes.
References
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inguinal hernia repair: a prospective two phase study. Ann Surg. 2011;254(1):1638.
2. Kehlet H. Chronic pain after groin hernia repair. Br J Surg. 2008;95(2):1356.
repair. Br J Surg. 2005;92(7):795801.
4. Aasvang EK, Bay-Nielsen M, Kehlet H. Pain and functional impairment 6 years after
inguinal herniorrhaphy. Hernia. 2006;10(4):31621.
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26. Chronic Orchialgia:
Workup and Management
Jamin V. Brahmbhatt, Ahmet Gudeloglu,

and Sijo J. Parekattil
Introduction
Chronic groin or scrotal content (inguinal canal, spermatic cord, tes-
ticular, scrotum) pain (CGSCP) is a common presenting problem for
several specialistsemergency room, primary care, general surgeon,
and urologists. It can be both acute and chronic in nature and can be
managed with medical or surgical interventions. The pain can be unilat-
eral or bilateral and intermittent or constant and lasts longer than 3
months [1, 2]. The pain can be idiopathic or caused by nerve irritation
or hypersensitivity through vasectomy, hernia repair, sports injury,
abdominal surgery, or any intervention that can irritate the genitofemoral
or ilioinguinal nerves. Although the exact mechanism for CGSCP is not
well understood, one common theme is a two-hit theory. There is a base-
line inflammatory or genetic process that leads to Wallerian degenera-
tion of the peripheral nerves. In the groin or scrotum this degeneration
may cause hypersensitivty of the ilioinguinal and genitofemoral nerves.
A second inciting eventtrauma, surgery, or irritation of these nerves
then leads to chronic neuropathic pain in this area (Fig. 26.1) [3].
CGSCP may affect over 100,000 men annually [4, 5]. Prevalence can
range up to 33 % of men after vasectomy [6] and 63 % after inguinal
hernia repair [79]. After hernia repair, the pain can be neuropathic or
non-neuropathic secondary to mesh. Even with such a high prevalence
after hernia repair, only 1 % of patients who suffer from CGSCP may be
referred for further evaluation [10]. In this chapter we will review the
current literature and present a structured algorithm for the evaluation
and management of CGSCP.

DOI 10.1007/978-3-319-21587-7_26
344 J.V. Brahmbhatt et al.
Fig. 26.1. Two-hit theory on cause of chronic groin and scrotal content pain
(From Brahmbhatt et al. [3], with kind permission Springer Science + Business
Media).
Anatomy and Function

Embryology
At 78 weeks gestation, gonads differentiate into testis in the poste-
rior abdominal cavity. After 8 weeks, through the influence of hormones,
the testicles begin their descent into the scrotum. Until 7 months, they
remain near the inguinal canal. Before birth or within a few weeks after
birth, the testicles complete their descent into the scrotum. As the testicle
descends from the abdominal cavity, it brings with it layers of the peri-
toneum and abdominal wall. Figure 26.2 lists the layers from external to
internal order. It is important to note that the external spermatic fascia is
derived from external oblique fascia, cremasteric muscle from internal
oblique fascia, internal spermatic fascia from transversalis fascia, and
tunica vaginalis from peritoneum. If the descent does not occur com-
pletely, then patients are labeled as having undescended testicles, which
may require medical or surgical intervention.
26. Chronic Orchialgia: Workup and Management 345
Fig. 26.2. Layers of the scrotal wall.
Anatomy
The testicle is egg shaped with an average length of 5 cm. Testicular
function is tightly regulated with signaling from the hypothalamus and
anterior pituitary gland. The main function of the testicle is to produce
sperm from germ cells and testosterone from Leydig cells. There is
another cell type (called Sertoli cells) that is important for support.
Sperm travels through the testicle (lobules, seminiferous tubules, rete
testis, epididymis) and vas deferens until it mixes with fluid from the
seminal vesicles and prostate to form semen. This combined fluid is
eventually expelled into the urethra during ejaculation.
The spermatic cord houses the testicular artery, testicular veins
(pampiniform plexus), vas deferens, artery of vas deferens, lymphatic
vessels, and nerves. Neural innervation to the testicle is via a complex
neural network with significant crossover. Afferent innervation of the
scrotum originates via somatic nerves in the genital branch of the geni-
tofemoral nerve, ilioinguinal nerves, and autonomic branches from T10-L1
parasympathetic ganglia [11]. The genitofemoral and ilioinguinal nerves
provide anterior scrotal wall and thigh innervation. The posterior scrotal
wall is innervated via the perineal branch of the pudendal nerve. There
is an alternate autonomic pathway between the pelvic plexus and testis
via the vas deferens, which explains the positive response to anesthetic
injections to the pelvic ganglia [12]. On average, there are 31 small
diameter (less than 1 mm) nerve fibers in the spermatic cord. The three
primary sites (trifecta nerve complex) of highest nerve density are (in
decreasing order): cremasteric muscle fibers, perivasal tissue and vasal
sheath, and posterior peri-arterial/lipomatous tissue [13].
Evaluation
Workup of CGSCP begins with a thorough history and physical
examination. The characteristics of pain, including onset, duration, and
severity, are questioned. Pain is rated using the visual analog scale and
externally validated pain impact questionnaire (PIQ-6, Quality-Metrics
Inc., Lincoln, RI, USA).
Physical examination focuses on the groin and testicle in the attempt
to identify any anatomic causes of the pain, including hernia, varicocele,
testicular masses, epididymal cysts, and granulomas from previous
vasectomy. All possible causes such as ureteral stones, infection (orchitis
or epididymitis), or back problems (lumbar disk hernia) need to be ruled
out. Urine analysis, scrotal ultrasonography, abdominal computerized
tomography (CT), and spinal magnetic resonance imaging (MRI) should
be performed when indicated. Scrotal ultrasound is not necessary when
physical examination and urine analyses are normal in patients with
chronic scrotal pain. Van Haarst et al. evaluated scrotal ultrasonography
imaging of 111 chronic scrotal pain patients with normal physical exami-
nation and urine analyses and found 12 epididymal cysts less than 0.5 cm
and three subclinical varicocele but no clinical significant abnormalities
[14]. Since a significant percentage of CGSCP is idiopathic, patients
often have completely negative evaluations. Treatment for these patients
is initiated using a structured algorithm (Fig. 26.3).
Medical Treatment
In the absence of any acute findings that require surgical intervention,
conservative medical therapy is a first-line treatment [15]. One month of
nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended [1].
We usually start with meloxicam 7.5 mg daily or high-dose ibuprofen
600 mg orally three times daily. Newer low-dose NSAIDs such as
Zorvolex 35 mg BID-TID can be used to decrease side effect potential.
Sexually transmitted infection with gonorrhea or chlamydia should
be considered in men between the ages of 1535. This is usually treated
with azithromycin 1 g orally once (or doxycycline 100 mg orally twice
Fig. 26.3. Algorithm for evaluation and management of chronic groin and scro-
tal content pain.
daily for 10 days) and ceftriaxone 125 mg intramuscularly once. Over

the age of 35, Escherichia coli is a common urinary pathogen that can
cause epididymal infection. E. coli infection can be treated with a course
of quinolones (ciprofloxacin 500 mg orally twice daily or levofloxacin
500 mg orally once daily for 10 days). A 1-month supply of quinolone
therapy can also be considered in combination with NSAIDs for refrac-
tory cases.
Antidepressants used at lower doses for chronic pain work by inhibit-
ing the reuptake of norepinephrine. A commonly used class of antide-
pressants is tricyclics, which include amitriptyline 1025 mg orally
daily and nortriptyline 10150 mg orally daily. These medications are
slowly titrated up to therapeutic levels. The use of these medications can
also help the comorbid psychological factors that may contribute to
genital pain. In a study of 48 patients with genital pain and no organic
findings, psychological disorders were diagnosed commonly, including
major depression (27 %), somatization disorder (56 %), and chemical
dependency (27 %) [16]. It is critical to taper patients off tricyclic anti-
depressantsthey should never be stopped abruptly.
Anticonvulsants contribute to pain management through their
ability to modulate central calcium channels with chronic use via an
effect on trafficking [17]. Gabapentin and pregabalin are common
anticonvulsants used for neuropathic pain. We start with gabapentin
300 mg orally three times daily and may titrate up as needed. Patients
tend to respond well to these medications, but its frequent dosing and
side effect profile lead to a high dropout rate. If patients are placed on
chronic medications, a multidisciplinary approach to their follow-up is
generally recommended.
Spermatic Cord Block

Spermatic cord nerve blocks using local anesthetic with or without
steroids can be therapeutic and diagnostic. In our practice, we mix 15
mL 1 % lidocaine, 15 mL 0.25 % marcaine, and dexamethasone 4 mg.
The blocks target three areas of high nerve density [13]. First, high-
pressure injection of the perivasal tissue is done using a Medi-Jet.
Another 5 mL, using a needle, is directly injected directly around the
perivasal tissue. We then inject 10 mL medially to the external inguinal
ring to target the branches of the ilioinguinal nerve and 10 mL laterally
to the external inguinal ring to target genital branches of the genitofemo-
ral nerve.
In patients with no apparent etiology, the blocks can provide tempo-
rary relief while helping to predict a positive response to surgical inter-
ventions. Benson et al. demonstrated that a positive response to
spermatic cord block helps predict a durable and complete resolution of
symptoms after microsurgical denervation of the spermatic cord
(MDSC) [18]. They achieved an average 89 % decrease in pain with
spermatic cord block for median 8 h (1168 h) in 74 men (77 testicular
units). Also improvement from the spermatic cord block was a predictor
of overall improvement after MDSC (p = 0.05).
Microsurgical Targeted Denervation

of the Spermatic Cord
Introduction
Microsurgical targeted denervation of the spermatic cord (MDSC) is
a minimally invasive surgical option for the management of CGSCP
after conservative treatments have failed [2, 19]. An animal study to
evaluate the effectiveness of the MDSC procedure showed a significant
decrease in median number of nerve fibers remaining around the vas
Fig. 26.4. Nerve fiber with and without Wallerian degeneration on H&E stain-
ing (From Brahmbhatt et al. [3], with kind permission Springer Science + Business
Media).
deferens after MDSC procedure, compared to sham (MDSC = 3.5

nerves, sham = 15.5 nerves, p = 0.003) [20]. In this procedure (described
in detail below), we target tissue in or around the spermatic cord that
carries high-density nerve fibers that contribute to chronic pain. Within
these nerve fibers, there are significant anatomic and pathologic differ-
ences (Wallerian degeneration) compared to controls (Fig. 26.4) [3, 13].
Targeting these specific areas leads to the preservation of a significant
portion of the spermatic cord and potentially fewer complications.
We published our most updated results of the 546 robotic targeted
MDSC (RTMDSC) procedures for chronic groin pain [21]. On the last
review of our data our total has increased to over 620 patients. Mean
preoperative duration of orchialgia in our patients is 2.4 years.The
median robotic operative duration was 20 min (range, 10150 min).
Using the externally validated pain assessment tool PIQ-6, we assessed
preoperative and postoperative pain. At 6 months there was a 71 % sig-
nificant reduction in pain and 72 % significant reduction at 1 year. Using
the visual analog pain scale, there was an 85 % significant reduction in
pain (63 % complete resolution and 22 % greater than 50 %).
Complications were limited to one testicular ischemia, two testicular
artery injuries (repaired intra-op with no long-term sequelae), one vasal
injury (repaired intra-op with no long-term sequelae), 11 hematomas,

three seromas, and five wound infections.
There are several advantages to using the robotic platform, which
includes improved visualization, decreased tremor, and less dependence
on a surgical assistant. Robotic-assisted MDSC seems safe and feasible,
and the outcomes appear promising for durable relief.
Technique in Detail
A 12 cm transverse subinguinal incision is made. The incision is
carried down until the spermatic cord is reached. The spermatic cord is
brought up to the surface. Posterior medial and lateral dissection and
cauterization are performed to ligate branches of the ilioinguinal and
genitofemoral nerves in this area.
The robot is positioned over the patient. A 0 camera lens is utilized.
The right, left, and the fourth robot arms are loaded with Black Diamond
microforceps, Maryland bipolar grasper, and monopolar curved scissors,
respectively (Fig. 26.5) [3]. If a flexible CO2 laser fiber is used for dis-
Fig. 26.5. Standard robotic instrumentation for targeted denervation (From

Brahmbhatt et al. [3], with kind permission Springer Science + Business Media).
Fig. 26.6. Flexible CO2 laser instrumentation during targeted denervation (From
section, then the fourth arm is replaced with a Black Diamond microfor-
ceps to hold the flexguide laser holder (Fig. 26.6) [3].
The anterior cremasteric muscle is divided. The presence of a testicu-
lar artery is confirmed with real-time intraoperative micro-Doppler
(Vascular Technology Inc, Nashua, NH). The posterior cremasteric
fibers and posterior fat component are ablated. The vas is isolated, and
generally the artery and vein to the vas are dissected away from the vas.
The perivasal tissue is now ablated. Hydrodissection of the perivasal
tissue is now performed (Fig. 26.7) [3], using the ERBEJET 2 hydrodis-
sector (ERBE Inc., Atlanta, GA) to ablate residual nerve fibers.
The cord is now wrapped with AmnioFix (MiMedx, Marietta, GA),
which serves as a barrier to reduce scar tissue formation, provide local
anti-inflammatory environment, and help with tissue healing. The wrap
is loosely secured using 6-0 Prolene or chromic interrupted sutures. The
robot is now undocked. The cord is placed back into through the inci-
sion, and the deep tissue and skin are closed.
Fig. 26.7. Hydrodissection of residual nerve fibers on perivasal tissue (From

Varicocelectomy for Chronic Scrotal Content Pain

Introduction
Varicoceles are an abnormal enlargement of the pampiniform venous
plexus veins within the scrotum. This abnormal enlargement is linked to
low sperm counts, decreased sperm quality, infertility, testicle atrophy,
and pain. Varicocelectomy (ligation of the enlarged veins) is often per-
formed on its own for fertility, hypogonadism, or in extreme cases, for
management of chronic pain. It is performed alongside a targeted dener-
vation if varicoceles are clinically present.
From June 2008 to September 2014, 264 robotic-assisted varicoce-
lectomies were performed in 220 patients. Indications for the procedure
were the presence of a grade two or three varicocele and the following
conditions: azoospermia in 20 patients, oligospermia in 63 patients, and
chronic orchialgia with or without oligospermia in 137 patients. The
median duration per side was 25 min (1080). Median follow-up was 36
months (176). 80 % with oligospermia had a significant improvement
in sperm count or motility and 30 % with azoospermia converted to
oligospermia, and 91 % of the testicular pain patients had a significant

reduction in pain (82 % of these patients had targeted denervation of the
spermatic cord in addition to varicocelectomy). Two recurrences or per-
sistence of varicocele occurred; one patient developed a small postop-
erative hydrocele; two patients had postoperative scrotal hematomas;
and five patients had wound seroma (treated conservatively).
Technique in Detail
A 12 cm subinguinal incision is made over the external inguinal
ring. A tongue depressor is placed underneath the cord to keep the cord
elevated. The robot is positioned over the patient. A zero-degree camera
lens is utilized. The Black Diamond microforceps are used in the right
robotic arm, the micro bipolar forceps in the left arm, and the curved
monopolar scissors in the fourth arm. The anterior cremasteric sheath of
the spermatic cord in now incised to separate the cord structures.
The arteries are identified using real-time micro-Doppler (Vascular
Technology Inc, Nashua, NH). All dilated veins are isolated and tied
using 3-0 silk (Fig. 26.8) [3]. Vessels are cut with curved monopolar
scissors. The cord is placed back into through the incision, and the deep
tissue and skin are now closed.
Fig. 26.8. Isolation and ligation of dilated vein (From Brahmbhatt et al. [3],
with kind permission Springer Science + Business Media).
Vasectomy Reversal for Post Vasectomy Pain

Introduction
Vasectomy is a common form of contraception. An estimated 4060
million men worldwide rely on this method of contraception [22].
Complications after vasectomy are rare, but 1015 % of men may suffer
from chronic post vasectomy testicular and groin pain. Congestive epi-
didymitis is one possible mechanism for the chronic discomfort, and
therefore, vasectomy reversal is a viable treatment option [19, 23].
Between July 2007 and March 2013, 147 robotic-assisted vasectomy
reversals were performed by two fellowship trained microsurgeons. There
were 90 robotic-assisted microsurgical vasovasostomy (RAVV) proce-
dures and 57 robotic-assisted microsurgical vasoepididymostomy (RAVE)
procedures performed. Twenty of these patients had chronic scrotal pain
after vasectomy, and the rest wished to regain fertility. Median patient age
was 42 years, and median duration from vasectomy 7 years for RAVV and
11 years for RAVE. Median OR setup duration was 30 min, and median
robotic OR duration was 120 min and 150 min for RAVV and RAVE,
respectively. After 23 months median follow-up, patency rates (>1 million
sperm/ejaculate) were 97 % in the RAVV group and 60 % in the RAVE
group. Pain relief occurred in 88 % of the patients who underwent RAVV
or RAVE for chronic scrotal pain related to vasectomy.
Technique in Detail: Robotic-Assisted Microsurgical

Vasovasostomy
The proximal and distal vas deferens (beyond the previous vasec-
tomy site) is palpated through the scrotal skin. Through the skin, the
distal vas is fixed into place with a towel clip. Local anesthetic is infil-
trated into this area. A 12 cm vertical incision is made over the vas,
starting inferiorly from the previously placed towel clip. Using fine
electrocautery and sharp dissection, the distal and proximal ends of the
vas are dissected free. The distal vas is dissected to allow a tension-free
anastomosis to the proximal vas. The proximal vas is carefully tran-
sected with a No. 11 blade. Microscopic examination of the proximal
vas fluid is performed. If no sperm is present in this proximal fluid,
RAVE is performed. If sperm is found, then RAVV is performed. The
adventitia from either end of the vasa is now secured together with a 3-0
Prolene suture to allow a tension-free anastomosis.
Fig. 26.9. RAVV posterior luminal anastomosis (From Brahmbhatt et al. [3],
The robot is now positioned over the patient to perform the microsur-
gical vasovasostomy. Black Diamond microforceps are inserted on the
right and left robotic arms. The micro-Potts scissors are inserted onto the
fourth robotic arm. The zero-degree camera lens is inserted onto the
robot camera arm. The two ends of the vas are placed over a 1/4
Penrose drain. A 9-0 nylon suture is held and manipulated using the
Black Diamond forceps in both left and right arms as needle drivers. The
posterior muscularis layer of the two ends of the vas is now approxi-
mated (Fig. 26.9) [3]. Two or three double-armed 10-0 nylon sutures are
now placed inside out to reanastomose the posterior mucosal lumen of
the vas. Three double-armed 10-0 nylon sutures are used to close the
anterior mucosal lumen of the vas (Fig. 26.10) [3]. Five to six 9-0 nylon
sutures are used to approximate the anterior muscularis layer of the vas.
The same procedure is now performed on the contralateral side by repo-
sitioning the robotic arms. The Penrose drain is gently removed from
under the repair. The vas is placed back into the scrotal cavity, and the
tissue and skin are closed with absorbable suture.
Technique in Detail: Robotic-Assisted Microsurgical

Vasoepididymostomy
The RAVE procedure starts from above when there is no sperm in the
fluid from the proximal vas. The scrotal incision is enlarged by 12 cm
inferiorly. The testicle is delivered, and the tunica is incised to expose
Fig. 26.10. RAVV anterior muscular anastomosis (From Brahmbhatt et al. [3],
the epididymis. The adventitial layer of the epididymis is incised above

the level of epididymal obstruction (blue/gray zone with dilated epididy-
mal tubules above this area). A 3-0 Prolene suture is used to attach the
testicle to the adventitia of the vas to prevent tension between the anas-
tomosis. The vas is stripped off the adventitia and flipped toward the
epididymal tubules. The robot is now positioned similar to above. Two
10-0 nylon double-armed suture needles are placed longitudinally
through a single epididymal tubule to expose the tubule. This tubule is
then incised longitudinally using the micro-Potts scissors between the
two suture needles to create a lumen in the tubule. The fluid is then
aspirated and examined under a separate phase contrast microscope for
the presence of sperm.
When sperm is confirmed, two double-armed 10-0 nylon needles in
the epididymal tubule are advanced through, and then all four of the
needles are brought inside out on the vas mucosal lumen to involute the
epididymal tubule lumen into the vas lumen (Fig. 26.11) [3]. Five to six
9-0 nylon sutures are placed circumferentially to approximate the mus-
cularis of the vas to the adventitia of the epididymal tubule (Fig. 26.12)
[3]. The testicle and anastomosis are carefully delivered back into the
scrotum. The dartos layer and skin are closed.
Fig. 26.11. RAVE involution vasoepididymostomy (From Brahmbhatt et al. [3],

Fig. 26.12. RAVE vas muscularis to epididymal adventitia approximation

(From Brahmbhatt et al. [3], with kind permission Springer Science + Business
Media).
Salvage Interventions Post Targeted Denervation

Microcryoablation
Approximately, 1215 % of patients will have persistent pain after
denervation [21, 24]. Orchiectomy and epididymectomy could be con-
sidered; however, these procedures seem to be controversial due to their
low success rates [2527]. Mirmovich et al. introduced intralesional
cryosurgery for the treatment of the pain due to hypertrophic scars and
keloids [28]. We adapted their technique and perform microcryoablation
of ilioinguinal and genitofemoral nerve fibers for patients with persistent
or recurrent CGSCP [29]. A small diameter EndoCare CryoProbe
(Healthtronics, Austin, TX) is used to perform cryoablation of the
medial and lateral edges of the cord under ultrasound guidance
(Fig. 26.13). As of September 2014, we have performed 69 targeted
microcryoablations in 60 patients (9 b/l, 22 left, 29 right). At median
follow-up of 11 months using the visual analog pain scale, there is a
74 % significant reduction in pain (9 % complete resolution and 65 %
greater than 50 % reduction in pain). Using the PIQ6 score, there is
59 % reduction in pain at 6 months. Complications were rare and
included one wound infection and one case of increased penile pain.
Fig. 26.13. Ultrasound guidance during microcryoablation.

Botox
Another adapted method for the persistent CGSCP patient is sper-
matic cord block using botulinum toxin. Mori et al. described intracrem-
asteric botulinum-A toxin injection for a patient who had pain due to
bilateral cremasteric muscle spasms [30]. We recently began botulinum
toxin injection for those persistent CGSCP patients. As of September
2014, we have performed 29 targeted botulinum toxin injections in 25
patients (94 b/l, 11 left, 10 right) at a dose of 100 units. At median fol-
low-up of 8 months, using the visual analog pain scale, there is a 70 %
significant reduction in pain (14 % complete resolution and 56 % greater
than 50 % reduction in pain). Using the PIQ6 score, there is 40 % reduc-
tion in pain at 6 months and 20 % at 1 year. No significant complications
have been noted.
Alternative Salvage Interventions

For patients with refractory pain, we may pursue serial nerve blocks,
abdominal neurolysis, and, in rare cases, orchiectomy.
Summary
CGSCP is a common problem that is often underdiagnosed. A multi-
disciplinary approach using a structured algorithm should be used for its
evaluation and management.
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Part III
Current Debates
27. The Role of Bioactive Prosthetic
Material for the Treatment of Sports
Hernias
David S. Edelman
Editors Comments (ST)

Athletic pubalgia remains one of the most controversial topics in the
arena of groin pain. Few surgeons in the world have chosen this spe-
cialty for their main focus of practice, and among them, they each have
a different approach as to how and why they perform their procedure(s)
of choice. Here, the author presents his unique practice of laparoscopic
approach to the treatment of athletic muscle tears, with the addition of
Surgisis, a porcine tissue derived from small intestine submucosa, and
fibrin. The term BPM is often applied when discussing Surgisis and
other Cook products, whereas the broader term of biologic mesh can
also be used when discussing human or nonhuman collagen-based
grafts. Also, Table 27.1demonstrates data as provided by each vendor,
such as whether the tissue has been intentionally cross-linked. This
information may not represent analyses performed independently by
scientific laboratories that have shown a special interest in determining
the final characteristics of implanted tissue, such as whether the steril-
ization and other manipulation of the tissue in fact result in uninten-
tional overprocessing or even cross-linking.
Nevertheless, the technique described is worthy of further discussion
and investigation. The author has shown good preliminary results. We
look forward to larger population and longer-term data. It would be
useful to know if other forms of collagen matrices would also show ben-
efit when implanted in this region and also which specific patients are
best candidates to undergo this type of approach for their athletic
pubalgia.

DOI 10.1007/978-3-319-21587-7_27
366 D.S. Edelman
Table 27.1. Bioactive prosthetic materials.

Cross- Sterilization
Mesh name Vendor Source linking
AlloDerm LifeCell Human dermis No None
AlloMax Bard/Davol Human dermis No Gamma irradiation
CollaMend Bard/Davol Porcine dermis Yes Ethylene oxide
FlexHD Ethicon Human dermis No None
FortaGen Organogenesis Porcine intestine Yes Gamma irradiation
MatriStem ACell Porcine bladder No E-beam
Peri-Guard Synovis Bovine pericardium Yes Liquid alcohol
Permacol Covidien Porcine dermis Yes Gamma irradiation
Strattice LifeCell Porcine dermis No E-beam
SurgiMend TEI Biosciences Fetal bovine dermis No Ethylene oxide
Surgisis Cook Medical Porcine intestine No Ethylene oxide
Tutopatch Tutogen Medical Bovine pericardium No Gamma irradiation
Veritas Synovis Bovine pericardium No E-beam
XenMatrix Bard/Davol Porcine dermis No E-beam
Introduction
The use of mesh in the repair of hernias is commonplace. Synthetic
meshes such as polypropylene and polyester have been the standard for
hernia repairs since the 1980s. Biologic graft material composed of puri-
fied porcine small intestinal submucosa was first introduced to the
United States in 1998, as an alternative to synthetic biomaterials. These
meshes, composed of extracellular matrix (ECM) collagen, fibronectin,
associated glycosaminoglycans, and growth factors [14], have been
extensively investigated in animal models [57] and used clinically in
many types of surgical procedures. Referred to as bioactive prosthetic
materials (BPM), they are considered a scaffold for the binding of
growth factors and other cellular elements for the healing response. The
subsequent healing response and strength are dependent on ingrowth
from the patients cells and blood vessels into the ECM of the
BPM. Fibrin may assist this ingrowth and thus may be added extrinsi-
cally as topical fibrin sealant [8]. The balance between ECM synthesis
and degradation contributes to the ultimate success of the hernia repair.
Surgisis (Cook Surgical, Bloomington, IN) was the first biologic
graft material to be marketed in the United States. I began using it in my
practice for hernia repairs and reported my initial results in Surgical
27. The Role of Bioactive Prosthetic Material 367
Technology International XV in July 2006 [9]. Since then, there have

been many more reports using BPM, acellular dermal matrices, and
other biologic materials for hernia repair. The aim of this chapter is to
review the topic of BPMs and their application to inguinal hernia and
sports hernia repairs.
Basic Differences in Bioactive Prosthetic Materials

Table 27.1 summarizes the BPMs currently on the market in the
United States. They differ based on their mammalian source (animal or
human), tissue of origin (dermal, pericardial, bladder, or intestinal sub-
mucosa), as well as their methods of processing (cross-linked or not
cross-linked) and sterilization. All of these differences may lead to dif-
ferences in the healing process and thus clinical outcome. With the
exception of AlloDerm, Surgisis, and StratticeTM, peer-reviewed stud-
ies outlining the clinical outcome from implantation of biologic tissue is
significantly lacking.
Mammalian source may be considered when choosing among the
various BPMs available. Human cadaveric tissues offer the advantage of
using allograft (within species) sourcing and thus lacking interspecies
rejection risk. The source of such tissues is donor dependent, with vari-
ability in composition, health, thickness, and age of the tissue.
Additionally, there is risk of disease transmission within species; indeed,
there have been reports of disease transmission in human cadaveric
allograft products of the dura mater in Japan from the 1990s [10].
Alternatively, animals can be raised to precise specifications to
achieve a more consistent product. The risk of allergic response to their
ECM is low because of the high homology with similar human proteins.
With nonhuman tissues, the risk of tissue rejection remains despite
decellularization, as does the rare possibility of disease transmission.
The specifics of each biologic material should be known prior to implan-
tation, especially when treating certain populations. For example, an
immune-compromised patient may be at higher risk if undergoing
implant with a human cadaveric allograft that is not sterilized. Similarly,
an atopic patient may be at higher risk of allergic response to a
xenograft.
BPMs vary in their tissue of origin. The dermis remains the preferred
tissue source, though products made from alternative tissues, such as the
368 D.S. Edelman
pericardium, stomach, bladder, and intestinal submucosa, are also avail-

able. There is not enough literature to compare differences in clinical
outcomes across different tissues of origin. All tissue sources contain
significant amounts of collagen and other ECM proteins. However,
some tissues such as the pericardium and intestinal submucosa lack the
protein elastin, a significant component of the dermis that gives skin its
elasticity. Elastin has been theorized to cause in vivo stretching of the
allograft, resulting in diastasis after bridged repair of ventral hernia [11,
12]. At the same time, the elasticity of dermis-based grafts is favorable
when implanted in areas where tissue pliability is necessary, such as in
breast reconstruction following mastectomy. Thus, the tissue of origin
may be a significant factor to consider when choosing the best BPM for
the procedure of interest.
Lastly, BPMs are either purposely cross-linked or non-cross-linked at
the time of their processing. Cross-linking is a way of stabilizing the
graft and making it more resistant to tissue-degrading enzymes and bac-
teria that break down collagen. While this process may increase the
durability of the graft [13], clinical studies have shown that the majority
of adverse events associated with hernia repair grafts have occurred with
cross-linked products [14]. These complications included acute mechan-
ical failure of the mesh, degradation of the mesh, and poor integration of
the mesh. Poor mesh integration is a result of poor angiogenesis into the
material, which can lead to encapsulation or prolonged inflammatory
response characterized by foreign body giant cell reaction. Recent find-
ings suggest that cross-linking does not necessarily translate to durabil-
ity, and, while there may yet be a place for cross-linked materials in
hernia repair, cross-linked materials need to be used with caution until
the optimal degree of cross-linking to overcome these complications can
be understood [15].
BPM and Inguinal Hernia Repair

One of the first studies reporting the use of BPM in humans was
reported in 2002 [16]. This was a preliminary study on 15 inguinal her-
nias in 12 patients. The preliminary results were good with no recur-
rences at 1 year and no chronic pain. Since then, there have been
multiple studies demonstrating positive results after inguinal hernia
repair with biologic tissue. Fine repaired 51 hernias in 38 patients with
BPM mesh and fibrin sealant [17]. He showed no major complications,
one recurrence at 13 months, and chronic pain in three patients (7.9 %).
This is lower than what is typically reported with synthetic mesh after
open repair, at approximately 12.5 %. We reported our results in 2008,
using fibrin sealant alone to laparoscopically secure BPM and polypro-
pylene mesh in comparable groups of 18 patients with 23 repairs [18].
The results were similar in both groups with no long-term chronic pain
or hernia recurrences. The biologic group had a few patients with short-
term (less than 3 months) groin discomfort. Lastly, in Italy in 2008,
Agresta and Bedin reported 11 patients undergoing laparoscopic TAPP
hernioplasty with BPM and fibrin sealant [19]. There was one technical
error leading to a recurrence at 14.5 months, and there were no reports
of chronic pain. He hypothesized for use of BPM in the young patient,
where there is a fear of leaving behind a foreign body in the long term.
Acellular extracellular dermal matrix mesh was implanted in 53
patients with 56 hernias using a Lichtenstein repair by Ma et al. in a
2005 report from China [20]. They reported no infections, chronic pain,
or discomfort; however, two patients with large direct Gilbert type V and
VI hernias had recurrences noted by 18 months. Ansaloni et al. from
Italy reported his 2-year follow-up in 2007, on 45 consecutive patients
undergoing Lichtenstein repair with BPM [21]. There was a low degree
of pain and no recurrences noted. A randomized double-blind trial com-
paring BPM to polypropylene mesh reported their 3-year follow-up on
70 patients [22]. The incidence of pain was similar, but the degree of
pain was less in the biologic mesh group. One recurrence was noted in
the polypropylene mesh group. Most recently, Bellows et al. reported
their randomized double-blind multicenter trial comparing patients
undergoing Lichtenstein hernioplasty with non-cross-linked porcine
dermis (N = 84) to soft polypropylene mesh (N = 88). Results were
equivalent at 3 months [23].
BPM and Sports Hernias

Groin pain in athletes is caused by a wide variety of musculoskeletal
disorders. The term sports hernia is a poor one and should be replaced
by athletic pubalgia. In patients who have this condition, the insertion
site of the rectus muscle and/or adductor longus muscle onto the pubic
bone is damaged. When an athlete engages these muscles during activ-
ity, there is a lack of function, which can sometimes be perceived as
groin pain. Some athletes describe a weakness. Most athletes describe
their inability to plant and turn, or kick, or jump, or perform something
similar corresponding to their sport. The physical exam does not reveal
370 D.S. Edelman
a true hernia in most instances; the presence of an inguinal hernia should

prompt an inguinal hernia repair.
Many times the examiner can elicit pain at the pubis while the athlete
does a Valsalva maneuver. I prefer to perform this exam with the patient
lying on my exam table while I place my index finger through the scro-
tum onto the top of the external ring. I then have the athlete do bilateral
straight-leg raises while he lifts his shoulder off the table at the same
time. Pain with this maneuver is a diagnostic sign.
An ultrasound with Valsalva may demonstrate an inguinal hernia. If
the ultrasound is negative for a true inguinal hernia and the physical
exam is equivocal, a noncontrast MRI of the pelvis with attention to the
pubis is indicated. With athletic pubalgia, the MRI will show acute or
chronic inflammatory changes at the rectus muscle insertion onto the
anterior/superior pubis and/or at the adductor longus muscle insertion
onto the inferior pubis.
It is recommended initially to offer a trial of rest with NSAIDs, fol-
lowed by a course of rehabilitative physical therapy. If there is no
improvement or continued inability to perform the sport, surgery may be
indicated. There is much literature available on this subject.
I prefer the laparoscopic approach, as it has been shown to provide
improved recovery over open repair for conventional inguinal hernia
repair [24]. I also prefer implantation of biologic repair in this patient
population. Clarke et al. first reported the use of biologic mesh, small
intestine submucosa (SIS), to repair the abdominal wall in dogs [25].
The resultant repair with SIS was well organized, with dense connective
tissue that was well incorporated into the adjacent fascia and skeletal
muscle. With this information and my extensive experience with laparo-
scopic inguinal hernia repair, I have since implanted BPM laparoscopi-
cally in 131 athletes. I reported the results of my first ten patients in
2006 [26]. No patient developed a recurrent sports hernia, and only
one patient did not have improvement in symptoms.
The laparoscopic approach offers an excellent visualization of the
rectus muscle and conjoined tendon insertion onto the pubis. I use a
10 15 cm biologic mesh, soak it in bupivacaine, and place it in the pre-
peritoneal space. The grasper positions the mesh over the myopectineal
space. I use 46 absorbable tacks to secure the mesh in place. I spray
fibrin sealant on and behind the mesh to secure it to the injured muscle
and periosteum. If there is an adductor injury, I make a separate 4 cm
skin incision over the affected side, along the inguinal crease. I expose
the adductor muscle and make micro-cuts in the tendon. I then use a
4 7 cm biologic mesh and tack it to the inferior pubis and suture it to
the adductor muscle using absorbable sutures (30 Vicryl). Again, I

apply fibrin sealant to the underside of the mesh that is in contact with
the tendon.
I have the player and the athletic trainer begin a structured rehabilita-
tion protocol on day 8 after surgery and continue for 34 weeks. The
results have been excellent, and most of these athletes have returned to
full participation of sports within 45 weeks.
Lastly, when discussing biologic treatments for sports hernias, it
is important to mention platelet-rich plasma (PRP). This product has
been popularized in the orthopedic literature for treatment of tendi-
nopathies and other orthopedic conditions. PRP is derived from the
patients own blood and then injected into the site of pain. It is a con-
centrated source of growth factors and cellular signals that play a role
in the biology of healingnot too dissimilar to description of the
purpose of biologic mesh. Basic science research infers that PRP may
improve tissue healing. There are few clinical studies in humans that
confirm the effectiveness of PRP. The controversy is further ques-
tioned when one considers that placing a needle into a bone or tendon
can stimulate bleeding containing platelets and a healing response
occurs. That said, the value of PRP is being proven in certain disease
states, demonstrating its role in improving healing, especially for ten-
dinopathies and orthopedic injuries [27].
Conclusions
While there are now several different BPMs available on the market,
they differ in their mammalian tissue source, their tissue of origin, and
their methods of processing. The existence of these various materials
suggests that the ideal mesh is not yet available. Also, the lack of clinical
evidence on most of these products prevents surgeons from making
evidence-based choices for their use.
From what has been learned over several years of research and pub-
lished clinical evidence, BPMs can be used clinically in many different
surgical procedures with low rates of complications and few reports of
mesh rejection. Certain types of hernias seem to be better adapted to the
use of BPMs; thus, the pathophysiology of the hernia should be consid-
ered when using these materials. BPMs have been successfully implanted
in young, healthy individuals who have developed a hernia or weakness
due to physical activity of extreme muscular training. As long as the
patient does not have a history of recurrent hernias, a large direct ingui-
372 D.S. Edelman
nal hernia, or a known type of collagen vascular abnormality, BPM can

be considered an adjunct to hernia repair. Athletes in particular have
fared well by having the biologic material support their tears as they heal
their injury.
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16. Edelman DS. Laparoscopic herniorrhaphy with porcine small intestinal submucosa: a
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28. Prevention of Pain: Optimizing
the Open Primary Inguinal Hernia
Repair Technique
Giampiero Campanelli, Marta Cavalli, Piero Bruni,

Andrea Morlacchi, and Gianni Maria Pavoni
The prevention of pain requires that surgeons should take care not
only during the entire surgical procedure but also before and after.
This chapter will provide some suggestions based on our experience
and up-to-date results from the literature for each of the following steps:
1. Preoperative patient selection
2. Selection of anesthesia
3. Choice of the approach: open anterior versus open
preperitoneal
4. Identification and respect of the three nerves
5. Choice of the prosthesis: plug, mesh, lightweight versus heavy-
weight, absorbable versus nonabsorbable
6. Choice of fixation
7. Administration of a proper postoperative therapy
Preoperative Patient Selection

Sometimes a patient will complain of apparently inexplicable postop-
erative pain, even if he has been treated in the same manner as other
patients reporting no postoperative pain. Do all patients have the same
risk to develop postoperative pain? Aasvang et al. [1] designed a novel
prospective study that had the primary end point of assessing the relative
contribution of preoperative, intraoperative, and postoperative factors in
the development of persistent postoperative pain (PPP) substantially

DOI 10.1007/978-3-319-21587-7_28
376 G. Campanelli et al.
affecting everyday activities after groin hernia repair. The authors found
four factors to be independently correlated to PPP-related impairment:
preoperative Activity Assessment Scale (AAS) score, preoperative pain
response to heat, intraoperative nerve injury, and early (day 30) postop-
erative pain intensity. A randomized study by Singh et al. [2] showed
that preoperative pain, younger age, open surgery, and 7-day postopera-
tive pain were independent risk factors for chronic pain. In other studies
[3, 4] age has again been found to be an independent factor for postop-
erative pain.
So how should we treat a painful hernia in a young man? All surgeons
should choose the operative technique that they know best, is safest in
their own hands, and therefore will have the lowest individual risk of
postoperative pain. Moreover, looking at our experience, groin pain with
a small bulge of posterior inguinal wall is often incorrectly labeled a
hernia; however, a proper physical examination and clinical history
investigation reveal all the features of the so-called pubic inguinal pain
syndrome (PIPS) [5]. Pain in PIPS is usually well localized and tends to
be focused on the pubic bone with radiation superiorly to the abdominal
rectus insertion and inferiorly to the adductor longus insertion. The site
of pain is typically provoked by athletic activities such as kicking,
sprinting, and changing directions; the symptoms usually persist the day
after; they improve after resting and recur if athletic activities are
resumed. Physical examination reveals tenderness or pain over the pubic
crest on resisted sit-up (abdominal crunch test). Palpation of the inter-
nal ring can be painful and a small bulge of the inguinal posterior wall
can be detected during coughing, but a palpable lump indicating a clas-
sical inguinal hernia is absent. During the adductor test, patients feel a
sharp pain in the groin [6].
For these reasons, surgery intended to treat this subset of pain should
not be limited to addressing the posterior wall. In order to maximize the
chance of relieving preoperative pain, release of the three inguinal
nerves in the region and tenotomy of the rectus abdominus rectus and
adductor longus should be included.
Selection of Anesthesia
Several randomized studies have compared local anesthesia with
general and/or regional anesthesia. They confirm the advantages of local
anesthetic, including less postoperative pain [713]. For these reasons,
28. Prevention of Pain Optimizing the Open Primary Inguinal 377
it is the favored anesthesia in centers specializing in hernia surgery

[1417]. The administration is technically quite easy but requires train-
ing and is successful only if the surgeon handles the tissues gently, has
patience, and is competent and facile with the technique. Local anesthe-
sia should be the first option for inguinal hernia repair in the adult, but
sedation or general anesthesia with short-acting agents and combined
with local infiltration anesthesia may be a valid alternative to local anes-
thesia alone for surgeons in training or outside of specialized hernia
centers [17].
Choice of Approach: Open Anterior Versus Open

Preperitoneal
In order to decrease the amount of dissection in the inguinal canal,
the manipulation of the inguinal nerves [18], and the interaction between
the foreign material of the mesh and the spermatic cord and nerves,
placement of the mesh in the preperitoneal space is an option to be con-
sidered [19]. By placing the mesh in the preperitoneal space, a more
physiologic location for the mesh with intra-abdominal forces on one
side and the oblique muscles on the other, fixation becomes less manda-
tory although may not be completely abandoned [19].
Usher et al. [20] introduced the prosthetic preperitoneal repair per-
formed through an anterior approach using polyethylene mesh (later
polypropylene), which was not slit because the spermatic cord was
lateralized. Mahorner and Goss [21] used anterior preperitoneal grafts
to support the overlying weakened transversalis fascia in two patients
with recurrent herniation and destruction of both Pouparts and
Coopers ligaments. Rives [22] pioneered both anterior and posterior
preperitoneal prosthetic repairs of groin hernias in France using
Mersilene mesh. More recently Kugel (1999) employed this approach
through an abdominal gridiron incision, using a fortified patch to rein-
force the overlying damaged transversalis fascial floor of the inguinal
and femoral canals [23].
With regard to prosthetic preperitoneal repair through a posterior
approach, the precursor to modern laparoscopic techniques [totally
extraperitoneal repair (TEP), transabdominal preperitoneal repair
(TAPP), enhanced or extended view TEP (eTEP)], Stoppa et al. [24]
reported on the giant prosthetic reinforcement of the visceral sac
(GPRVS) in 1965. Large bilateral Dacron meshes were inserted deep
into the weakened transversalis fascia, covering Fruchauds myopectineal

orifice with extensive overlap. This operation provided an alternative to
the anterior preperitoneal approach, which, in cases of recurrent hernia-
tion, encounters scarring possibly leading to damage of the spermatic
cord, nerves, and blood vessels. Wantz [25] proposed a unilateral ver-
sion of this operation, reaching the preperitoneal spaces of Bogros and
Retzius using a transverse incision extending laterally 9 cm from the
linea alba and 3 cm below the anterior superior iliac spine.
Gilbert [26] developed a two-layered prosthesis; the superficial por-
tion rests on the transversalis fascial floor of the inguinal canal, while
the lower portion lays beneath in the anterior preperitoneal space. The
patches were connected by a plug that passed through the internal ingui-
nal ring. A slit in the onlay portion allowed for passage of the spermatic
cord to the inguinal canal below the external oblique aponeurosis.
Widespread release of the device from its manufacturer (1998) led to the
technique being called the Prolene Hernia System (PHS).
More recently the transinguinal preperitoneal repair (TIPP) technique
had been proposed by Pellisier [27]: this technique involves a standard
anterior approach through the inguinal canal where a patch with a
memory ring is placed into the preperitoneal space behind the transver-
salis fascia. Willaert et al. [19] recently proposed with the Cochrane
collaboration a review with the aim to compare the efficacy of an elec-
tive open preperitoneal mesh repair via either anterior or posterior
approach with the Lichtenstein technique. Efficacy was considered as
the absence of chronic pain after at least three months of follow-up. All
published and unpublished randomized controlled trials (RCTs) compar-
ing any elective open preperitoneal mesh technique with Lichtenstein
repair were considered for inclusion. Strangulated inguinal hernias,
bilateral inguinal hernias, and recurrent inguinal hernias were exclusion
criteria.
Unfortunately, many studies did not address the primary outcome of
the review and only three studies were included. In these three trials, the
Lichtenstein technique was compared with Read-Rives technique [28],
TIPP [19], and Kugel patch [29]. The last two studies reported less
chronic pain after preperitoneal repair; however, the Muldoon study
described slightly more chronic pain after preperitoneal repair. Few data
are present in the literature about chronic pain after Wantz posterior
preperitoneal repair: this technique is usually used in the specialized
hernia center for the treatment of very large, incarcerated hernias, recur-
rent hernias, femoral hernias, or in the treatment of postoperative
chronic pain [30].
Identification of and Respect for the

Three Nerves
As previously mentioned, intraoperative nerve injury has been shown
to correlate independently with postoperative pain-related impairment
[1]. Damage to, or entrapment of, one or more of the three inguinal
nerves passing through the operative field may cause neuropathic pain.
It is not always possible to follow traditional teaching dictating that
every effort should be made to identify, preserve, and prevent traumati-
zation or interruption of the inguinal nerves during operation. Inguinal
nerves might interfere with placement of mesh or might be traumatized
inadvertently during the operation. Several patterns of nerve injury dur-
ing elective inguinal hernia repair have been described, including
inadvertent suture entrapment, partial division, crushing, diathermy
burn, or scar encroachment [31]. Identification and routine excision or
division of selected inguinal nerves, termed pragmatic neurectomy,
during inguinal hernia repair has been proposed as a method for avoid-
ing postoperative neuralgia [32].
Overall, the systematic review and meta-analysis proposed by Hsu
et al. [33], including six RCT studies, indicate that preserving the ilioin-
guinal nerve during open mesh repair of an inguinal hernia was associ-
ated with decreased incidence of sensory loss at 6 and 12 months
postoperatively compared with nerve division technique. They found no
difference between the two surgical procedures in regard to the occur-
rence of chronic groin pain or numbness. In the 2014 update of the
European Hernia Society Guidelines for the treatment of inguinal hernia
in adults [34], all studies with the longest follow-up interval were com-
bined in a new meta-analysis, and they concluded that routine prophy-
lactic resection of the ilioinguinal nerve is not recommended (Grade A).
It remains speculative whether this approach would be beneficial in a
subset of patients with preoperative risk factors for chronic pain [34].
Importantly, five of the six studies included in the meta-analysis
compared the effects of nerve preservation and of prophylactic neurot-
omy for just the ilioinguinal nerve, ignoring that all three nerves contrib-
ute to the sensory innervation of the groin.
Only the study reported by Karakayali et al. [35] focuses on the addi-
tional role of the iliohypogastric nerve: in this study patients had been
divided into a nerve preservation group, ilioinguinal neurectomy group,
iliohypogastric neurectomy group, and a group in which both nerves
were transected. The only significant difference between the groups for
chronic groin pain at the 1-year postoperative follow-up was between

the nerve preservation group and the dual nerve transection group, in
favor of the latter.
The majority of surgeons do not routinely detect all three inguinal
nerves: the identification of the iliohypogastric nerve ranges between 32
% [36] and 97.5 % [37] of cases and for the genital branch of the geni-
tofemoral nerves ranges between 21.3 % [37] and 36 % [36] of cases.
An Italian prospective multicenter study [38] of 973 cases and a French
single center study [39] of 1332 cases are the only two published studies
reporting the results of the role of the identification of all three inguinal
nerves (2305 cases all together) with a long follow-up period (ranging
from 1 to 5 years). Both studies concluded that identification and pres-
ervation of all three inguinal nerves during open inguinal hernia repairs
reduce chronic incapacitating groin pain to less than 1 %: the mean
incidence of chronic pain was 0.8 % (range 01.6 %). The Italian study
[38] also demonstrated that the risk of developing inguinal chronic pain
increased with the number of nerves concomitantly undetected. Likewise,
the division of nerves was correlated strongly with the presence of
chronic pain.
Results from studies reporting data concerning division or neurec-
tomy versus preservation of only the ilioinguinal nerve without giving
any data concerning the other two nerves may be distorted because the
two nerves not considered could be unintentionally divided or injured
during the operation and, for this reason, chronic pain may result [40].
For all these reasons, we strongly suggest the identification and protec-
tion of all three inguinal nerves, to avoid removing the nerves from their
natural bed as much as possible, and not to remove their covering fascia,
as recommended in the international guidelines [41]. In case of a sus-
pected or clearly injured nerve or an at risk nerve running in the way
of the repair, pragmatic neurectomy is recommended with complete
removal and reimplantation of its proximal cut end into the underlying
muscle [41].
We also suggest that attention should be given during the placement
of mesh to minimize mesh contacting or distorting the course of the
inguinal nerves (the medial edge of the mesh sometimes meets and
crosses the ilioinguinal or often the iliohypogastric nerve): in this case
neurectomy can be done or, preferably, a small window in the edge of
the mesh can be cut so that the interaction between mesh and nerve is
minimalized.
Choice of the Prosthesis: Plug, Mesh,

Lightweight Versus Heavyweight,
and Absorbable Versus Nonabsorbable
Polypropylene mesheswere developed in 1959 and have been used

commonly since then. Although the use of synthetic mesh substantially
reduces the risk of hernia recurrence [42], polypropylene meshes have
been found to cause chronic inflammatory reactions that persist for years
and can have potentially negative effects, including chronic pain [43].
It has been surmised that the extent of the foreign body reaction with
its provoked scar tissue is correlated with the amount of the synthetic
material used [44]. This led to the development of so-called lightweight
mesh characterized by a reduction in the polypropylene volume, an
increase in the pore size, or different web structures [45, 46].
The meta-analysis of RCTs reported by Uzzman et al. [47] shows that
lightweight mesh is associated with significantly less chronic groin pain
(14.3 %), compared with heavyweight mesh (20.3 %) in Lichtenstein
inguinal hernia repair, and less foreign body sensation (15.2 % vs. 26.1
%). These benefits did not appear to be at the expense of an increased
rate of hernia recurrence. Smietanski [48] performed a meta-analysis
including two more studies in addition to those included in Uzzaman
et al. study: results were similar, but there was no difference in the two
groups for severe chronic pain. Therefore, while there is clearly a benefit
with regard to foreign body sensation, it is still uncertain whether light-
weight mesh has a real clinical benefit over heavyweight with regard to
severe inguinodynia. No statistical significance was found regarding
chronic pain at 5 years in an RCT comparing Lichtenstein with the PHS
[49]. We advise lightweight meshes especially in thin patients and in
case of small indirect inguinal hernia.
Choice of Fixation
Another factor that should be addressed concerning the prevention of
pain is the influence of fixation of the mesh. Penetrating fixating or
traumatic devices like sutures, staples, and tacks cause local trauma that
may result in nerve injury and chronic pain and should, therefore, be
used with caution.
A prospective randomized multicenter trial [50] reported a significant

reduction in postoperative pain at 1 and 6 months and a 45 % reduction
in incidence of a composite end point regarding chronic disabling com-
plications (pain/numbness/groin discomfort) at 1 year after Lichtenstein
repair with fibrin glue (heavyweight) mesh fixation compared to stan-
dard suture fixation. The first study on the use of the self-gripping
Parietene Progrip mesh (large pore polypropylene with resorbable poly-
lactic acid microgrips) also demonstrated less pain on the first postop-
erative day versus the use of another large pore polypropylene mesh
without gripping capacity [51]. Three other randomized studies compar-
ing atraumatic (cyanoacrylate glue, self-fixating mesh) versus suture
fixation in Lichtenstein hernioplasty with a large pore mesh showed no
difference in acute or chronic pain [5254]. Atraumatic mesh fixation
(glue, self-fixating mesh) is more expensive than standard fixation,
although the operation time was shorter in the majority of the studies.
All studies with at least 1-year follow-up showed no differences in
recurrence rates. We prefer to adopt a sutureless technique [55] or a
fibrin glue technique: the latter is essential when a lightweight mesh is
chosen because it allows an immediate fixation and prevents mesh dis-
location during closure.
Administration of a Proper Postoperative Therapy

Inadequately treated postoperative pain may be a risk factor for persis-
tent pain after hernia surgery [1]. A systematic review of RCTs up to
March 2009 [56] emphasizes the use of a pre- or intraoperative field block
(ilioinguinal, iliohypogastric, genitofemoral nerve) with or without local
wound infiltration for all patients undergoing open inguinal hernia sur-
gery. The same authors describe a standardized approach to postoperative
pain consisting of paracetamol and conventional NSAID or Cox-2-
selective inhibitors, followed by opioid administration if needed.
Conclusion
In conclusion, for primary inguinal hernias, surgeons should identify
for each individual patient the operative technique they know to be saf-
est in their own hands and with the lowest risk of postoperative pain. It
is important to keep in mind the features of patients at risk for postoperative
pain and in these cases consider, if available, the laparoscopic approach
(and in the case of PIPS the complete approach we suggested previ-

ously). The surgeon is always reminded that a proper physical examina-
tion and clinical history investigation can avoid mistakes in the choice
of optimal technique.
Choosing the operative technique means not only selecting the right
approach, but also identifying the right anesthesia, the right mesh, and
the correct fixation technique for each patient (tailored approach).
It is usually preferable to use local anesthesia in adult patients (on the
condition that the surgeon is experienced in its use), while sedation or
general anesthesia in the case of anxious and apprehensive patients or
with large scrotal hernias can be used.
The anterior open approach is recommended for primary inguinal her-
nias [or in case of a first recurrence, high lateral (indirect) reducible
hernia with a small defect in the thin patient, recurrence R1 according to
the Campanelli classification] [57]. The posterior open preperitoneal
approach with general anesthesia (Wantz or Stoppa) is reserved for the
treatment of very large, incarcerated hernias, femoral hernias, postopera-
tive chronic pain, and recurrent R2 [first recurrence, low medial (direct)
reducible hernia with a small (<2 cm) defect in the thin patient] and recur-
rent R3 (multi-recurrent hernia and/or not reducible, large wide defect in
the posterior inguinal wall, femoral recurrent).
Ideally, nerve identification and preservation with a no touch tech-
nique for all the three inguinal nerves is recommended. However, if this
cannot be achieved, pragmatic neurectomy with division of an injured or
at risk nerve is preferred.
The choice of a light- or medium-weight polypropylene flat mesh for
normal patients is recommended, and we prefer lightweight mesh for
thin patients with an indirect inguinal hernia or in the treatment of
PIPS. We prefer a sutureless or glue fixation of the mesh to minimize the
risk posed by fixation. Always provide appropriate postoperative anti-
inflammatory therapy in full dose for 7 days to minimize the risk of con-
verted severe acute pain to chronic pain. These considerations based upon
best available data will help to optimize outcomes and limit the incidence
and severity of chronic pain with open hernia repair techniques.
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29. Prevention of Pain: Optimizing
the Laparoscopic TEP and TAPP
Techniques
Jorge Daes
Introduction
We have known for a long time that fast and accurate surgery is
associated with good postoperative outcomes, including relatively low
levels of postoperative pain. However, it is difficult to determine the
precise maneuvers that affect outcome. This is especially true in the
field of inguinal hernia surgery, where there is a wide variation of
techniques among surgeons, and data about different techniques show
conflicting results.
It was previously hoped that meta-analyses would answer most of our
questions about optimal surgical techniques, but such analyses are
limited by lack of methodological rigor in studies and by the fact that
biological systems (as well as social and economic systems) are com-
plex and cannot be completely understood by the usual methods of sta-

DOI 10.1007/978-3-319-21587-7_29
390 J. Daes
tistical analysis. Experience and common sense have therefore regained

their importance for determining optimal surgical techniques.
This chapter describes strategies for optimizing the laparoscopic
repair of inguinal hernias to prevent postoperative pain, based on review
of the relevant literature, our own experience, and the experience of
leading surgeons in the field.
General Aspects of Preventing Pain After

TEP and TAPP Hernia Repair
Surgeons should master the laparoscopicanatomy of the inguinal
region before performing laparoscopic inguinal hernia repair and should
be particularly aware of the anatomy of the inguinal nerves.
Surgeons should be appropriately trained in all techniques for laparo-
scopic hernia repair, including the totally extraperitoneal (TEP),
enhanced or extended view TEP (eTEP), transabdominal preperitoneal
(TAPP), and intraperitoneal onlay mesh (IPOM) techniques, in addition
to primary closure of defects. Comprehensive training allows surgeons
to offer the appropriate procedure according to individual patient char-
acteristics and to convert from one procedure to another if necessary.
One of the best ways to avoid pain after inguinal hernia repair is to
avoid operating on patients with unusual preoperative inguinal pain or
inguinal pain that is disproportionate to the hernia. Pain is usually not a
remarkable symptom of inguinal hernias, except in complex cases.
Many patients with disproportionate preoperative pain have a different
cause for their pain and develop chronic pain after hernia repair.
We recommend administration of a first-generation cephalosporin
during the induction of anesthesia. We do not routinely use prophylactic anti-
thrombotic medication, but use pneumatic compression devices in all patients.
Patients should be reexamined while standing immediately before
surgery, and the physical examination findings should be compared with
the laparoscopic findings. This is an excellent method for ensuring that
hernias are not missed.
We prepare the skin, drape the patient, and set up the equipment while
the patient is still awake (but sedated) so that surgery starts almost imme-
diately after the induction of anesthesia, thereby reducing costs and facili-
tating a faster recovery. Optimal muscle relaxation is important to ensure a
fast and easy procedure, and the anesthesiologist should be asked to pro-
vide a short period of full relaxation before the start of the operation.
29. Prevention of Pain: Optimizing the Laparoscopic TEP 391
Technical Aspects of Preventing Pain After TEP

and TAP Hernia Repair
We inject long-acting local anesthetic into the skin before incision to
reduce postoperative pain [1]. Surgeons should be able to perform sur-
gery both in a triangulated position and with the camera lateral to the
working ports, so that they can adapt to different setups.
When using the TEP technique, the use of a balloon trocar to create
the surgical space makes the procedure easier and faster and reduces
blood loss, which may result in less postoperative pain [2].
The eTEP technique creates a larger surgical space and allows a more
versatile distribution of ports than the TEP technique. The eTEP tech-
nique takes advantage of the fact that the preperitoneal space can be
reached from almost any part of the anterior abdominal wall [3]. A video
showing this technique can be found online [4].
The creation of large peritoneal flaps during the TAPP procedure
facilitates complete dissection of the myopectineal orifice of Fruchaud,
placement of a large mesh, and perfect apposition of the peritoneal edges
at the end of the procedure. This is a faster, less expensive, and less pain-
ful alternative to closing the peritoneum using tacks, glue, or sutures.
The peritoneal edges come together as CO2 is carefully released, and the
wound heals quickly. The findings of an experimental study support this
approach [5]. We have never closed the peritoneum, and other groups
have also reported that they do not close the peritoneum. We have not
experienced any cases of bowel obstruction or fistula using this
approach. For the same reason, we do not close accidental tears created
during the TEP or eTEP procedures. A video showing peritoneal apposi-
tion at the end of a TAPP procedure can be found online [6]. However,
not physically closing the peritoneal edges is controversial, and most
consensus statements recommend some type of peritoneal closure, with
suture closure being the most frequently used. The recent development
of barbed sutures has increased the ease of peritoneal closure.
We advise a stepwise approach to dissection. In the TEP procedure,
we dissect Coopers ligament (both ligaments in cases of direct hernias),
free the lax transversalis fascia from preperitoneal structures in cases of
direct hernias, dissect the space of Bogros, divide the posterior transver-
salis fascia that usually overlaps the indirect sac and peritoneum at the
level of the internal ring, and finally identify the indirect sac. A video
showing the seldom-mentioned posterior transversalis fascia is available
online [7]. Cauterization should be performed with care and avoided at
the triangle of doom and the electrical hazard zone or triangle of
392 J. Daes
pain. The use of fine, low-voltage instruments and bipolar cautery helps
to avoid damage to sensitive structures and to prevent residual hema-
toma, which is one of the most commonly cited causes of postoperative
pain.
One rarely mentioned cause of pain after hernia surgery is grasping
and traction of the cord structures, which is common during open sur-
gery. This pain may be caused by injury to the vasa nervorum. In
laparoscopic repair, traction may occur during separation of an indirect
sac from the cord structures, as some surgeons grasp the cord structures
to dissect them from the sac. We advise pulling the sac medially while
dissecting the fibrous and fatty tissues next to the cord structures, using
fine Maryland forceps without directly touching the cord structures. As
dissection progresses, the sac can be grasped more laterally and rotated
medially. This process is continued until the hernia sac is separated from
the vas deferens and the spermatic vessels by a bluish transparency.
Videos of these maneuvers are available online [8, 9]. It is then possible
to deal with the sac in two ways. If the sac does not extend deeply into
the scrotum, it can be reduced completely. In cases of large inguinoscro-
tal hernias, attempting to completely reduce the sac risks damage to the
cord structures and the development of orchitis. Failure to deal with the
distal sac, however, carries the risk of formation of large and sometimes
cumbersome hematomas, seromas, or pseudohydroceles. Repeated
drainage and occasionally surgery may be necessary in such cases.
We previously described a technique for managing the distal sac in
large inguinoscrotal hernias [10]. After ligating the sac and dividing it
distally, at the level of the internal ring, we reduce the distal sac by pull-
ing it out of the scrotum and fixing it high and laterally to the posterior
inguinal wall with tacks or sutures. Using this maneuver, we were able
to reduce the incidence and severity of seromas, with no cases of post-
operative orchitis, testicular pain, or neuralgia [10]. A video showing
this maneuver is available online [11].
The next step is parietalization of structures, which consists of proxi-
mal dissection of the sac and peritoneum to allow proper placement of
the mesh over the cord structures. Extensive proximaldissection helps to
prevent recurrence by rolling of the mesh or a sac sliding under the
mesh. Parietalization is complete when upward traction of the sac does
not move the cord structures. A video showing parietalization is avail-
able online [12].
Three important lipomatousstructures should be properly identified

during the laparoscopic repair of hernias: lipomas, a fatty spermatic
cord, and lymph nodes. Only the first of these should routinely be
removed to avoid hernia recurrence. Lipomas lie anterolateral to the
cord structures, are light yellow, have a thin capsule, are usually devoid
of accompanying vessels, and are easily dissected out of the internal
ring. A fatty cord, often seen in obese patients or in patients who have
undergone bariatric surgery, could be confused with a lipoma and par-
tially divided. A fatty structure with vessels running toward or from the
internal ring is usually a cord structure. Lymph nodes are usually posi-
tioned posterior and lateral to the cord structures, are dark yellow, are
not easily displaced, and bounce when pushed with the dissector.
Lymph nodes should generally not be resected, to avoid bleeding and
nerve damage. The nerves usually run posterior to the lymph nodes. A
video showing these structures can be found online [13].
One meta-analysis concluded that the use of a low-weight mesh (less
material, large pores, some elasticity) lessens the risk of postoperative
pain, groin stiffness, and foreign body sensation, especially during the
first few months after laparoscopic inguinal hernia repair [14]. However,
another meta-analysis did not have the same findings [15]. Some studies
found that the use of a very-low-weight mesh increased the risk of recur-
rence, probably because of the difficulty of fixing the mesh and the
tendency of the mesh to roll up. We use a mid-weight (45 g/m2), large-
pore, polyester mesh. A low- or mid-weight polypropylene mesh is also
suitable. The mesh should be at least 1517 1012 cm in size to com-
pletely cover the myopectineal orifice of Fruchaud.
Many studies have reported that lack of fixation does not increase the
recurrence rate, reduces the cost of the procedure, and is associated with
less postoperative pain, but most of these studies focused on small her-
nias (defects of <3 cm) or included patients with unmeasured defects
[1620]. The mesh should be fixed according to the learning curve and
preference of the surgeon, especially for direct or large hernias.
Tacks are known to cause postoperative pain, but this can be avoided
by careful placement. Two tacks placed over Coopers ligament and one
placed high on each of the superomedial and superolateral corners of the
mesh are all that are needed. Some studies have reported that the use of
fibrin glue causes less acute and chronic pain than stapling, with no dif-
ference in recurrence rate [2125]. Other studies have not found clear
394 J. Daes
differences in chronic pain rates according to the method of mesh fixa-

tion [2628]. Other options include the use of self-fixing meshes [29]
and cyanoacrylate.
At the end of the TEP procedure, the inferolateral corner of the mesh
should be held in position with a closed grasper (if not fixed by glue or
a carefully placed suture) to ensure that it does not roll up anteriorly and
medially while the CO2 is slowly released. We instill diluted bupivacaine
into the space at the end of the procedure, which we believe improves
recovery, but we do not have definitive evidence to prove this hypothe-
sis. The final maneuvers can be observed in a video posted online [30].
Associations Between Surgical Techniques

and Types of Postoperative Pain
Most of the strategies described in this chapter help to prevent
nociceptive-type postoperative pain, and some help to prevent visceral-
type postoperative pain. The most troublesome postoperative pain is
chronic neuralgic pain, which has specific causes. lvarez studied a
series of cases with well-documented dermatome mapping and surgical
exploration and found that the ilioinguinal nerve was the most com-
monly injured nerve (60 %) during laparoscopic inguinal hernia repair
(see Chap. 21). This nerve descends from the lumbar plexus, penetrates
the abdominal wall muscles, and turns abruptly at the anterior superior
iliac spine to run transversely, eventually lying anterior to the cord
structures. The nerve is not exposed during the laparoscopic approach
but may be injured when a tack penetrates deep into the abdominal wall
along the imaginary line between the anterior superior iliac spines,
which is an unacceptably low place for fixation. This may occur when
using a small mesh or with low placement of the mesh. Tacks should
therefore be placed very high on the posterior inguinal wall. The femoral
branch of the genitofemoral nerve was the next most commonly injured
nerve (40 %) and was usually injured during dissection. The study did not
include any cases of injury to the lateral femoral cutaneous nerve, and
the occurrence of this injury is generally overstated. It is also useful to know
that an intact epineurium prevents nerve damage from adjacent mesh.
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30. Prophylactic Neurectomy Versus
Pragmatic Neurectomy
Ryan Berg and Matthew I. Goldblatt
Editors Comment (DCC)

The data presented in this chapter represent the best available high-
quality studies to date on this topic. The counterargument to the proposi-
tion of prophylactic neurectomy is that the incidence of significant chronic
pain may be reduced to less than 1 % with three-nerve identification and
meticulous operative technique (Alfieri S et al. International guidelines for
prevention and management of post-operative chronic pain following
inguinal hernia surgery. Hernia. 2011;15(3):23949). This is lower than
the rates of pain reported in both the control and prophylactic neurectomy
groups in each of these cited studies. If pain rates can be reduced with
good technique, intentionally causing the sensory disturbances or risk of
deafferentation pain with neurectomy in all patients may be considered
unnecessary. Pragmatic neurectomy was coined in response to the
concept of prophylactic neurectomy and simply refers to the logical prac-
tice of performing a neurectomy at the time of hernia repair whenever a
nerve is recognizably injured or is at risk for injury due to its neuroana-
tomic location, course, or operative factors. Neurectomy in these cases is
absolutely recommended. The authors conclusion that no patient in each
of these studies developed severe pain is significant, and prophylactic
neurectomy in at-risk individuals is likely prudent. Mild sensory distur-
bances and numbness are vastly preferable to chronic pain in high-risk
patients. Using preoperative risk calculators such as the Carolinas
Equation for Quality of Life (CeQOL;www.carolinashealthcare.org/ceqol)
and understanding high-risk populations for the development of chronic
pain will help surgeons to decide who will benefit from prophylactic neu-
rectomy. Tailoring the right operation for each patient in conjunction with
a good informed consent makes for good practice.

DOI 10.1007/978-3-319-21587-7_30
398 R. Berg and M.I. Goldblatt
Introduction
Chronic inguinal neuralgia is one of the most common and signifi-
cant complications following open inguinal hernia repair. Incidence of
long-term (1 year) postoperative neuralgia following Lichtenstein
repair ranges from 6 to 29 % [1]. Subsequent patient disability can be
debilitating and require multiple further interventions for treatment.
Further, while many cases result in out-of-court settlement, it is worth
noting that 57 % of patients with postoperative inguinal neuralgia will
sue their surgeon [2].
The ilioinguinal nerve is a sensory nerve that innervates the skin over
the groin, the medial aspect of the thigh, the upper part of the scrotum,
and the penile root [3]. Routine ilioinguinal neurectomy has been adopted
by many as a means of minimizing the troubling pain that can result from
inguinal dissection and hernia repair. It is proposed that excision of the
nerve would eliminate the possibility of nerve entrapment, inflammation,
neuroma, and fibrosis. The counterargument to this practice is that rou-
tine nerve excision may not only decrease the incidence of chronic groin
pain, but it may also cause disturbing and potentially disabling neuro-
logic deficits in the aforementioned distribution, including both decreased
touch and pain sensations. Examining these arguments is certainly chal-
lenging, in large part owing to the significant subjectivity and variability
that is inherent to a patient rating his or her severity of pain and loss of
sensation. That said, the issue of chronic groin pain after inguinal surgery
is by its very nature a subjective complaint, and as such subjective data
are necessary and valuable in its study.
Pragmatic Neurectomy
Routine neurectomy is a concept that is not unique to inguinal sur-
gery and is commonly practiced in other general surgical procedures. In
1998, Abdullah et al. performed a randomized, controlled trial studying
routine division versus preservation of the intercostobrachial nerve in
patients undergoing axillary dissection for breast cancer [4]. This study
was performed in an intention-to-treat fashion and as such was essen-
tially a comparison between routine and pragmatic neurectomies. The
study demonstrated that there is increased incidence of sensory loss at
hospital discharge in the routine neurectomy group (78 vs. 60 %,
p < 0.05), as well as pain (30 vs. 16 %, p < 0.05). However, differences
30. Prophylactic Neurectomy Versus Pragmatic Neurectomy 399
in pain, diminished sensation, sensory loss, and paresthesia were lost by

3-month follow-up [4]. While the authors suggest that nerve preserva-
tion may be favored given the early symptomatic differences, the longer-
term follow-up results suggest nerve division does not portend significant
functional or sensory deficits. In addition, nerve pain during inguinal
hernia repair is typically due to nerve entrapment within suture or mesh,
which are not used during axillary dissection.
Ravichandran et al. were among the first to perform a randomized
trial on the topic of ilioinguinal neurectomy [5]. This study was, and still
is, unique in this body of literature in that it is self-controlled. The
authors enlisted patients who were planned for bilateral inguinal hernia
repair and randomized the patients right or left side to undergo routine
neurectomy, while the other side had nerve preservation. In comparing
the neurectomy side to that of nerve preservation, there was no differ-
ence in pain rated on a 10-point scale noted on postoperative day 1 (2.9
vs. 2.5, p = 0.98). At 6 months, just two patients complained of minor
wound discomfort, one on the divided side and one on the preserved
side. Physical examination on patients 6 months postoperatively
revealed an increased incidence of diminished touch sensation on the
divided side (9 patients vs. 1 patient; no p-value given) as well as
increased incidence of diminished pain sensation (8 vs. 5; no p-value
given). However, it is important to note that just two of the 20 patients
reported any symptoms of numbness at their 6-month follow-up, includ-
ing one complaining of lateral thigh numbness, an area not supplied by
the ilioinguinal nerve [5]. As such, it is reasonable to conclude from this
study that patients undergoing routine neurectomy do not have increased
incidence of immediate postoperative nor chronic pain, nor do they have
increased incidence of symptomatic sensory loss. The study is under-
powered to provide statistically significant differences in these groups
and does not provide statistical analysis of all its data; however, it is a
landmark and otherwise well-designed study of the debate.
As routine neurectomy in inguinal hernia repair increased in popular-
ity, so did the size of the studies. Tsakayannis et al. prospectively
observed a cohort of 191 patients, all of whom underwent routine, elec-
tive resection of both the ilioinguinal and iliohypogastric nerves [6].
These patients were followed up at 1 month, 6 months, and 1 year to
determine their pain rating and degree of sensory loss. At no point post-
operatively did any patient report moderate or severe pain. 9.4 % of
patients reported subjective numbness at 1 month, while at both 6 and 12
months postoperatively, 6.3 % of patients noted numbness. Patients who
complained subjectively of sensory loss were subjected to a detailed
physical exam. Just two patients (1 %) had sensory loss confirmed in the
distribution of the excised nerves on exam, of which neither deficit was
found to be disabling [6]. This study was certainly limited by its obser-
vational nature with lack of a control group; however, it serves to dem-
onstrate in a large cohort that neurectomy may be safely performed in the
inguinal region without disabling consequences.
Perhaps the largest study on the topic of neurectomy during inguinal
hernia repair came from Picchio and colleagues. In 2004, they enlisted
813 patients in a double-blind study and randomized them into routine
ilioinguinal nerve transection versus preservation [7]. They followed
these patients at 1 month, 6 months, and 1 year postoperatively. Utilizing
a survey with a 4-point pain scale (none, mild, moderate, severe), the
study did not find any significant differences in patient pain rating
between the two groups at any endpoint. The study did, however, find
differences in touch and pain sensation between the groups. These sen-
sory deficits were tested with focused, detailed physical examination on
follow-up visits. There was an increased incidence in loss of touch sen-
sation for those undergoing routine neurectomy at 1 month (49 vs. 21 %,
p < 0.001), 6 months (29 vs. 6 %, p < 0.001), and 1 year (11 vs. 4 %,
p = 0.002). There was also an increased incidence in loss of pain sensa-
tion for neurectomy at 1 month (56 vs. 45 %, p = 0.004) and 6 months
(33 vs. 25 %, p = 0.04). There was no difference in loss of pain sensation
at 1 year (9 vs. 8 %, p = 0.89) [7]. Given the size of enrollment and study
design, these were the strongest data to date suggesting that there is
increased incidence of sensory deficits for patients undergoing routine
ilioinguinal nerve excision. At the same time, the study did not address
the question of whether these deficits were disabling or disturbing to the
patient. As demonstrated previously by Ravichandran et al., it is possible
for patients to have little to no subjective complaints of sensory loss
despite objective physical exam findings to suggest that a deficit is pres-
ent. Again, given that the endpoints of chronic groin pain and troubling
or disabling neurologic deficits are primarily subjective in nature, to
disregard the patients subjective neurologic complaints is a shortcom-
ing of this otherwise strong evidence.
Prophylactic Neurectomy
As studies on this controversialtopic have continued, evidence has
become increasingly suggestive of a potential benefit of routine neurec-
tomy in combating chronic inguinal pain after hernia repair. Dittrick
et al. conducted a small retrospective chart review in 90 patients who

underwent open inguinal hernia repair. These patients had either routine
nerve preservation or nerve excision, primarily owing to differing prac-
tice patterns of two surgeons whose patients were included. Data were
obtained through patient interview, which in most cases included asking
the patient to recall the severity and duration of pain at different time
points. The endpoints assessed included 1 month, 6 months, 1 year, and
3 years postoperatively. The study found that patients who underwent
routine ilioinguinal neurectomy reported decreased incidence of neural-
gia at 1 month (5 vs. 21 %, p = 0.016), at 6 months (3 vs. 26 %,
p < 0.001), and at 1 year (3 vs. 25 %, p = 0.003). No difference was
observed at 3 years (6 vs. 8 %, p = 0.75). Additionally, patients were
asked to report postoperative paresthesia, and comparison between the
groups revealed no differences at any endpoint in the reported incidence
of sensory loss [1]. This study was clearly limited in a number of ways,
not the least of which includes a likely significant recall bias. The study
was also not randomized, had small enrollment, and may have been
influenced by the other surgical technical differences between surgeons,
and patients may not all have been blinded to the details of their proce-
dure. That said, this was one of the first studies to suggest an improve-
ment in outcomes in patients undergoing routine neurectomy during this
procedure and laid the foundation for more convincing evidence to
follow.
Among the more recent studies to examine this topic, Malekpour and
associates recently conducted a double-blind randomized controlled trial
comparing routine ilioinguinal nerve preservation to excision. One hun-
dred twenty one patients were studied, and their pain rated on a 10-point
visual analog scale (VAS). Their analysis revealed that the incidence of
chronic inguinodynia, defined as the presence of pain at 3 months post-
operatively, was lower in the nerve excision group (6 vs. 21 %,
p = 0.033). Further, the mean severity score on the VAS was noted to be
lower in the neurectomy group 1 day after surgery (2.2 vs. 2.8, p < 0.001)
as well as at 1 month (0.7 vs. 1.5, p < 0.001). However, at both 6 months
and 1 year, these differences had been eliminated, with median pain
scores of 0 in both groups. Patient rating of hypoesthesia at all time
points was also equivalent between the groups, with no patients com-
plaining of loss of sensation at 1 year in either treatment arm [2]. As with
much of the research on this topic, this study is limited in part by the
subjectivity of the data it analyzes. Given this, it is noted that cultural
differences may factor into these data, as this Middle Eastern study
population provided lower overall VAS scores when compared to their
Western counterparts. This only serves to reinforce that analyzing this

topic is quite challenging, as its subjectivity provides such variation.
Among the stronger evidence to date in support of routine ilioingui-
nal neurectomy in patients undergoing open inguinal hernia repair is that
from Mui et al. [3]. These authors also conducted a double-blind con-
trolled trial randomizing 100 patients to undergo either prophylactic
ilioinguinal neurectomy or nerve preservation. In follow-up, patients
were not only asked to rate their pain generally but also were asked to
rate their pain while performing various common tasks. These included
coughing 10 times, walking up three flights of stairs, and riding a bicy-
cle for 10 min. Groin sensation was also tested using the Semmes-
Weinstein monofilament test. Patients were followed up to 6 months
postoperatively. At 1 month, there was not a significant difference
between the groups in groin pain or sensation. However, at 6 months, the
overall incidence of chronic groin pain was significantly lower in the
routine neurectomy group (8 vs. 29 %, p = 0.008). This incidence of pain
at 6 months was also noted to be lower when climbing three flights of
stairs (2 vs. 14 %, p = 0.03) and cycling 10 min (4 vs. 20 %, p = 0.015).
There was no significant difference in pain noted between groups at rest,
during normal daily activities, or with coughing. There were also no
objective differences in groin numbness or loss of sensation. This study
is also notable for including patient overall quality of life in its analysis,
and it found no difference between groups at any time point, including
at baseline, 1 month, and 6 months [3]. This study is commendable in
that it studied pain with multiple tasks as well as included a quality of
life measure in its analysis and notable in that it demonstrated improved
pain ratings at 6 months in patients undergoing neurectomy. It is impor-
tant to note, however, that follow-up was fairly short compared to other
studies, and while routine nerve excision was noted to decrease pain
with various activities, it also showed no significant reduction in the
incidence of pain noted at rest, pain with normal activities of daily liv-
ing, or in patient-reported improved quality of life.
Despite an ever-growing set of data examining the practice of routine
ilioinguinal neurectomy in patients undergoing inguinal hernia repair,
there is lack of consensus regarding its efficacy and potential morbidity.
Again, this may be attributed in large part to the inherent subjectivity of
the endpoints in question, namely, the incidence of chronic pain and
disabling sensory deficit. While there are data that demonstrate an
increased incidence of objective sensory loss on detailed, focused physi-
cal exam after neurectomy, there are no strong data that support the
assertion that nerve excision increases the incidence of disabling or even
perceptible neurologic symptoms. Additionally, the data are also mixed

in regard to the efficacy of routine neurectomy in decreasing chronic
groin pain. That said, there are certainly no data to suggest that the inci-
dence of chronic groin pain is increased with routine neurectomy.
Further, the data do imply that there is at least equivalence in pain out-
comes with neurectomy, and there is increasing evidence in well-
designed trials that the incidence of chronic pain months after inguinal
hernia repair is decreased with routine neurectomy. Given this, it is these
authors opinion that routine ilioinguinal neurectomy is a reasonable
treatment option in patients undergoing open inguinal surgery as it does
not increase patient morbidity and there is an increasing body of evi-
dence that it may decrease incidence of chronic groin pain.
References
1. Dittrick G, Ridl K, Kuhn J, McCarty T. Routine ilioinguinal nerve excision in inguinal
hernia repairs. Am J Surg. 2004;188(6):73640.
2. Malekpour F, Mirhashemia S, Hajinasrolah E, Salehi N, Khoshkar A, Kolahi
A. Ilioinguinal nerve excision in open mesh repair of inguinal hernia results of a ran-
domized clinical trial: simple solution for a difficult problem? Am J Surg. 2008;95(6):
3540.
3. Mui W, Ng C, Fung T, Cheung F, Wong C, Ma T, et al. Prophylactic ilioinguinal neurec-
tomy in open inguinal hernia repair: a double-blind randomized controlled trial. Ann
Surg. 2006;244(1):733.
4. Abdullah T, Iddon J, Barr L, Baildam A, Bundred N. Prospective randomized controlled
trial of preservation of the intercostobrachial nerve during axillary node clearance for
breast cancer. Br J Surg. 1998;85(10):14435.
5. Ravichandran D, Kalambe B, Pain J. Pilot randomized controlled study of preservation
or division of ilioinguinal nerve in open mesh repair of inguinal hernia. Br J Surg.
2000;87(9):11667.
6. Tsakayannis D, Kiriakopoulos A, Linos D. Elective neurectomy during open, tension
free inguinal hernia repair. Hernia. 2004;8(1):679.
7. Picchio M, Palmento D, Attanasio U, Malarazzo P, Bambini C, Caliendo A. Randomized
controlled trial of preservation or elective division of ilioinguinal nerve on open inguinal
hernia repair with polypropylene mesh. Arch Surg. 2004;139(7):7558.
31. Triple Neurectomy Versus Selective
Neurectomy
Wolfgang M.J. Reinpold and Alexander D. Schroeder
Introduction
While recurrences after groin hernia repair have decreased after the
introduction of open and laparoscopic mesh techniques, today chronic
pain figures among the most frequent postherniorrhaphy complications
[16]. Despite the fact that the use of mesh does not lead to an increase of
chronic pain, the surgeons focus of interest has shifted toward the preven-
tion and treatment of chronic inguinodynia. Persistent postoperative pain
affects everyday activities in 58 % of patients [1, 2, 7, 8] and may cause
long-term disability. It is now widely accepted that surgery with inguinal
nerve neurectomy is the last treatment option for persistent posthernior-
rhaphy pain. Before neurectomy, multidisciplinary diagnostics with local
and paravertebral infiltrations, MRI of the lower abdomen and spine, and
a multimodal nonsurgical treatment of at least 6 months should be per-
formed. The pain management should include a pain specialist, and hernia
recurrence should be excluded. Details of the workup and management of
chronic postherniorrhaphy pain are described in Chap. 18.
Neurectomy: What Do We Know?

Currently, there are 19 reports on selective neurectomy and four pub-
lications on triple neurectomy available. Studies with less than 10 patients
were not considered in this report. Tables 31.1 and 31.2 [2, 823] sum-
marize the publications on selective neurectomy, and Table 31.3 [5, 6, 24,
25] shows the available data on triple neurectomy. All studies except one
have reported significant pain relief after neurectomy. After considering

DOI 10.1007/978-3-319-21587-7_31
Table 31.1. Selective neurectomy with follow-up <24 months.
Primary Pain Mesh New
Authors N surgery surgery Neurectomy removal mesh Pain relief Follow-up
Loos et al. [8] 54 Suture 24 Open IIN 44 Partly No Pain-free 25/49 18 months PE and Q
Mesh 30 GFN 25 19/54 Improved 12/49
Lap 10 IHN 9 Worsened 8/49
Starling et al. [9] 13 Open Open GB, IIN, or IHN No No 10/13 Not reported
Starling et al. [10] 17 Open Open GB, IIN, or IHN No No 12/17 Not reported
Heise et al. [11] 20 Open 17 Open IIN or IHN Yes No Improved 12/20 Phone-Q, PE
Lap 3
a a
Lee et al. [12] 11 Open 8 Open IHN, IIN, GFN, Nine improved 618 months, phone-Q
Lap 3 or LFCN
Deysine et al. [13] 22 Open Open IHN No No Twenty-two pain-free Not reported
Madura et al. [14] 100 Open 87 Open IHN, IIN, or Yes No Seventy-two pain-free 1 month, PE (no data)
Lap 13 GFN
a a
Kim et al. [15] 16 Open Open IIN or IIN + IHN 14/16 1246 months, phone-Q
Keller et al. [16] 21 Suture 2 Comb. IIN 2, IHN + IIN Yes Yes Pain-free 15/21 6 weeks, PE
Mesh 14 9, TNE 7 Improved 5/21 (no data)
Lap 6 Pain recur 1/21
Giger et al. [17] 39b Suture 20 Lapar. GFN 19 No No Improved 27/39 12 months PE
Mesh 9 ERN GFN + IIH 20
Lap 4
Vuilleumir et al. [18] 43 Open 31 Open IIN 35, IHN 11 Yes Yes Pain-free 41/43 12 months PE
Lap 12 Improved 2/43
BMR biologic mesh repair, Sr suture repair, Q questionnaire, PE physical examination, LFCN lateral femoral cutaneous nerve
a
Not reported, QL quality of life, Lapar ERN retroperitoneoscopic neurectomy
b
Includes noninguinal hernia surgery
Table 31.2. Long-term results after selective neurectomy (>24 months).
Primary Pain Mesh New
Authors N surgery surgery Neurectomy removal mesh Pain relief Follow-up
Bischoff et al. [2] 54 Open: mesh 46 Open Selective NE IIN 37 Yes No Improved 16/25 36 months, PE 3
Plug 8 IHN 19 Unchanged 6/25 months, Q pain,
GFN 10 Worsened 3/25 physical + sexual.
Function
Bower et al. [19] 12 Open Open IHN, IIN, GFN, No No Improved 9/12 66 months PE
LFCN (no data)
Ducic et al. [20] 19 Not reported Open Selective No No Improvement in 24 months PE
neurectomy pain and quality (no data)
of life 16/19
Zacest et al. [21] 18a Not reported Open Selective IIN 25, No No Pain-free 5/18 35 months (3108
GFN 2 Improved 7/18 months) Q
Koopmann et al. [22] 67 Open 54 Open Selective Yes 35 BMR Improved: BMR 32 bis 80 months,
Lap 13 neurectomy 32 SR 29/35 56 % phone-Q
SR 23/32
Valvekens et al. [23] 12 Open 2 Comb. Unspecified Yes 6/12 No Improved 4/12 32 months (11118
Lap 10 neurectomy Unchanged 7/12 months) Q
Worsened 1/12
BMR biologic mesh repair, Sr suture repair, Q questionnaire, PE physical examination
a
Includes noninguinal hernia surgery
31. Triple Neurectomy Versus Selective Neurectomy
407
408
Table 31.3. Triple neurectomy studies.

Primary Mesh New
Authors N surgery Pain surgery Neurectomy removal mesh Pain relief Follow-up
Amid and Hiatt [5] 415 Sr 212 Open TNE No No Pain-free 85 % 1 month 100%
Mesh 195 Improved 14 % 6 months > 90 %
Lap 8 PE and phone-Q
(no data)
Amid et al. [6] 16 Open Open Extended TNE Part. Part. Improved 14/16 46 weeks, PE
Lap Me Me (no data)
W.M.J. Reinpold and A.D. Schroeder
Campanelli et al. [24] 46 Open Open ant + post TNE 44 Yes Yes Pain-free 40/46 12 months
mesh IHN 2 40/46 42/46 Not improved 6/46 (1266 months)
PE 100 %
Chen et al. [25] 20 Open 10 Lap Lapar. ERTNE No 18 No Improved 20/20 22 weeks (1640
Lap 10 Yes 2 (Me) weeks) PE
Sr suture repair, Q questionnaire, PE physical examination, QL quality of life, TNE triple neurectomy, Lapar ERTNE retro-
peritoneoscopic triple neurectomy, Me meshoma
31. Triple Neurectomy Versus Selective Neurectomy 409
the cumulative data of three multiphase studies [25, 7, 16, 26], there
remained 21 studies with 1035 patients. Ninety-three percent of neurec-
tomies were performed after open inguinal hernia repair and 7 % after
laparoscopic procedures [transabdominal preperitoneal repair (TAPP);
totally extraperitoneal repair (TEP)]. Four studies with 497 patients
reported on triple neurectomy [5, 6, 24, 25] and 17 studies with 538
patients on selective neurectomy [2, 823]. The overall success rate
(patients pain-free or pain improved) of neurectomy is 87 %, 77 % after
selective neurectomy, and 98 % after triple neurectomy. The interpreta-
tion and comparison of the studies are limited due to different pre- and
postoperative pain assessments; different type, duration, and percentage
of follow-up; and limited reports on surgical complications. Eight studies
did not report on early complications at all [46, 9, 13, 19, 23, 24]. Four
trials assessed pain-related physical disabilities and restrictions of daily
activities [2, 7, 12, 17]. Three trials reported on pain during sexual activ-
ity [2, 7, 8].
Only seven studies included a workup of a multidisciplinary pain
team [36, 10, 17, 25], and 12 publications integrated preoperative
peripheral or paravertebral blocks in their study [8, 10, 11, 13, 1618, 20,
21, 2426]. Fifty-nine (5.6 %) of the neurectomies were performed ret-
roperitoneoscopically with a success rate of 80 % [17, 25]. Patients do
not seem to benefit from a general meshectomy. Table 31.4 [2, 5, 6, 825]
shows the success rates of neurectomies with or without mesh removal.
The Rationale of Selective Neurectomy

Starling et al. [9, 10] were the first to publish on neurectomy for the
treatment of disabling chronic pain after open inguinal hernia repair.
After a multidisciplinary approach with conservative pain treatment, as
well as local blocks of the inguinal nerves and paravertebral blocks of
L1 and L2, ilioinguinal and genitofemoral neuralgia were diagnosed in
19 and 17 patients, respectively. After a selective neurectomy of the
entrapped portion of the ilioinguinal nerve (IIN), 17 patients were
reported to be completely pain-free. Twelve patients improved after
neurectomy of the entrapped genitofemoral nerve (GFN). The authors
did not report on mesh removal, and there are no follow-up data in their
publications.
The selective neurectomy approach today is commonly used as an
alternative to the triple neurectomy concept coined by Amid and col-
leagues in 2004 [4]. The aim of a selective neurectomy is to resect only
410
Table 31.4. Improvement of pain after neurectomy with or without mesh removal [2, 5, 6, 825].
Pain-free Pain-free
or improved (n) or improved (%) Not improved (n) Not improved (%)
Neurectomy without mesh removal 516 95 30 5
W.M.J. Reinpold and A.D. Schroeder
Neurectomy with mesh removal 273 77 82 23

Neurectomy + mesh removal + new mesh implantation 154 87 23 13
Neurectomy + mesh removal without new mesh implant 117 66 61 34
painful and damaged nerves and to preserve those nerves that are intact
and unlikely to cause chronic pain. The concept of selective neurectomy
is supported by the fact that nerve resection may lead to neuropathic
pain and pain relapse in some cases even after several years [27, 28].
Thus, in this paradigm only definitely damaged nerves should be
resected. A nerve can be damaged by suture material, tacks, wadded
mesh, or fibrotic nerve encasing scar tissue. The problem consists in
diagnosing and differentiating damaged nerves from intact nerves before
and during a surgical exploration [4]. Especially after open hernia repair,
the spermatic cord and the inguinal nerves are surrounded by scar tissue.
During the primary operation or previous operations, inguinal nerves
might have been resected, which makes it sometimes very difficult or
even impossible to identify the nerves. The difficulty in performing a
selective neurectomy is clearly demonstrated in the well-designed recent
study by Bischoff et al. [2] that included 54 patients with chronic pain
after open mesh repair. The IIN, iliohypogastric nerve (IHN), and GFN
were identified in 40 (74 %), 20 (37 %), and 13 (24 %) patients, respec-
tively. Neurectomies of the IIN, IHN, and GFN were performed in 37
(69 %), 19 (35 %), and 10 (19 %) patients, respectively. The data show
that only 7 of 73 (10 %) identified nerves were preserved. Despite the
fact that all neurectomies in this study were performed by one experi-
enced surgeon, a triple neurectomy would have been possible in at most
10 (19 %) patients. Noteworthy is the fact that 3 years after neurectomy,
3 (12 %) out of 25 patients suffered from an increase of pain compared
to their preoperative pain intensity. Moreover, the study demonstrates
that even in a country with an excellent structured health-care system,
long-term data (36 months) could be obtained from only 25 patients
(46 %). The selective neurectomy studies include all single, double, or
multiple neurectomies that were not planned as a triple neurectomy
before the operation [2, 823]. These studies might also include opera-
tions where the surgeon planned a triple neurectomy but could not iden-
tify all of the three inguinal nerves.
After selective neurectomy, 77 % of the patients reported less pain or
were pain-free [2, 823]. In six studies the follow-up was 24 months or
longer (see Table 31.2) [2, 1923]. In these studies 60 % of the patients
improved. Twelve patients suffered from worse pain after selective neu-
rectomy [2, 8, 23]. The following early postoperative complications have
been reported: six wound infections, six hematomas, one wound dehis-
cence, one seroma, orchiectomy due to impingement in scar tissue, one
deep venous thrombosis, and one pulmonary thromboembolism [2, 8
23]. There were five publications of seven cases of ischemic orchitis
412 W.M.J. Reinpold and A.D. Schroeder
leading to testicular atrophy [2, 7, 8, 11, 21]. Two studies [2, 7] out of six
with mesh removal and without mesh replacement [2, 7, 8, 11, 14, 23]
reported six recurrences in 233 patients. In three studies of 88 patients
with mesh removal and mesh replacement, there were eight recurrences,
seven of these after acellular human dermis repair [16, 18, 22].
The Rationale of Triple Neurectomy

The open triple neurectomy was essentially developed by Amid [3
6], who published on 431 open cases that he performed himself. There
is only one triple neurectomy publication from another institution [24].
According to Amid [4], it is extremely difficult to pinpoint the ingui-
nal nerves involved in the pain pathology because:
1. The innervation fields of the three inguinal nerves overlap [9, 29].
2. The IIN, IHN, and genital branch (GB) of the GFN often have
peripheral communications, which results in an additional
overlap of their sensory innervation [29].
3. At the spinal level the IIN and IHN derive from T12 and L1,
and the GFN and IIN receive communication from the first
lumbar nerve [9, 29].
4. Frequently there is more than one nerve involved in the posth-
erniorrhaphy neuropathic pain complex syndrome.
Often peripheral nerve blocks and differential paravertebral root
blocks cannot precisely discern between damaged and intact nerves.
This finding led Amid [3, 4] to develop the concept of triple neurectomy.
By the triple neurectomy approach, all three inguinal nerves (IHN, IIN,
and GB) that potentially might be involved in the chronic pain pathology
are resected.
The concept of triple neurectomy was first published in 2002 [3, 4].
The entire length of the IHN, IIN, and GB of the GFN should be
resected as far proximally and distally as possible to be sure that the
pain-triggering segment of the nerve is included and intercommunica-
tions between the nerves are removed [3, 4]. Later Amid et al. [5]
focused their attention on the additional resection of the intramuscular
segment of the IHN.
After open or laparoscopic preperitoneal groin hernia mesh repair, the
involved segment of the GFN is often located proximal to the internal
ring. In these cases the resection of the GB at the level of the inguinal ring
is not sufficient. In these cases Amid and Chen [6] recommend the exten-
sion of the triple neurectomy to the preperitoneal space and additional

resection of the main trunk of the GFN, which can always be identified
on the ventral surface of the psoas muscle. According to Amid, the triple
neurectomy should be performed without mobilization of the spermatic
cord [3, 4]. Only plugs and wrinkled or wadded pieces of mesh
(meshoma) should be removed. Recently, Campanelli et al. [24] reported
on 40 cases of triple neurectomy with mesh removal and new mesh
placement. The open triple neurectomy and extended open triple neurec-
tomy are described in detail in Chap. 24.
Recently, Chen et al. [25] published a series of 20 retroperitoneo-
scopic triple neurectomies. After a medium follow-up of 22 weeks
(1640 weeks), all patients were pain-free or their pain had improved.
According to our recent anatomic study of the retroperitoneal inguinal
nerves on 30 fixed cadavers, the retroperitoneoscopic approach allows
for reproducible identification of the proximal portion of the IHN and
IIN on the surface of the quadratus lumborum muscle and the GFN on
the ventral surface of the psoas muscle [30]. The minimally invasive
approach allows for reliable proximal nerve identification and triple
neurectomy in a territory of virtually untouched tissue.
The results of the open and laparoscopic triple neurectomy are excel-
lent. Ninety-eight percent of the patients are either pain-free, or their pain
improved after surgery. There are no reports on pain relapse. However,
there are no long-term follow-up data available. Except for one minor
wound healing problem after open triple neurectomy and one small
lesion of the diaphragm during laparoscopic triple neurectomy (which
was intraoperatively fixed), there were neither surgical nor general com-
plications reported, especially no testicular or visceral complications [3].
Summary
Today neurectomy is the last treatment option for patients with dis-
abling persistent postherniorrhaphy pain. Selective or triple neurectomy
can be performed open or laparoscopically and give good results with
low morbidity. Wrinkled or wadded mesh and plugs should be removed
concomitantly. Patients do not seem to benefit from the removal of well-
incorporated mesh. According to the available data, triple neurectomy
seems to have an edge over selective neurectomy. However, more than
90 % of the published triple neurectomy data derive from a single insti-
tution with one dedicated surgeon [36, 24, 25]. There are no reports on
long-term follow-up after triple neurectomy and scarce long-term fol-
414 W.M.J. Reinpold and A.D. Schroeder
low-up data after selective neurectomy. Fortunately, postneurectomy

impairment of pain seems to be a rare complication. Moreover, interpre-
tation and comparison of the studies are limited due to heterogenous
demographics, different pre- and postoperative pain assessments, differ-
ent kinds and duration of follow-up, and limited reports on surgical
complications.
There is a strong need for high-quality randomized multicenter trials
with uniform pre- and postoperative assessment of pain and pain-related
functional and psychologic impairment, as well as long-term follow-up.
References
1. Werner MU. Management of persistent postsurgical inguinal pain. Langenbecks Arch
Surg. 2014;399(5):55969.
Hernia. 2013;17(3):33945.
3. Amid PK. A 1-stage surgical treatment for postherniorrhaphy neuropathic pain. Arch
Surg. 2002;137(1):1004.
4. Amid PK. Causes, prevention, and surgical treatment of postherniorrhaphy neuro-
pathic inguinodynia: triple neurectomy with proximal end implantation. Hernia.
2004;8(4):3439.
2011;213(4):5316.
7. Aasvang EK, Kehlet H. The effect of mesh removal and selective neurectomy on
persistent postherniotomy pain. Ann Surg. 2009;249(2):32734.
8. Loos MJ, Scheltiga M, Roumen RM. Tailored neurectomy for treatment of postherni-
orrhaphy inguinal neuralgia. Surgery. 2010;147(2):27581.
9. Starling JR, Harms BA, Schroeder ME, Eichman PL. Diagnosis and treatment of geni-
tofemoral and ilioinguinal entrapment neuralgia. Surgery. 1987;102(4):5816.
10. Starling JR, Harms BA. Diagnosis and treatment of genitofemoral and ilioinguinal
neuralgia. World J Surg. 1989;13(5):58691.
12. Lee CH, Dellon AL. Surgical management of groin pain of neural origin. J Am Coll
Surg. 2000;191(2):13742.
13. Deysine M, Deysine GR, Reed Jr WP. Groin pain in the absence of hernia: a new
syndrome. Hernia. 2002;6(2):647.
14. Madura JA, Madura JA, Copper CM, Worth RM. Inguinal neurectomy for inguinal
nerve entrapment: an experience with 100 patients. Am J Surg. 2005;189(3):2837.
15. Kim D, Murovic J, Tiel R, Kline D. Surgical management of 33 ilioinguinal and

iliohypogastric neuralgias at Louisiana State University Health Sciences Center.
Neurosurgery. 2005;56(5):101320.
16. Keller JE, Stefanidis D, Dolce CJ, Iannitti D, Kercher KW, Heniford BT. Combined
open and laparoscopic approach to chronic pain after inguinal hernia repair. Am Surg.
2008;74(8):695700.
17. Giger U, Wente MN, Buchler MW, Krahenbuhl S, Lerut J, Krahenbuhl L. Endoscopic
retroperitoneal neurectomy for chronic pain after groin surgery. Br J Surg.
2009;96(9):107681.
18. Vuilleumier H, Hubner M, Demartines N. Neuropathy after herniorrhaphy: indication
for surgical for surgical treatment and outcome. World J Surg. 2009;33(4):8415.
19. Bower S, Moore BB, Weiss SM. Neuralgia after inguinal hernia repair. Am Surg.
1996;62(8):6647.
20. Ducic I, West J, Maxted W. Management of chronic postoperative groin pain. Ann
Plast Surg. 2008;60(3):2948.
21. Zacest AC, Magill ST, Andersen VC, Burchiel K. Long-term outcome following
inguinal neurectomy for chronic pain. J Neurosurg. 2010;112(4):7849.
22. Koopmann MC, Yamane BH, Starling JR. Long-term follow-up after meshectomy
with acellular human dermis repair for postherniorrhaphy inguinodynia. Arch Surg.
2011;146(4):42731.
23. Valvekens E, Nijs Y, Miserez M. Long-term outcome of surgical treatment of chronic
postoperative groin pain: a word of caution. Hernia. 2015;19(4):58794. 2013 Jun 19
[Epub ahead of print] doi:10.1007/s10029-013-1125-4.
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25. Chen D, Hiatt JR, Amid PK. Operative management of refractory neuropathic
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scopic approach to chronic pain following open inguinal hernia repair. Hernia.
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27. Borsook D, Kussmann BD, George E, Becerra L, Burke DW. Surgically induced
neuropathic pain: understanding the perioperative process. Ann Surg. 2013;257(3):
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29. Moosman DA, Oelrich TM. Prevention of accidental trauma to the ilioinguinal nerve
during inguinal herniorrhaphy. Am J Surg. 1977;133(2):1468.
30. Reinpold W, Schroeder AD, Schroeder M, Berger C, Rohr M, Wehrenberg U.
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2015 Jun 17.
32. Chronic Groin Pain:
Mesh or No Mesh
Nathaniel F. Stoikes, David Webb, and Guy R. Voeller
Introduction
Inguinal hernia repair techniques have evolved over time. In the days
when tissue repairs were more prevalent, recurrence rates were as high
as the 1020 % range. For this reason, the primary outcome of impor-
tance was reduction of recurrence. Now that mesh-based repairs of
inguinal hernias have reduced recurrence rates, the outcome of postop-
erative chronic groin pain (CGP) has gained importance. The concern
for postoperative CGP has increased in direct correlation with the
increased use of synthetic mesh for inguinal hernia repair; thus, many
have thought the relationship was a causal one.
However, there are a multitude of risk factors and variables that influence
CGP after inguinal hernia repair. The exact role that mesh and its various
forms of fixation play in the development of postoperative CGP remains to
be determined. In addition, it remains unclear whether the incidence of CGP
has actually increased due to the use of mesh for inguinal hernia repairs. It
may be that groin pain had been an issue with tissue repairs and it was over-
looked due to the main focus on recurrence as an outcome measure.
It is the focus of this chapter to specifically evaluate not only the
objective data but also the perceptions surrounding the role that synthetic
mesh may play related to inguinal hernia repair and postoperative CGP.
Risk Factors
Regardless of the use of mesh, there are many factors that affect the
risk of development of CGP in inguinal hernia repair. The presence of
preoperative pain, psychosocial issues, and aberrant nerve anatomy can

DOI 10.1007/978-3-319-21587-7_32
418 N.F. Stoikes et al.
all contribute to postoperative CGP development. Furthermore, periop-

erative factors such as tissue and nerve trauma, seroma, hematoma, and
infection can all contribute to chronic pain. Some or all of these factors
can be present regardless of a mesh or non-mesh inguinal hernia repair
[1]. One must consider all of these risk factors when trying to determine
the reason for the development of CGP, but the focus of this chapter is
the role synthetic mesh may or may not play in the development of post-
operative CGP.
Mesh as a Foreign Body

There is no question that all synthetic mesh elicits an inflammatory
response. Whether that response is clinically significant is debatable.
Animal studies have shown that mesh in contact with nerves does cause
inflammatory changes characterized by an increase in fiber diameter and
increased nerve demyelination [2]. However, the clinical significance of
these findings in animals alone cannot be substantiated.
A translational study, Mesh-Related SIN Syndrome. A Surreptitious
Irreversible Neuralgia and its Morphologic Background in the Etiology
of Post-Herniorrhaphy Pain by Bendavid et al., has recently been pub-
lished. Given the title alone, one can surmise that the mesh is perceived
as the sole instigator of chronic pain, though perhaps not in the tradi-
tional manner of being a foreign body that causes inflammation. In this
study, a scientific model was implemented comparing 10 explants of
virgin tissue of the posterior inguinal wall, 10 explants of scar tissue
from tissue repairs, and 10 explants from mesh repairs. Mesh was not
found to significantly inhibit or promote nerve growth in scar. However,
deformation of mesh was found to provide potential compartments for
entrapment of nerves and to create more surfaces for random nerve
ingrowth into the mesh. These issues can be further potentiated by con-
traction and migration of mesh, which can occur after it is implanted [3].
Objective scientific findings from implanted mesh provide data to
support a convincing case for mesh-related chronic pain. However,
based on these findings, one should expect CGP to be an even larger
problem than it is currently. In fact, much of the existing clinical data
support the contrary. Therefore, despite evidence of the foreign body
reaction seen after synthetic mesh implantation, one must understand the
contemporary history and clinical data surrounding CGP to gain a full
perspective of this complex and multifactorial problem.
32. Chronic Groin Pain: Mesh or No Mesh 419
Perceptions
Perceptions about mesh use for inguinal hernia repair can vary
greatly; trying to understand the thoughts and biases of surgeons,
patients, and research data can be challenging. Some believe the use of
mesh in and of itself is the cause for the apparent increase in CGP. Others
believe there has not been an objective increase in CGP due to mesh, but
at the same time they recognize that mesh can play a role in the develop-
ment of CGP postoperatively.
Fischer recently wrote a commentary on the continued use of mesh for
inguinal hernia repair despite the human toll of inguinodynia [4]. He
comments that conventional tissue repairs had sound results, including
acceptable recurrence rates of 46 % and CGP in 24 % of patients. Along
the way, mesh repairs became more popular and with it his personal per-
ception of increased incidence of inguinodynia. These complications were
superimposed with issues of pending litigation, potential malingering by
patients for secondary gain, and ruined lives. After evaluating the data,
including mesh use and nerve management, he concludes that there has
been little gained by the use of mesh in inguinal hernia repair due to the
risk of chronic debilitating pain and really no improvement of recurrence
rates. He contributes the etiology of CGP to the inflammatory response of
mesh as it involves the three inguinal nerves (ilioinguinal, iliohypogastric,
and genital branch of the genitofemoral nerve). His recommendation is
that it would be better to learn to do tissue repairs, similar to the Shouldice
repair, so as to not create inguinodynia in patients, as it has significant
societal and economic implications. He also notes that the U.S. Food and
Drug Administration has become increasingly concerned about the issue
of CGP and the use of mesh.
The opposite view was expressed by Gilbert, a hernia surgeon spe-
cialist and originator of a commonly used mesh prosthesis for inguinal
hernia repair. He wrote a response to Fischers article with a perception
that was strikingly different, starting with the issue of inflammation due
to a foreign body [5]. He states, Ordinarily reactions to inert mesh are
minimal and short lived. He goes on to interpret the existing data that
incriminate mesh to have bias, as they are not the result of randomized
controlled trials. His personal experience includes both Shouldice tis-
sue-based repairs and thousands of mesh-based repairs. His perceptions
of CGP were that it occurred in his patients with recurrences and not
necessarily in those with mesh. He further states that the mesh repair
decreases the incidence of recurrence. His feeling is that CGP is due to
inadequate knowledge of the groin and is directly related to surgical
technique and not necessarily due to the use of mesh. He states the cause
of CGP is due to the absence of careful technique.
There is a difference of opinion between two expert and well-
respected surgeons regarding the issue of CGP after inguinal hernia
repair. As with most controversial issues, the answer lies somewhere
between these two extremes.
Studies Evaluating CGP and Mesh

One of the first papers to describe inguinodynia after mesh repair as
a clinical syndrome was from Heise and Starling [6]. They reviewed 117
patients with inguinodynia, 20 of whom had mesh removal, neurectomy
(when involved), and tissue repair (modified Bassini or McVay). Sixty
percent of patients had favorable results with their technique. Most
importantly, the authors did a review of CGP in non-mesh repairs and
reported that it was as high as 10.6 % with certain tissue repairs
(McVay), and that the etiology most commonly was entrapment of
nerves. They concluded by noting, We strongly believe that mesh
inguinodynia does occur, [and] will occur more frequently than antici-
pated now that mesh is used with impunity. This conclusion about mesh
in the study is interesting, given the historical data provided about cer-
tain tissue repair techniques having a predicted rate of chronic pain of
10.6 %. It also points out the fact that since mesh is now used much
more often than autogenous repairs, it is only natural that we speak
about CGP in relation to the use of mesh.
Since Starlings work there have been other reviews of CGP and the
use of mesh in inguinal hernia repair. Poobalan et al. reviewed CGP and
hernia repair in 2001 [7]. They defined chronic pain as pain that persists
for greater than 3 months. Forty studies were reviewed and they found
that the incidence of chronic pain ranged from 0 to 53 %. Moderate to
severe pain was experienced by up to 10 % of patients. Within the
review, they found three studies that looked at mesh versus non-mesh
repairs and the development of CGP. They found that two of the three
studies evaluated reported less CGP with the mesh-based repairs.
Aasvang and Kehlet also reviewed chronic postoperative pain in
inguinal hernia in 2004 [8]. In their review, they specifically looked at
studies comparing mesh versus non-mesh repairs, and they showed no
increase in the incidence of CGP with the use of mesh.
A more recent randomized clinical trial of mesh versus non-mesh
methods of inguinal hernia repair was done by van Veen et al. [9]. Three
hundred patients were reviewed with follow-up in 153 of the patients out
to a median of 129 months. None of the patients in either group had pain
as defined by persistent pain or pain interfering with daily activities.
Autogenous repairs including Bassini, McVay, and Shouldice tech-
niques were compared to the Lichtenstein repair. At all time points, pain
was similar with mesh repair trending toward less pain compared to
non-mesh repairs, except at 10 years when neither group had chronic
pain. This agrees with most comparative studies that have found the
incidence of CGP to be similar between the open mesh repairs versus the
autogenous repairs. The Hernia Trialists reviewed 20 trials and over
5000 repairs comparing mesh-based and non-mesh-based repairs for
inguinal hernia [10]. The incidence of CGP was equal in both groups.
Nordin et al. found similar results when comparing the mesh-based
Lichtenstein repair versus the autogenous Shouldice repair [11]. At
3-year follow-up, the incidence of CGP was 4.2 % in the Shouldice
repair and 5.6 % in the Lichtenstein group.
The differences between laparoscopic inguinal hernia repair with
mesh and the open autogenous Shouldice repair are even more pro-
nounced. Bittner et al. completed a meta-analysis showing CGP in 2.2 %
of laparoscopic repairs and 5.4 % of Shouldice repairs [12]. The SMIL
study reviewed laparoscopic transabdominal pre-peritoneal (TAPP)
repair versus open autogenous Shouldice repair and found CGP to be
similar between the two groups (8.5 % TAPP vs. 11.4 % Shouldice) [13].
Koninger et al. looked at 280 patients at 52 months follow-up and com-
pared the incidence of CGP in those having a Shouldice, Lichtenstein, or
TAPP repair [14]. CGP was found in 36 % of the Shouldice repairs, 31 %
of the Lichtenstein repairs, and 15 % of those with TAPP.
Looking at the collection of studies including autogenous and mesh
repairs, it becomes evident that mesh use may not be the sole cause of
chronic pain. An objective review of the data actually indicates that the
laparoscopic repair, which is a mesh repair, has the lowest incidence of
CGP. These findings indicate the complex nature of inguinal hernia
repair. Also of importance is the technical detail of each approach.
Mesh Weight
To complicate matters and to reinforce the concept of mesh and the
foreign body response, mesh weight has been speculated to contribute to
CGP. The general principle is that less synthetic mesh implies less for-
eign body, less inflammatory response, and therefore less pain.
Numerous studies have evaluated the differences between conven-

tional heavyweight (or normal weight) mesh and lightweight mesh and
the development of CGP. Bringman et al. evaluated 600 patients who
underwent hernia repair at 3 years [15]. Patients were randomized to
have implantation of polypropylene mesh of 80 g/m2 or a 30 g/m2. The
lightweight mesh group was found to have less pain and less sensation
of mesh. The lightweight mesh group was also found to have less
minor groin problems. Paajanen et al. reviewed 228 patients who were
randomized to various lightweight and heavyweight mesh options, and
these patients were followed up at 2 years [16]. There was no difference
in pain, quality of life, sensation of mesh, or hernia recurrences. Page
and ODwyer also found no difference in pain scores at one year
between patient groups (N = 300) who underwent repair with either par-
tially absorbable mesh or nonabsorbable mesh [17]. They did find a
significantly higher recurrence rate among patients who had repairs
using the partially absorbable mesh (5.6 vs. 0.7 %). Currently, there are
no strong data to confirm that mesh weight is a contributor to CGP in
inguinal hernia repair.
Fixation
Another cause of chronic pain in inguinal hernia repair may be the
type of fixation used to secure the mesh. There are a wide variety of
options, including sutures (absorbable and permanent), tacks (absorb-
able and permanent), and adhesives. These various options apply to both
laparoscopic and open techniques. Referring to open mesh repair, the
TIMELI trial by Campanelli et al. included 319 patients and compared
the use of fibrin sealant for fixation versus sutures [18]. At 1 year, there
were less disabling complications among patients in the adhesive group,
with less pain at 1 month and 6 months. Meta-analysis by Colvin et al.
also found a reduction in CGP with adhesive use in open inguinal hernia
repair with mesh [19]. Comparisons of suture material in open inguinal
hernia have been done as well. Paajanen randomized 162 patients to
absorbable (DexonTM, polyglycolic acid) versus permanent (polypropyl-
ene) suture fixation with Lichtenstein hernia repair [20]. At 2 years,
there was no difference between the two groups. Twenty-four percent
described some pain in follow-up, but over 90 % of patients were
satisfied with their result. In contrast, Jeroukhimov et al. conducted a
single-blinded randomized controlled trial comparing Vicryl (polygla-
ctin 910) and polypropylene fixation with a Lichtenstein approach [21].
There were 100 patients in each arm. Chronic pain rate and time to pain
disappearance were higher among patients in the permanent suture
group. Similar comparisons have been done comparing adhesive and
tacks in laparoscopy. Lovisetto et al. reviewed 197 patients with TAPP
repair randomized to fibrin glue or tacks and followed them out to 2
years [22]. Patients who had fixation with fibrin glue had significantly
less acute and chronic postoperative pain. Topart et al. evaluated 168
patients undergoing totally extraperitoneal (TEP) technique hernia
repair [23]. Chronic pain occurred in 14.7 % of patients who had tacks
for mesh fixation versus 4.5 % of patients with fibrin glue.
Basic science studies evaluating different fixation methods and their
effects on mesh and CGP are lacking. A recent study by Stoikes et al.
compared fibrin glue fixation of lightweight mesh with permanent
suture fixation in an animal model [24]. Though sutures were stronger
than fibrin glue at 24 h, fibrin glue fixation was found to be adequate at
24 h. At 1 week postoperatively, the fixation strength was equal between
the groups. A secondary outcome was evaluation of mesh contraction
between the two groups. The contraction rate was consistently greater in
the suture group compared to the glue group, although not statistically
significant. Possibilities affecting mesh contraction may be that the
adhesive group fixates the entire surface of the mesh, thereby preventing
folding and wrinkling. This ultimately allows the full area of the mesh
to be fixed in granulation tissue. Such a finding links to the previously
mentioned study by Bendavid, which showed that disfigured mesh cre-
ated potential compartments for nerve entrapment, leading to CGP [3].
Within the spectrum of mesh repairs, one can see that fixation choices
and careful application of fixation can play a role affecting CGP, inde-
pendent of the actual type of mesh used. The difference found with fixa-
tion alone is an example of the multitude of factors that can affect CGP
independent of mesh or mesh type.
Discussion
There is a full spectrum of opinions about the use of synthetic mesh
in inguinal hernia repair. There are valid points from both sides of the
controversy, but the data show that in reality CGP exists with both tissue
repairs and mesh repairs. Their etiologies are likely different. With tis-
sue repairs, CGP may be due to entrapment of nerves by layers of
sutures; with mesh, it may be due to nerve entrapment from mesh defor-
mation or a foreign body response causing nerve demyelination [2, 3].
However, the clinical data are not consistent and do not seem to corre-
spond with the objective findings found in the basic science. Overall,
autogenous and mesh repairs have been found to have similar outcomes
of CGP. Further complicating the landscape are the different outcomes
found with different techniques of either autogenous or mesh repairs. It
has been suggested that there is more CGP with the McVay repair com-
pared to the Shouldice repair [4]. There are the same issues found with
mesh repairs. Whether it is laparoscopic versus open, or fixation with
fibrin glue, tacks, or sutures, they have all been evaluated and found to
have different outcomes independent of the mesh. In fact, studies have
supported that the laparoscopic approach appears to have the best results
out of all autogenous and mesh repairs combined. Given this, mesh is
clearly not the sole cause of CGP in inguinal hernia repair.
CGP is a multifactorial process that is influenced by the innate com-
plexity of groin anatomy, psychosocial issues, and various technique
options requiring different anatomic knowledge for each approach. In
spite of the difference of opinion between Fischer and Gilbert, they both
indicated in their commentaries that the performance of excellent surgi-
cal techniqueregardless of actual technique choicewas one of the
most important factors in preventing CGP [4, 5]. Therefore, the best
approach for an inguinal hernia repair lies in the hands of the surgeon to
select a technique in which the surgeon has complete knowledge of all
the potential technical pitfalls and is the most comfortable performing.
References
1. Kehlet H, Aasvang E. Chronic pain after inguinal hernia repair. In: Schumpelick V,
Fitzgibbons RJ, editors. Hernia repair sequelae. Berlin: Springer; 2010. p. 1637.
2. Demirer S, Kepenekci I, Evirgen O, Birsen O, Tuzuner A, Karahuseyinoglu S, et al.
The effect of polypropylene mesh on ilioinguinal nerve in open mesh repair of groin
hernia. J Res Surg. 2006;131(2):17581.
3. Bendavid R, Lou W, Koch A, Iakovlev V. Mesh-related SIN syndrome. A surreptitious
irreversible neuralgia and its morphologic background in the etiology of post-hernior-
rhaphy pain. Int J Clin Med. 2014;5:799810.
4. Fischer JE. Hernia repair: why do we continue to perform mesh repair in the face of
the human toll of inguinodynia. Am J Surg. 2013;206(4):61923.
5. Gilbert AI. Hernia repair: do you know your own results? Am J Surg.
2013;207(6):10023.
8. Aasvang E, Kehlet H. Chronic postoperative pain: the case of inguinal herniorrhaphy.

Br J Anaesth. 2004;95(1):6976.
9. van Veen RM, Wijsmuller AR, Vrijland WW, Hop WC, Lange JF, Jeekel J. Randomized
clinical trial of mesh versus non-mesh primary inguinal hernia repair: long term
chronic pain at 10 years. Surgery. 2007;142(5):6958.
10. EU Hernia Trialists Collaboration. Mesh compared with non-mesh methods of open
groin hernia repair: systematic review of randomized controlled trials. Br J Surg.
2000;87(7):8549.
11. Nordin P, Bartelmess P, Jansson C, Svensson C, Edlund G. Randomized trial of
Lichtenstein versus Shouldice hernia repair in general surgical practice. Br J Surg.
2002;89(1):459.
12. Bittner R, Sauerland S, Schmedt CG. Comparison of endoscopic techniques versus
Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-
analysis of randomized controlled trials. Surg Endosc. 2005;19(5):60515.
13. Eklund A, Montgomery A, Bergkvist L, Rudberg C, Swedish Multicentre Trial of
Inguinal Hernia Repair by Laparoscopy (SMIL) Study Group. Chronic pain 5 years
after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair.
Br J Surg. 2010;97(4):6008.
14. Koninger J, Redecke J, Butters M. Chronic pain after hernia repair: a randomized trial
comparing Shouldice, Lichtenstein and TAPP. Langenbecks Arch Surg. 2004;389(5):
3615.
15. Bringman S, Ramel S, Heikkinen TJ, Englund T, Westman B, Anderberg B. Tension-
free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: a prospective
randomized controlled trial. Ann Surg. 2003;237(1):1427.
16. Paajanen H. A single-surgeon randomized trial comparing three composite meshes on
chronic pain after Lichtenstein hernia repair in local anesthesia. Hernia.
2007;11(4):3359.
17. Page B, ODwyer P. Does the choice of prosthetic mesh type make a difference in
postherniorrhaphy pain? In: Schumpelick V, Fitzgibbons RJ, editors. Hernia repair
sequelae. Berlin: Springer; 2010. p. 27986.
18. Campanelli G, Pascual MH, Hoeferlin A, Rosenberg J, Champault G, Kingsnorth A,
Miserez M. Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixa-
tion in patients undergoing Lichtenstein technique for primary inguinal hernia repair:
results of the TIMELI trial. Ann Surg. 2012;255(4):6507.
19. Colvin HS, Rao A, Cavali M, Campanelli G, Amin AI. Glue versus suture fixation of
mesh during open repair of inguinal hernias: a systematic review and meta-analysis.
World J Surg. 2013;37(10):228292.
20. Paajanen H. Do absorbable mesh sutures cause less chronic pain than nonabsorbable
sutures after Lichtenstein inguinal herniorraphy? Hernia. 2002;6(1):268.
21. Jeroukhimov I, Wiser I, Karasic E, Nesterenko V, Poluksht N, Lavy R, Halevy
A. Reduced postoperative chronic pain after tension-free inguinal hernia repair using
absorbable sutures: a single blind randomized clinical trial. J Am Coll Surg. 2014;
218(1):1027.
22. Lovisetto F, Zonta S, Rota E, Mazilli M, Bardone M, Bottero L, et al. Use of human
fibrin glue (Tissucol) versus staples for mesh fixation in laparoscopic transabdominal
preperitoneal hernioplasty: a prospective, randomized study. Ann Surg. 2007;245(2):

22231.
23. Topart P, Vandenbroucke F, Lozach P. Tisseel versus tack staples as mesh fixation in
totally extraperitoneal laparoscopic repair of groin hernias: a retrospective analysis.
Surg Endosc. 2005;19(5):7247.
24. Stoikes N, Sharpe J, Tasneem H, Roan E, Paulus E, Powell B, et al. Biomechanical
evaluation of fixation properties of fibrin glue for ventral incisional hernia repair.
Hernia. 2015;19(1):1616.
Part IV
Case Reports
and Patients Perspectives
33. Foreign Body Reaction,
Fibromyalgia, and Autoimmune
Disorders
Shirin Towfigh
Chief Complaint
There is chronic pain after inguinal hernia repair.
History
The patient is a 30-year-old female, BMI 22 kg/m2, status post-rou-
tine laparoscopic bilateral inguinal hernia repair with mesh.
Preoperatively, she had presented to her medical doctor with bilateral
lower pelvic pain and was diagnosed with presumed inguinal hernias.
She was evaluated by a general surgeon and found to have tenderness
along her groin areas bilaterally. Her pain was constant, worse with
straining during bowel movements, and worse with her menses. She was
offered exploratory laparoscopy and inguinal hernia repair. Laparoscopy
was normal and TEP inguinal hernia repair was performed with polypro-
pylene mesh.
Postoperatively, the patients health worsened to the point of debilita-
tion. Her preoperative pain did not resolve. In addition, she progres-
sively worsened in health. She developed chronic pelvic pain; cramping
of the lower abdomen and pelvis; urinary frequency; pain with full blad-
der; bloating; nausea; inability to tolerate normal meals; weight loss;
hair loss; subjective feeling of hotness without fevers, especially at
lower abdomen; thigh numbness and tingling; and feeling of swelling of
the upper thighs. She also had vaginal burning and pain. Her menses

DOI 10.1007/978-3-319-21587-7_33
430 S. Towfigh
were irregular and sometimes missed. Sexual intercourse was painful.

She was chronically fatigued. She was unable to work and uses a wheel-
chair, as she cannot tolerate walking long distances. She is found lying
in bed most of the day.
Physical Exam
The patient was found in fetal position, shivering, unable to be exam-
ined comprehensively due to severe pain. Temperature and other vital
signs were normal. Abdomen was mildly distended but soft. Incisions
were well healed. She had 4+ tenderness to light touch along bilateral
lower groin and upper thigh areas, without specific dermatomal distribu-
tion and no skin changes.
Nonoperative Management Options

The patient was first admitted to the hospital for pain control. This
included epidural catheter placement, which helped relieve many of her
symptoms. This allowed us to perform imaging and gynecologic and GI
evaluation to help determine the plan of care. She had already had intoler-
ances to many medications as well as certain tapes as noted from her prior
operation. During this hospitalization, she also showed intolerances (nau-
sea, rashes, swelling) from more medications, tapes, and even IV needles.
She was evaluated for autoimmune disorders as well as endocrine abnor-
malities and complement and nutritional deficiencies, all of which were
normal.
Imaging
Abdominal x-ray showed normal pelvis with normal bowel gas pat-
tern. Also, there was a normal number and placement of spiral titanium
tacks (i.e., 34 on each side, and none placed laterally). Magnetic reso-
nance imaging (MRI) of the anterior pelvis, non-contrast, with valsalva
and dynamic views demonstrated intact flat extraperitoneal mesh with
no hernia recurrence and no evidence of mesh-related fluid collection or
inflammation (Fig. 33.1). Pelvic ultrasound was concerning for adhesive
disease and endometriosis.
33. Foreign Body Reaction, Fibromyalgia 431
Fig. 33.1. MRI pelvis T2 axial image. Bilateral inguinal mesh found to be in
appropriate position (white arrows).
Operative Treatment
Based on extensive evaluation by gynecology and general surgery,
the patient consented to undergo laparoscopy for diagnoses of endome-
triosis and mesh-related chronic pain reaction. Laparoscopy demon-
strated severe endometriosis, and she underwent extensive adhesiolysis
and painstaking endometriosis excision, which involved her rectum,
uterus, adnexa, and pelvic side walls. The mesh was confirmed to be flat
and in appropriate position. No attempt was made at mesh removal.
Her postoperative recovery was difficult; she required a lot of assis-
tance from the pain management specialists to develop a combination
therapy of opioids, neuromodulating medications, muscle relaxants, and
antidepressants to help control her pain. She was also maintained on
hormonal therapy for her endometriosis.
Upon follow-up, much of her chronic symptoms remained. She con-
tinued to have chronic pelvic pain, fatigue, lower abdominal bloating,
pain with full bladder, swelling and tingling of the upper thighs, feeling
of hotness, and weakness of the extremities. She was losing her hair.
She could not maintain her weight. She remained in bed most of the day
and could not function to perform her normal daily activities. She had
weaned herself off of most of her medications, as they were ineffective
432 S. Towfigh
in addressing her symptoms or she developed intolerances to them, such

as nausea, vomiting, and dizziness. Evaluation by gynecology and fur-
ther imaging demonstrated no suggestion of recurrence of her
endometriosis.
Due to the direct relationship between the hernia repair with mesh
and her debilitated state at such a young age, she was offered laparo-
scopic mesh removal. She understood that this might not cure her of her
problem and that indeed there was no concrete diagnosis. Also, she
understood the risks of the procedure, which included the risk of nerve
injury and vessel injury at the time of mesh removal. She underwent
uneventful laparoscopic mesh removal bilaterally. No hernias were
noted after mesh removal.
Postoperative Course and Outcomes

In anticipation of a difficult postoperative course, she had an epidural
placed preoperatively. This allowed for smooth recovery postopera-
tively. She had shown sensitivity to many different pain medications and
was able to tolerate pain control with ice and acetaminophen. Pathology
of the mesh demonstrated dense fibrosis and chronic inflammation with
foreign body giant cell reaction. Over a span of 1 year, she was able to
recuperate toward a more normal life. Repeat MRI confirmed no hernia
recurrence. She is now eating and gaining weight. Her hair loss has
stopped. She is regaining her conditioning with physical therapy.
Discussion
It is unpredictable which patients may develop a mesh reaction. A
true mesh allergy is notable as an erythematous blotch on the skin, usu-
ally demarcating the exact dimensions of the mesh itself. There may be
associated edema or systemic reaction such as fever. Such a mesh
allergy is rare and few surgeons have witnessed it.
However, there does seem to be another reaction to mesh, specifically
to synthetic mesh, which is a foreign body reaction. To date, there is no
literature to support such a clinical problem and its presentation; how-
ever, we know that histologically this reaction does occur [1]. Also,
clinically, it has been shown very nicely that positron emission tomog-
raphy (PET) scan may be positive in patients with mesh implantation,
demonstrating the inflammatory response to synthetic mesh [2].
33. Foreign Body Reaction, Fibromyalgia 433
In my experience, patients with a mesh foreign body reaction present

in very nonspecific constitutional manner; however, many share similar
complaints. These include pain in the general area of the mesh implanta-
tion, bloating, edema, and feeling that their waist or pants size has
increased. It is not uncommon to have other gastrointestinal symptoms,
most commonly nausea and sometimes pain with defecation. Some have
intermittent diarrhea or constipation. Due to the predominance of the
bloating, many are diagnosed with irritable bowel syndrome (IBS). Most
get minimal to no response to IBS medications or changes in diet (e.g.,
gluten-free). Some have urinary symptoms, especially pain with full
bladder and urinary frequency and urgency. Many are diagnosed with
interstitial cystitis (IC) as a result. The feeling of temperature changes,
especially feeling hot in the area, is also a common complaint. Body
temperature is rarely over 99 Fahrenheit. Also, numbness, tingling, and
swelling of the lower body, mons/base of the penis, and upper thigh are
commonly seen symptoms. These symptoms may be in a general pattern
of the ilioinguinal or genital nerves, thus leading some to provide nerve
blocks, sympathetic blocks, or even neurectomies. In most situations,
there is no true neuralgia. Also, most fail treatment with anti-inflamma-
tories, steroids, neurological modulating agents (e.g., gabapentin, prega-
balin), and antidepressants.
Most patients with mesh-related foreign body reactions are female.
They are also often young and have demonstrated sensitivities and intol-
erances to a wide range of environmental allergens, medications, and
even tapes, the plastic of IV needles, and certain plastics and sutures.
Some patients are already diagnosed with fibromyalgia, which is
recognized as a diagnosable disorder by both the National Institutes of
Health and the American College of Rheumatology. Unfortunately, not
much is known about the cause of fibromyalgia, and there are likely
multiple subtypes that are yet to be determined. That said, patients with
fibromyalgia tend to be hypersensitized to pain and live in a heightened
inflammatory state. Thus, the use of inflammatory agents, such as syn-
thetic implants for hernia repair, can spiral the disease in these patients
out of control. Interestingly, as a manifestation of their disease, many of
these patients also have bowel and bladder derangements, thus the
prevalent diagnoses of IBD and IC among them. Endometriosis and
chronic pelvic pain are also notably higher in this patient population.
There also seems to be an overlap of this disease with autoimmune dis-
orders that affect inflammation at the tissue level, such as systemic lupus
erythematosus and rheumatoid arthritis [3, 4].
434 S. Towfigh
Conclusion
We have yet to prove a direct cause and effect of synthetic mesh and
chronic debilitating pain. However, some of usthose with surgical
practices that treat high volumes of patients with chronic pain after mesh
implantationhave noticed a commonality in a subset of these patients.
The details of their clinical presentation are noted above. Patients with
such a clinical presentation should be evaluated for a possible adverse
mesh foreign body reaction, and mesh removal should be a consider-
ation in their treatment plan. Many of these patients are already diag-
nosed with fibromyalgia or have an autoimmune disorder. Using the
same logic, I strongly recommend that patients who present with a
known diagnosis of fibromyalgia or autoimmune disorder should not
undergo implantation of any inflammatory agent, such as a synthetic
mesh, for their hernia repair. If a tissue repair cannot be performed, then
a biologic allograft may be considered. Perhaps in the future we will
have an understanding of the disease of fibromyalgia and a better under-
standing of the bodys reaction to mesh. And perhaps we will have an
objective diagnostic test for either fibromyalgia or mesh reaction prior
to implantation of such a foreign body.
References
1. Klinge U, Klosterhalfen B, Mller M, Schumpelick V. Foreign body reaction
to meshes used for the repair of abdominal wall hernias. Eur J Surg.
1999;165(7):66573.
2. Aide N, Deux J-F, Peretti I, Mabille L, Mandet J, Callard P, et al. Persistent
foreign body reaction around inguinal mesh prostheses: a potential pitfall of
FDG-PET. Am J Roentgenol. 2005;184(4):11727.
3. Hawkins RA. Fibromyalgia: a clinical update. J Am Osteopath Assoc.
2013;113(9):|6809.
4. Yunus MB. Role of central sensitization in symptoms beyond muscle pain,
and the evaluation of a patient with widespread pain. Best Pract Res Clin
Rheumatol. 2007;21(3):48197.
34. Patient with Groin Pain After
an Athletic Event
Kent W. Kercher
Chief Complaint
Left groin pain.
History
A healthy 20-year-old college scholarship football player presented
with a 6-month history of left groin pain. He was referred for possible
sports hernia related to pain that developed relatively acutely during
summer workouts prior to his most recent season. The pain was initially
localized to the pubic tubercle on the left and had improved somewhat
over the past 6 months with rest, physical therapy, and alterations in his
exercise routine, although he continued to have a deep, gnawing pain
localized to the left groin. There was no radiation of pain to the testicle
or into the left anterior thigh. He was able to play football during the past
season, but had significant ongoing discomfort with sit-ups, lunges, and
running, particularly when it involved quick changes in direction. Pain
was relieved with rest and oral anti-inflammatory medications. He had
been evaluated by an orthopedic surgeon who diagnosed athletic pubal-
gia and recommended general surgical consultation. The patient wanted
to begin spring practice in the upcoming months and preferred to pursue
surgical intervention as soon as possible in order to facilitate return to
competitive athletics.

DOI 10.1007/978-3-319-21587-7_34
436 K.W. Kercher
Physical Examination
Well-developed male. 510 246 lbs BMI: 35.
Abdomen: soft, non-tender. No masses.
Focused inguinal examination: Moderate tenderness to palpation at
the pubic symphysis, extending laterally along the pubic tubercles to
both sides of midline. Focal tenderness to palpation over the external
rings and inguinal canals. No palpable hernia defect on either side.
Increased discomfort with resisted sit-up. Internal and external hip rota-
tion negative for pain. Mild pain with adduction of the hips against
resistance.
Imaging
Magnetic resonance imaging (MRI) pelvis: Bilateral rectus abdomi-
nis and adductor longus aponeurosis pubic osteotendinous junction
avulsion injuries (Figs. 34.1, 34.2, 34.3, and 34.4). MRI findings of a
secondary cleft are visible on fluid-sensitive sequences as a curvilin-
ear fluid-signal interface that is continuous with the symphysis pubis
and undermines the inserting structures at the pubis.
Fig. 34.1. Right adductor tear with secondary cleft sign (fluid in pubic symphy-
sis).
34. Patient with Groin Pain After an Athletic Event 437
Fig. 34.2. Right rectus avulsion injury with secondary cleft (sagittal view).
Fig. 34.3. Right rectus avulsion with secondary cleft (axial view).
438 K.W. Kercher
Fig. 34.4. Left adductor tear with adductor edema and secondary cleft.
Diagnosis
Bilateral athletic pubalgia with MRI demonstrating bilateral rectus
abdominis and adductor avulsions from their insertions on the pubis.

Conservative treatment is the first-line therapy for musculoskeletal
strains of the groin. Nonsurgical strategies include anti-inflammatory
medications, deep massage, heat or ice, and prolonged rest followed by
gradual return to activity. Physical therapy may be effective and should
focus on core strengthening to allow for resolution of hip and pelvic
muscular imbalance. In patients with radiographic and clinical evidence
of osteitis pubis and/or adductor tendinopathy, fluoroscopically guided
injection of the symphysis pubis and adductor origin with local anes-
thetic and/or steroids may be effective.
Operative intervention is generally indicated for chronic pain of
greater than 23 months duration that is refractory to conservative man-
agement, including prolonged rest, physical therapy, nonsteroidal anti-
inflammatory drugs (NSAIDS), nerve blocks, and/or steroid injections.
For this patient, nonoperative treatment strategies had been employed

for 6 months without significant improvement in symptoms. Further
attempts at rehabilitation were felt unlikely to provide relief. Surgical
intervention was offered.
Operative Treatment
Laparoscopic Bilateral Transabdominal Pre-peritoneal (TAPP)
Repair The technique utilized for sports hernia repair is identical to the
standard repair of inguinal hernias and is well described in the literature.
Briefly, a three-port technique is used, with a Hasson cannula at the
umbilicus and one 5-mm port lateral to the rectus on either side of the
umbilicus. The peritoneum is sharply opened at the medial umbilical
ligament in a curvilinear fashion extending laterally. The pre-peritoneal
space of Retzius is entered medially and the bladder bluntly dissected
away from the pubis and Coopers ligaments. The inferior peritoneal flap
is retracted and the cord structures are dissected away from the
peritoneum. Any direct or indirect inguinal hernia defects are reduced.
The posterior aspect of the rectus insertion is inspected to confirm
evidence of attenuation or avulsion injuries of the rectus insertion onto
the pubis.
After development of a wide pre-peritoneal pocket bilaterally, a large
polypropylene mesh (minimum 12 15 cm) is used to reinforce the
entire myopectineal orifice on each side. Bilateral mesh prosthetics are
confirmed to overlap in the midline in order to provide for complete
reinforcement of the entire myopectineal orifice, Coopers ligaments,
and the pubic tubercle (Figs. 34.5 and 34.6). The mesh is secured with
several tacks or staples to Coopers ligament and then further secured
circumferentially with fibrin glue. No tacks or staples are placed into the
abdominal wall musculature and no mechanical fixation is utilized
below the iliopubic tract. The peritoneum is re-approximated. The same
procedure is performed for the contralateral groin in order to allow for
wide coverage of all potential inguinal defects on both sides.
Postoperative Course
The patient was discharged to home following surgery and seen in
follow-up at 2 weeks and at 6 weeks postoperatively. His postoperative
course was uncomplicated and he returned to activity following our
440 K.W. Kercher
Fig. 34.5. After development of a wide pre-peritoneal pocket, a large polypro-

pylene mesh (minimum 12 15 cm) is used to reinforce the entire myopectineal
orifice (left side).
Fig. 34.6. Polypropylene mesh reinforcement of the myopectineal orifice (right

side). Note mesh overlap of pubic tubercle in the midline.
sports hernia physical therapy protocol (Table 34.1). He began aerobic

activity 2 weeks following surgery and gradually progressed to range of
motion exercises and resumption of dynamic core training over the fol-
lowing month. He returned to light sporting activity at 6 weeks and was
allowed to resume full activity including football 2 months postopera-
tively. He was able to compete at the collegiate level during the fall
football season several months later. He had a successful senior season
as a tight end and on special teams as a long snapper.
Table 34.1. Sports hernia repair postoperative protocol.

Phase I: Immediate postoperative phase (weeks 02)
Pain and edema control, gentle stretching, walking
Phase II: Intermediate postoperative phase (weeks 23)
Gentle strengthening/pelvic stabilization, light exercise (pool, bike)
Phase III: (Weeks 34)
Range of Motion, strengthening, dynamic core training, straight plane jogging
Phase IV: (Weeks 45)
Light sport specific activity, plyometrics, interval bike training
Phase V: (Weeks 56)
Return to full sport activity
General recommendations
Avoid trunk hyperextension for first 2 weeks
Avoid hip extension past 0 for first 2 weeks
Avoid crunch and lifting activities for first 6 weeks
Pain and edema control, ice 34 times per day as needed for first week, as
needed thereafter
Return to work and sport to be determined on an individual basis by the
physician and physical therapist
Outcomes and Discussion

Chronic groin pain in the athlete can be disabling and in some cases
career-ending. The exact cause is debated but is theorized to be due to
repetitive loading of the pubic symphysis, leading to symphyseal degen-
eration and loss of mechanical stability. Shearing forces across the pubic
symphysis are more prominent in athletes with an imbalance between
the strong adductor muscles of the thigh and the relatively weaker lower
abdominal wall musculature. These factors are believed to cause weak-
ness and attenuation of the transversalis fascia portion of the posterior
wall of the inguinal canal. Weakness in the inguinal floor can lead to
localized bulging and compression of the genital branch of the genito-
femoral nerve, which is believed to be a source of pain in these patients.
Other proposed pathophysiologic mechanisms of injury remain an area
of debate and include disruption of the conjoined tendon as well as tears
of the rectus abdominis and adductor longus aponeurosis at the point of
insertion on the pubis [1].
A number of surgical approaches have been utilized to address the
above anatomic abnormalities. All focus on repair or reinforcement of
442 K.W. Kercher
the posterior wall of the inguinal canal by employing the traditional

repairs used to treat true inguinal hernias. These include open tension
repairs (Bassini and Shouldice), anterior tension-free repairs
(Lichtenstein), and laparoscopic repairs trans-abdominal preperitoneal
repair (TAPP) and total extraperitoneal (TEP)] with mesh [26].
Specific sports hernia repairs have also been applied and include the
open pelvic floor repair described by Meyers and the minimal repair
technique popularized by Muschaweck [7, 8]. The open anterior repairs
selectively include decompression and/or division of the genitofemoral
nerve with or without an adductor release.
While results vary based upon technique and patient selection, most
series report that >90 % of athletes return to full activity within 24
months of surgery. In the only randomized control study to date, nonop-
erative management consisting of physical therapy and NSAIDs was
compared with open repair and neurolysis in 66 soccer players with
chronic groin pain of more than 3 months duration. In this study, only the
surgically treated group demonstrated substantial, statistically significant
improvement in symptoms during a 6-month follow-up interval [9].
When chronic groin pain is related to an isolated tear at the adductor
longus origin, conservative treatment with rest, NAIDS, physical ther-
apy, and local injection is usually effective, with few patients requiring
surgical intervention in the form an adductor tenotomy. In a prospective
randomized trial by Holmich and colleagues, incorporation of an active
training and core-strengthening program was found to be superior to
physical therapy alone in athletes with adductor-related groin pain [10].
For those who fail conservative management of osteitis pubis and/or
adductor tendinopathy, periodic injections of the pubic cleft and adduc-
tor origin with dextrose and lidocaine have been effective for resolution
of chronic pain [11, 12]. In a small subset of athletes who fail these
nonoperative measures, adductor tenotomy (surgical release of the
adductor longus tendon at its origin from the pubis) has provided
encouraging long-term symptomatic and functional results [13].
In our patient, a laparoscopic bilateral TAPP repair with polypropyl-
ene mesh was utilized. His recovery was uncomplicated, and he was
able to return to full activity within 2 months of surgery. Given the pres-
ence of bilateral radiographic findings and clinical symptoms, the lapa-
roscopic approach was felt to offer the ideal solution for mesh
reinforcement of both groins. The primary disadvantage of the laparo-
scopic technique is that it does not afford the opportunity for neurolysis
of the sensory nerves, which some authors believe is important in
achieving pain relief.
A number of prospective non-randomized series have evaluated the

efficacy of laparoscopic TAPP and TEP repairs for athletic pubalgia.
Most have included small numbers of patients (n = 14131) and have
utilized mesh reinforcement of the myopectineal orifice. Over an aver-
age follow-up of 12 months (range 348 months), 87100 % of athletes
were able to return to full activity within 3 months of surgery, with many
patients resuming full competitive athletics within 34 weeks [4, 5, 16, 17].
One potential advantage of the laparoscopic repair is the ability to treat
patients with bilateral injuries simultaneously through a three-port
approach.
In our patient, preoperative imaging demonstrated evidence of bilat-
eral rectus abdominis and adductor longus avulsion injuries, while clini-
cal symptoms and examination findings were localized primarily to the
inguinal canals and pubic tubercle, consistent with musculotendinous
disruptions of the posterior inguinal wall, transversalis fascia, and the
rectus insertions onto the pubis. In our experience, these patients are best
served by initial reinforcement of the groin with mesh, as the large
majority will experience symptom resolution without any further inter-
vention. For those patients in whom adductor symptoms predominate,
adductor release can be performed either as an isolated procedure or can
be combined with TAPP, TEP, or open repair using mesh. Since many
surgical options exist, patient selection is critical and the approach must
be tailored to the specific diagnosis, based upon preoperative clinical
and radiographic localization of the anatomic site of injury. As shown in
Table 34.2, there is no single procedure that can be universally applied
to all patients with athletic pubalgia; the specific intervention must be
applied to the pathology being treated. Results have been excellent in
general, with the large majority of athletes returning to full sporting
activity following surgical intervention [4, 1217]. Due to small num-
bers of patients being treated in most series, however, these techniques
cannot be compared from a statistical standpoint, nor has there been a
controlled trial to determine whether one surgical technique is superior.
Conclusion
Athletic pubalgia (frequently referred to as sports hernia) is a com-
mon entity among athletes, though the specific anatomic and physio-
logic mechanisms for chronic groin pain remain poorly understood. As
a result, no one surgical solution can be applied to all patients. In athletes
444 K.W. Kercher
Table 34.2. Surgical technique and outcomes.

Return to
Author Number activity (%) Surgical technique
Hackney [14] 15 87 Open inguinal floor repair
Canonico [15] 16 100 Lichtenstein
Ingoldby [4] 28 96 50 % Open mesh
50 % Laparoscopic mesh
Paajanen [16] 41 95 TEP
Genitsaris [17] 131 97 TAPP
Topol [12] 24 92 Pubic symphysis/adductor
injection
Akermark [13] 16 62 Adductor tenotomy
who present with insidious, deep groin pain in the absence of an inguinal
hernia, a sports hernia should be considered. Initial treatment is conser-
vative and should involve a multidisciplinary approach (orthopedist,
sports medicine, athletic trainer, and/or physical therapist). Imaging
(MRI) and surgical referral may be indicated after a failure of conserva-
tive management. While small series of laparoscopic and open repair
have provided encouraging results, a multicenter prospective random-
ized controlled trial is needed.
References
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Res. 2007;455:7887.
2. Polglase AL, Frydman GM, Farmer KC. Inguinal surgery for debilitating chronic
groin pain in athletes. Med J Aust. 1991;155(10):6747.
3. Gilmore OJ. Gilmores groin: ten years experience of groin disruptiona previously
unsolved problem in sportsmen. Sports Med Soft Tissue Trauma. 1991;3:124.
4. Ingoldby CJ. Laparoscopic and conventional repair of groin disruption in sportsmen.
Br J Surg. 1997;84(2):2135.
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6. Economopoulos KJ, Milewski MD, Hanks JB, Hart JM, Diduch DR. Sports hernia
treatment: modified Bassini versus minimal repair. Sports Health. 2013;5(5):4639.
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(Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group.
Am J Sports Med. 2000;28(1):28.
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tive open-suture repair to treat chronic inguinal pain. Hernia. 2010;14(1):2733.
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K. Effectiveness of active physical training as treatment for long-standing adductor-
related groin pain in athletes: randomised trial. Lancet. 1999;353(9151):43943.
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related groin pain in competitive athletes. Role of adductor enthesis, magnetic reso-
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12. Topol GA, Reeves KD, Hassanein KW. Efficacy of dextrose prolotherapy in elite male
kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005;
86(4):697702.
13. Akermark C, Johansson C. Tenotomy of the adductor longus tendon in the treatment
of chronic groin pain in athletes. Am J Sports Med. 1992;20(6):6403.
14. Hackney RG. The sports hernia: a cause of chronic groin pain. Br J Sports Med.
1993;27(1):5862.
15. Canonico S, Benevento R, Della Corte A, Fattopace A, Canonico R. Sutureless ten-
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17. Genitsaris M, Goulimaris I, Sikas N. Laparoscopic repair of groin pain in athletes. Am
J Sports Med. 2004;32(5):123842.
35. Chronic Post-inguinal
Herniorrhaphy Pain: A Patients
Perspective
David C. Chen and Brian P. Jacob
Introduction
Patient ZP is an acclaimed writer and columnist. We have asked her
to share her story to illustrate the experience, frustrations, hopes, and
fears from a patients perspective. Her story also demonstrates the
importance of referral patterns and how physicians themselves should
pay more attention to the skill set of their trusted referrals. These
patients navigate a sea of doctors, studies, interventions, and surgeries
often without enough guidance or expertise. Their difficulties finding
adequate care turn lives upside down, and while we can usually ulti-
mately make patients better, the road is long, and some lives never return
to normal. It is a reminder for all of us to try always to do better.
Background
I am a writer by vocation but a dancer by avocation. As someone
whose body is very important to hernot for vanity but for health reasons
and a daily sense of well-beingany interruption in that routine has reper-
cussions beyond the norm. Every day I do somethingrunning, walking,
hiking, Pilates, core conditioning, or dancingto keep my body and my
brain in shape. Once upon a time I was a Balanchine baby, but most
recently, in the last six years, have been studying flamenco.
About seven years ago, I noticed a tiny bump on my lower right
abdomen, barely visible, close to my pelvic region. I was not in any pain

DOI 10.1007/978-3-319-21587-7_35
448 D.C. Chen and B.P. Jacob
or discomfort, but after I noticed it grew ever so slightly about a year

later, I pointed it out to my gynecologist in case it was a tumor. She
checked it out visibly and said, I think its probably a hernia so eventu-
ally you should go see a surgeon, and she gave me some referrals. I
waited almost another year. Every once in a while after I danced it would
pop out slightly further.
My Preoperative Experience
Finally I decided to go see a surgeon. But instead of following the
gynecologists suggestions, I asked my internist for a name or names. I
wanted a female surgeon. My doctor gave me the name of a colleague,
Dr. A (who, I learned later, was also a trusted friend). Dr. A examined
me, ordered a scan, and reported to me shortly after that I indeed had a
femoral type hernia and that it eventually would have to be removed.
Because it had infarcted already, she said I would not be a candidate
for laparoscopic surgery (which she did not perform). Dr. A said eventu-
ally it was possible that my hernia could incarcerate at any time, when I
could be traveling or away from home, and it was best to nip it in the
bud. It was left to me to decide if and when to do this open surgery, but
I should not wait too long. Mistake number one.
I decided to get a second opinion, as I still had no discomfort but just
the occasional tiny bulge. I got a second opinion from the suggestion of
my friend who was a prominent vascular surgeon. I again asked for a
female surgeon. My friend asked around and got the name of another
respected female general surgeon. I went to see Dr. B, who looked at
the imaging and agreed that it was a femoral hernia and that it eventu-
ally should probably be removed, but that there wasnt any great
urgency and I should do it within the year. Regarding technique, at
some point, Dr. B told me that if I wanted to pursue laparoscopic sur-
gery, a colleague, Dr. C, would be more experienced at that technique.
When I called back to Dr. A, this surgeon opined that I was not eligible
for a laparoscopic repair. My second opinion, Dr. B, did not push me
toward a consult with Dr. C, an experienced laparoscopic hernia sur-
geon. Mistake number two.
I eventually decided to do the surgery over the summer when things
were quieter at work and made a date with Dr. B to do the surgery. My
internist thought I was making a mistake and told me if it were she, she
would do it with the original surgeon, Dr. A, at the outpatient clinic. I
was told this was better than having surgery at the university, which was
35 Chronic Post-inguinal Herniorrhaphy Pain 449
much busier and where I was apt to also have medical students involved.
So at the last minute, I called Dr. A, who was able to schedule me a few
days later in the same time frame away from work I had already allowed
for. Mistake number three:
big mistake not to have consulted the Internet.
I felt that with these two recommendations I had done enough home-
work, but alas it was an error (mistake number four) not to have con-
sulted the Internet. Though some doctors may complain of this system
of checking them out, in fact, it is essential for patients to trade informa-
tion. Its another important step in making a decision about surgery.
The surgery was short, a little over an hour, and seemed to go well
enough. I was sent home to recover with instructions about icepacks and
rest. After about a week I was able to get around at home and then even-
tually left the house after a few weeks. I stayed in touch with my surgeon
Dr. A; however, because the healing seemed to be going slower than
anticipated, I was still not pain-free and was taking Percocet after a
month. I saw the surgeon before my scheduled post-op; actually, it was
a partner, as my surgeon was out of town, and I told this partner of my
concerns about pain:
I could not sit, I could not lie down
Over the next weeks and months, I continued to inform the surgeon
of this pain. It felt like the pain I remembered having with my IUD in
the 1960s, a Dalkon Shield, which was eventually removed from the
market. It felt like uterine pain, high up inside, not really near the ingui-
nal nerves. I was unable to exercise or to walk very much without pain
and to sit comfortably, and because I am a writer, this totally inhibited
my work. I could not do chores or cook or anything domestic either. At
this point, I became totally obsessed with reading on the Internet
where I learned much to my dismay about the issues with mesh and this
surgery. I read and read and began to compile a list of doctors who might
have the answer for me. Finally, after a number of calls, my surgeon
apologized to me and said there must indeed be a problem and that I
should see another surgeon if I did not want to come back.
I could not sit. I could not lie down. I could not walk. I could not
dance. I could not exercise. I could not jog. I could not concentrate on
work. I could not interact with family members. I could not care for my
mother, who was dying. I could not read. I could not attend work events
or any social events. I could not travel. I had sexual dysfunction, bladder
dysfunction, and gastritis from the Advil, which Dr. A told me I could
take and did not warn me that high doses could corrupt my stomach.
Though I consulted by e-mail and phone with a number of offices all
over the country, I had already learned of two surgeons who specialized
in revisional surgery after hernia repair. I very much liked Dr. C. Dr. C
said after viewing new imaging that my mesh was indeed corrupted, that
it had formed a ballthat I had a meshomaand that in order to excise
it, the procedure would likely include cutting my three important sen-
sory nerves, called a triple neurectomy. Dr. D made the same diagnosis
but said that the nerves might not need to be cut. Though I preferred Dr.
C due to this doctors patience and accessibility, I waited the requisite
six months they had both urged as the wait-and-see period for the pain
to go away:
Frightened and depressed
During that time I also consulted pain doctors. Dr. E, a pain doctor,
decided to do an exploratory block and scheduled me in the OR, as I was
in such discomfort. I was crying all the time, miserable, frightened, and
depressed. I was diagnosed with post-traumatic stress disorder. The
block did not do much, and so I went ahead and scheduled with Dr. D,
as I was hoping to save my nerves, particularly the genital nerve.
In the meantime, my insurer broke off relations with the Dr. Cs hos-
pital. Dr. C was most accessible and did not push me in one direction or
another, but gave me information as I requested it. Again at the last
minute, I became afraid and canceled the surgery with Dr. D and
rescheduled with Dr. C. I had to do it within a month, as my insurer
would only cover up to three months.
I had numerous bad side effects from the pain medication. Percocet
was the only thing that helped, but its side effects of constipation eventu-
ally took me back to the doctor, to Dr. F, a gastroenterologist who rec-
ommended a diagnostic colonoscopy and some antidepressants. I have
always been afraid of antidepressants, and though I filled the prescrip-
tion, I could not get myself to take them. I did not proceed with the
colonoscopy. I felt sure that if I could get off the pain meds, I would
return to normal.
Revisional Surgery
I had to move mountains to get the surgery approved with my insurer;
it made everything even more painful and complicated. Finally in late
March, seven months after the original surgery, Dr. C eventually did the
35 Chronic Post-inguinal Herniorrhaphy Pain 451
fix. Right before I was wheeled in, I implored Dr. C to save my nerve if
possible and begged Dr. C not to put back any more mesh. Dr. C knew
my surgery might require more mesh, so no promises were made. But
during the five-hour surgery, Dr. C discovered that two of my nerves
were on the same trunk and cut those, but that my genital nerve seemed
unaffected and decided to risk saving it, since I had asked for this if pos-
sible. Dr. C took out the old plug mesh, which was adherent to my
insides and my blood vessels. Dr. C advised that the mesh was accom-
plishing its normal role, but that a 3-dimensional mesh was entirely
wrong for my thin pelvic region and femoral canal. It took nearly five
hours in the operating room to remove it, and Dr. C felt it best to replace
it with a different, more flexible mesh.
Recovery
Right afterward I felt better, but it took another three months for me
to feel real relief. I was therefore still on Percocet and terribly frightened
that the surgery had not worked. But suddenly, at the end of June, things
improved. For the entire summer through September, I was in better
shape. I did have pain, but I could manage to travel and did so, and in
September, I felt I was well enough to begin dancing again. I was thrilled
and relieved. I had my life back:
Profound depressionplunged me into despair.
I gradually built up to dancing again at least three nights a week. I

made mistake number five in succumbing to my love for a very special
but extremely challenging footwork. One night in mid-October, I knew
I had pushed too much. The pain returned and with it a profound
depression that plunged me into despair. This time, I could blame
nobody but myself.
I went back on the physician rounds, via Dr. C, to a new gynecologist
who specialized in pelvic floor repair, a new pain consult, and who was
in constant touch with Dr. C, who basically kept me alive. I was back on
Percocet, back with the debilitating constipation even with nightly
Miralax. I developed a bout of transverse colon diverticulitis from the
narcotics. I had to do enemas at least once a week, often more. It was a
living hell.
My mother died around the same time that the pain returned, and other
family and work complications ensued. Finally, by January, I had a break-
down and returned to Los Angeles. I was bedridden for a month, but with
the help of a new psychiatrist was finally able to go on antidepressants. I

tried three, and finally the third (Lexapro) made an enormous gradual dif-
ference. Not only did it help me emotionally, it masked the pain. I knew
the pain was still there, but I was able to resume something of a normal
life, to exercise, and to travel. I talked to Dr. C constantly about another
surgery, this time to remove the mesh altogether. He said he would ask me
to wait again and try everything else short of surgery.
In addition, after the surgery, my right leg and ankle became swollen,
and my ankle has never gone back to its original size. I consulted with
another vascular surgeon, who thought the lymphatic drainage might have
been damaged during reoperation. We never got to the bottom of this.
By then I had been through every type of pain medication possible.
But the Lexapro mostly took care of it all. Since then, over two years
from the original surgery and a year and a half from the fix, I have had
relief. Recently, the pain returned, but I am trying to presume that it is a
temporary issue or that I possibly have to up the Lexapro dose. Alas, my
hair has fallen out, which is possibly connected with the Lexapro, which
has also had the side effect of a little weight gain and a few other side
effects, but has so far been worth the trade-off.
Conclusions
In summation I would counsel every doctor performing hernia
surgery to really look closely at the statistics upon which this surgery is
based. There are very few femoral surgeries to begin with, so the statis-
tics are from a tiny sample. Do not recommend surgery if the patient has
no pain. Think about mesh and what it is doing to peoples insides and
think about going back to plain tissue repair. Think about laparoscopic
surgery and see if more people are candidates.
I wish everyone with hernias could have it fixed right the first time.
It has totally changed my life, much for the worse, and I will never for-
give Dr. A for what she has done to me. Never. She was not qualified to
do this surgery. She was not up to date with medical literature and the
pros and cons of various meshes. She was too out of date to be doing this
surgery and perhaps others. Doctors need to be reevaluated to make sure
they keep up with current thinking. Retraining should be mandatory.
And doctors should know themselves: if they have any doubts about
performing a surgery or about their qualifications, they should pass the
patient off to another doctor. Its not worth the money to ruin a life.
36. Sports Hernia with Adductor
Tendonitis
Fredrick J. Brody and Jeffrey Harr
Chief Complaint
Pain in the left groin that extends to the thigh.
History
A 21-year-old lacrosse player presents with an 8-month history of
pain in his left groin that radiates to his left upper thigh. The patient first
developed these symptoms after an arduous lacrosse practice. He con-
tinued to practice in discomfort over the next several days, and was
evaluated subsequently by his team doctor who treated him with ice and
anti-inflammatories. Despite these treatments, his pain persisted and he
was unable to perform explosive lateral movements. Ultimately he
underwent two cortisone injections in the groin, which enabled him to
complete the season in variable degrees of pain. After the season he
avoided all athletic activities for 4 weeks, which resolved his symptoms
completely. However, he returned for summer league lacrosse, and his
groin and thigh pain returned immediately with strenuous activities.
Electronic supplementary material: The online version of this chapter

(doi:10.1007/978-3-319-21587-7_36) contains supplementary material, which is
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DOI 10.1007/978-3-319-21587-7_36
454 F.J. Brody and J. Harr
Physical Exam
On physical examination, he was exceedingly fit with minimal body
fat, pronounced abdominal muscles, and large quadriceps. His abdomen
was flat without overt hernia defects. Upon palpation, the left groin was
tender, particularly cephalad to the pubic bone at the insertion of the left
rectus abdominis. His tenderness extended toward the pubic tubercle and
laterally for 2 cm into the inguinal crease. Active sit-ups, with or without
resistance, replicated his groin and abdominal pain. He was also tender
along the left adductor longus tendon starting at the inferior aspect of the
pubic tubercle, and extending along the tendon for 10 cm. The adductor
tendon pain was exacerbated with hip adduction and abduction. He had
full range of motion of his hip, and there were no clinically evident
inguinal hernias even after multiple Valsalva maneuvers.
Workup
Plain radiographs did not show evidence of femoroacetabular
impingement, hip dysplasia, or lumbar or sacroiliac degenerative
changes. There was also no evidence of bone resorption or sclerosis.
Magnetic resonance imaging (MRI) of the abdomen and pelvis revealed
high signal uptake on T1- and T2-weighted images along the pubic bone
consistent with pubic osteitis. There was also increased uptake along the
left rectus abdominis insertion at the pubic bone consistent with edema
and a possible tear. A cleft sign was also visible along the inferior por-
tion of the pubic bone at the insertion of the left adductor longus, signi-
fying a tear of the tendon (Fig. 36.1a, b). There was no evidence of any
associated intra-articular hip pathology.
Diagnosis
The history, physical exam, and radiologic findings were consistent
with the diagnosis of a sports hernia with adductor tendonitis. Other
differential diagnoses should include iliopsoas strains or bursitis, avul-
sion injuries of the pubic bone, nerve entrapment syndromes, stress
fractures of the femoral neck or pubic rami, vertebral body pathology,
and associated hip injuries [1]. The most common hip pathology associ-
36. Sports Hernia with Adductor Tendonitis 455
Fig. 36.1. (a) T2-weighted axial oblique image of the pelvisdemonstrating a

cleft sign (arrow) just inferior to the pubic symphysis (PS); (b) T2-weighted
sagittal image of the pelvis demonstrating hyperintense aponeurotic tears
(arrows) of the rectus abdominis (RA) and adductor longus (AL) tendon inser-
tions into the pubic bone (P).
ated with a sports hernia is a labral tear, which is diagnosed with MRI
[2]. Other diagnoses that are not part of the musculoskeletal system
include appendicitis, urinary tract infections, testicular pain, varicoceles,
round ligament entrapment, endometriosis, and ovarian cysts.
Nonoperative Management
Nonoperative management is initially provided for adductor tendon-
itis associated with groin pain and may include 39 months of rehabilita-
tion with a physical therapist. These modalities may involve extensive
stretching, deep tissue massage, electrical stimulation, and local injec-
tions. These injections employ mixtures of steroids with local anesthet-
ics, and are injected directly into the pubic symphysis, pubic tubercle, or
associated aponeuroses. Mixtures commonly include methylpredniso-
lone mixed with 0.5 % bupivacaine, but other combinations of methyl-
prednisolone, dexamethasone, lidocaine, and bupivacaine have been used
as well. Overall, the majority of adductor tendon injuries should resolve
with inactivity and nonoperative therapy. The goal of nonoperative ther-
apy should restore a full range of motion, while maintaining muscle
strength and preventing contracture of the adductor tendon or rectus
sheath. Ultimately, the patient should regain strength, flexibility, and
endurance quickly if nonoperative management is successful. However,
chronic injuries located along the musculotendinous junction usually
require operative intervention if athletic activities cannot be halted.
Our technique entails an inguinal incision along the skin crease
located directly above the superficial ring. The dissection extends
through Scarpas fascia to the external oblique aponeurosis. Tears in the
external obliqueaponeurosis are repaired with 4-0 nonabsorbable
sutures since these tears may cause nerve impingements. The external
oblique aponeurosis is then opened superiorly and inferiorly through the
superficial ring. The spermatic cord is dissected at the level of the pubic
tubercle, retracted laterally, and skeletonized to exclude a hernia sac.
Once a hernia sac is excluded, a relaxing incision is made along the
fascia of the conjoined tendon starting at the level of the deep ring, and
extended inferiorly along the pubic bone (Fig. 36.2). The anterior rectus
sheath is then released from the pubic bone by incising the aponeurosis
approximately one cm superior to the pubic bone. This relaxing incision
is then extended laterally until the transversalis fascia of the inguinal
floor is encountered. The undersurface of the relaxing incision is under-
mined in an avascular plane. The sports hernia repair is performed by
plicating the previously released fascia of the conjoined tendon to the
iliopubic tract with a continuous 2-0 Prolene suture (Fig. 36.3). The first
Subcutaneous Internal oblique

tissue muscle
Retracted external
oblique fascia
Conjoint
Transversus abdominis
tendon
muscle
Pubic Iliopubic tract
tubercle
Spermatic cord
Pubis
symphysis
Richardson
retractor
Fig. 36.2. After undermining the conjoined tendon beneath the relaxing the inci-
sion, the flap is secured with a running 2-0 Prolene suture to the iliopubic tract.
A second 2-0 Prolene is used to imbricate the first suture line.
Laterally reflected
Transversalis conjoint tendon
fascia
Conjoint
tendon
Subcutaneous Iliopubic tract

tissue
Pubis
symphysis
Fig. 36.3. Relaxing incision starts at the pubic tubercle and extends along the
conjoined tendon to the level of the deep ring. The relaxing incision also extends
medially along the conjoined tendon to release the aponeurosis from the pubic
symphysis for approximately 2 cm.
layer starts at the pubic tubercle and extends superiorly to the deep ring.
A second layer of 2-0 Prolene imbricates the initial layer. At this point,
10 cc of 0.25 % bupivacaine is injected into the pubic tubercle. Mesh is
not placed since the intent of the repair is to lateralize the vector force
away from the pubic symphysis and tubercle.
The adductor tenotomyis performed to release the vector force that
extends inferiorly from the pubic bone to the large muscles of the thigh.
Conceptually, the tenotomy divides the vertical vector or the common
aponeurosis that incorporates the adductor tendon and rectus sheath.
This maneuver dissipates the distracting forces from the pubic bone.
Technically, a Deaver retractor is inserted through the inguinal wound,
and the subcutaneous tissues are retracted in an avascular plane above
the fascia of the adductor longus muscle (Fig. 36.4a). The tendon is eas-
ily palpated as a strong band extending from the pubic bone. Starting at
the 12 oclock position and extending medially and inferiorly, the
tenotomy is performed 2 cm from the pubic tubercle (Fig. 36.4b). The
tenotomy extends toward the 7 oclock position and is performed in a
superficial manner, utilizing a right angle dissector to avoid injury to the
underlying muscle. The tenotomy separates the overlying tendon and
fascia from the underlying adductor longus muscle. Hemostasis is typi-
cally well controlled with the electrocautery as long as the muscle is not
divided. Associated nerve fibers are encountered rarely in this plane
along the upper medial aspect of the adductor musculature. Once the
tenotomy is completed, hemostasis is verified. From the inferior aspect,
the pubic tubercle and the proximally divided tendons of the adductor
longus are injected with 10 cc of 0.25 % bupivacaine. After closing the
incision in layers, the patient is extubated and taken to recovery room in
stable condition (Videos 36.1, 36.2 and 36.3).
Outcome
Upon discharge, the patients activity was restricted to walking and
activities of daily living. After his first postoperative visit (14 days after
surgery), he was allowed to increase his activities slowly, which
involved cycling, jogging, and swimming. At 4 weeks, he resumed core
activities, including sit-ups and running an under 8-min mile. At 6
weeks, he initiated activities involving lateralizing movements, but full-
speed activities were restricted. After approximately 8 weeks, the patient
resumed his normal activities, and ultimately returned for his final sea-
Internal oblique Subcutaneous tissue

muscle
External oblique
Conjoint tendon fascia
Spermatic
Pubic tubercle cord
Deaver
Adductor longus retractor
muscle
Adductor longus
muscle and tendon
Fig. 36.4. (a) A Deaver retractor is placed in the wound and the adductor tendon
is visualized with inferior retraction; (b) The tenotomy begins at the 12 oclock
position on the adductor tendon and extends to the 7 oclock position.
son of lacrosse without restrictions. With nonoperative management,

approximately 50 % of patients are able to resume full athletic activities,
free of pain, within a year [3]. As with this patient who failed nonopera-
tive management, surgery engenders a full recovery in 80100 % of
patients [4].
Complications
The most common postoperative complaints include minor bruising
or edema involving the abdomen, thighs, genitalia, and perineum.
Postoperative complications are rare and entail seromas, hematomas,
dysesthesias, surgical site infections, and penile vein thrombosis [5].
The majority of these adverse events are self-limiting and resolve non-
operatively within 46 weeks.
Conclusion
Sports hernias, also referred to as athletic pubalgia, encompass inju-
ries to the tendons and muscles of the rectus abdominis and adductor
longus at their respective insertions along the pubic bone. Typically,
there is a common aponeurosis that connects both the rectus and adduc-
tor mechanism. However, the rectus and adductor muscles exert their
forces in competing vectors, which lead to injuries of the common apo-
neurosis. These injuries, or micro-tears, may induce a degree of com-
partment syndrome, and concurrent injuries to both aponeurotic regions
may be found in up to 23 % of patients [6]. Therefore, both injuries
should be treated simultaneously.
It was not until 1991 that Taylor et al. reported their initial experience
with an open inguinal approach to address groin pain in athletes [7]. This
study was followed quickly in 1992 by a paper from Malycha and
Lovell, in which they coined the term sportsmans hernia to describe
a complex of chronic groin pain in athletes [8]. Despite being a misno-
mer, this term was adopted quickly to describe chronic groin pain in
athletes and has been popularized over the last two decades. The etiol-
ogy of this pain encompasses injuries to the tendons and muscles of the
rectus abdominis and adductor longus at their respective insertions at the
pubic bone. Magnetic resonance imaging (MRI) is the optimal test to
diagnose this entity, discover concurrent injuries, and rule out other
causes of groin pain. Initially, a trial of nonoperative management

including physical therapy is recommended. If unsuccessful, surgical
intervention is offered, and has a high success rate. An overlying tenot-
omy (fasciotomy) of both aponeurotic sheaths and tendons usually
resolves the underlying edema and inflammation. Consequently, this
alleviates the scarring induced from chronic tendonitis, and allows the
region to appropriately relax and regain its original propensity for high
impact activities.
References
1. Nam A, Brody F. Management and therapy for sports hernia. J Am Coll Surg.
2008;206(1):15464.
2. Morelli V, Espinoza L. Groin injuries and groin pain in athletes: part 2. Prim Care.
2005;32(1):185200.
3. Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain
in athletes is more effective than nonoperative treatment: a randomized clinical trial
with magnetic resonance imaging of 60 patients with sportsmans hernia (athletic pub-
algia). Surgery. 2011;150(1):99107.
4. Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health.
2014;6(2):13944.
5. Meyers WC, McKechnie A, Philippon MJ, Horner MA, Zoga AC, Devon
ON. Experience with sports hernia spanning two decades. Ann Surg. 2008;248(4):
65665.
6. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J
Sci Med Sport. 1995;27(3):769.
7. Taylor DC, Meyers WC, Moylan JA, Lohnes J, Bassett FH, Garrett Jr WE. Abdominal
musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and
pubalgia. Am J Sports Med. 1991;19(3):23942.
8. Malycha P, Lovell G. Inguinal surgery in athletes with chronic groin pain: the sports-
mans hernia. Aust N Z J Surg. 1992;62(2):1235.
a Plug and Patch Hernia Repair
Christopher G. DuCoin and Garth R. Jacobsen
Postoperative groin pain following hernia repair is common. For

most, the pain is acute and resolves with time; however, some patients
develop chronic inguinal pain, termed inguinodynia. Inguinodynia may
occur after any type of hernia repair. One of the most common inguinal
hernia repair techniques is the plug and patch mesh herniorrhaphy.
Though extremely popular, this procedure has its own set of potential
complications that may lead to inguinodynia.
Chief Complaint
Extreme pain when pressing bump in groin
History
A 60-year-old male presents with a history of a prior open right ingui-
nal hernia repair with the plug and patch technique 4 years earlier. His
past medical and surgical history is otherwise not significant except for
a history of chronic narcotic use secondary to his inguinal pain. He
reports that he can press on the mass and make it disappear, but the
maneuver is extremely painful, with pain score increasing to 10/10 in
severity. The pain has been present since the operation. It worsens
throughout the day, starting with fairly little pain in the morning and
crescendoing toward the evening. It radiates into his scrotum. Physical
activity makes the pain unbearable. He denies any electrical shock or
burning sensation in the groin or skin.

DOI 10.1007/978-3-319-21587-7_37
464 C.G. DuCoin and G.R. Jacobsen
Physical Exam and Workup

On physical exam, he was found to have a firm palpable mass in the
right groin that was quite solid and not consistent with that of herniated
tissue. He had hyperesthesia in the region of the mass and full deep
examination was not feasible due to his pain. His abdomen was benign.
He was able to walk without a limp, but this caused an extreme amount
of pain. We could not delineate any specific neuropathic distribution of
the pain. Targeted injections by our anesthesia pain colleagues provided
little relief and therefore did not provide guidance as to which nerve
might be definitively involved.
Diagnosis and Management Options

(Nonoperative vs. Operative)
We had a discussion regarding his diagnosis and possible treatment
options. Nonoperative management was discussed; however, both the
patient and surgeon felt that this would be of little merit, as the pain was
chronic and conservative therapies had failed over prior years. Indeed, he
had resorted to chronic narcotic use as the only modality that helps his pain.
The reducible painful nature of the mass represented either a recur-
rence of his hernia, poor integration of the plug, or both. Also, nerve
entrapment or other involvement could not be definitively ruled out. His
surgical treatment options were discussed. The final plan consisted of
diagnostic laparoscopy for evaluation of the groin area for recurrence,
possible recurrent inguinal hernia repair with mesh, possible laparoscopic
versus open explant of mesh plug, and possible triple neurectomy, depend-
ing on operative findings. The risk of injury to the testicular vessels and
subsequent ischemic orchitis was discussed with the patient, as was the
possible need for vasectomy or orchiectomy. It is important in the reopera-
tive patient to discuss these potential complications and their implications,
as this may sway some patients to continue with observation.
The operation began with a diagnostic laparoscopy via the umbili-
cus. There was no inguinal hernia on the left. On the right, the mesh plug
could be seen to be freely floating through the deep inguinal ring and
was almost completely enveloping the spermatic cord structures. It was
37. Patient with Groin Pain After a Plug and Patch Hernia Repair 465
felt that the mesh migration and entrapment of the cord structures were
creating the patients inguinal pain with radiation into the scrotum.
At this point a transabdominal preperitoneal (TAPP) hernia repair
was initiated with the goal of mesh explantation and placement of a
macroporous lightweight polypropylene mesh to cover the myopectineal
orifice. Two additional 5 mm trocars were placed in the standard fashion
and position, and the preperitoneal space was developed, starting at the
anterior superior iliac spine and working medial to the umbilical liga-
ment. Here the mesh was found to encompass the cord structures. This
can be seen deep and lateral to the plug (Fig. 37.1). Note the testicular
artery medial to the vas deferens, as its normal course lateral to the
structure is deviated due to adherence to the mesh plug. Here we
weighed the feasibility of removal of the meshoma and the risk of injury
to the surrounding structures such as the vas deferens, testicular artery,
testicular veins, and the iliac vessels. With slow and meticulous sharp
dissection, the mesh was successfully dissected free of the cord struc-
tures without injury. Next a standard TAPP recurrent inguinal hernia
repair with macroporous lightweight polypropylene mesh was com-
pleted. The mesh plug was removed through the umbilical port site,
which was enlarged to allow extraction.
Fig. 37.1. Laparoscopic preperitoneal view of right groin. Mesh plug found
deep to internal ring, overlying and densely encompassing the spermatic cord
structures. Mesh plug is medial; spermatic cord is lateral. Spermatic cord lipoma
noted laterally.
466 C.G. DuCoin and G.R. Jacobsen
Operative time was 65 min. The patient was discharged home from
the postoperative unit. He reported near-immediate improvement of his
preoperative chronic pain and was off from all narcotic pain medications
by his 2-week follow-up appointment.
Outcomes and Complications

There is at least a single case report of mesh migration for every type
of hernia repair, both open and laparoscopic. However, there is an exceed-
ingly greater number of mesh migrations reported for the mesh plug
repairs than for flat mesh repairs [16]. The location of migration and the
organs involved determine the symptoms produced. Reported locations of
mesh migration include the scrotum, bladder, and hollow viscous struc-
tures such as the cecum and small bowel [16]. The symptoms produced
include chronic pain, recurrent urinary tract infections, intestinal obstruc-
tions, volvulus, and even intestinal perforation [16]. One underlying
similarity of these reports is that of lack of mesh fixation or fixation of
original mesh with absorbable suture [7]. In the end, this patients pain
was relieved by removal of the plug and reinforcement of the myopectin-
eal orifice with a flat sheet of mesh. The authors remain skeptical that the
addition of a mesh plug to a standard Lichtenstein herniorrhaphy provides
any benefit and, at worst, can result in the above complication.
References
1. Chuback JA, Singh RS, Sills C, Dick LS. Small bowel obstruction resulting from mesh
plug migration after open inguinal hernia repair. Surgery. 2000;127(4):4756.
2. Benedetti M, Albertario S, Niebel T, Bianchi C, Tinozzi FP, Moglia P, et al. Intestinal
perforation as a long-term complication of plug and mesh inguinal hernioplasty: case
report. Hernia. 2005;9(1):935.
3. LeBlanc KA. Complications associated with the plug-and-patch method of inguinal her-
niorrhaphy. Hernia. 2001;5(3):1358.
4. Tokunaga Y, Tokuka A, Ohsumi K. Sigmoid colon diverticulosis adherent to mesh plug
migration after open inguinal hernia repair. Curr Surg. 2001;58(5):4934.
5. Moorman ML, Price DP. Migrating mesh plug: complication of a well-established
hernia repair technique. Am Surg. 2004;70(4):2989.
6. Nowak DD, Chin AC, Singer MA, Helton WS. Large scrotal hernia: a complicated case
of mesh migration, ascites, and bowel strangulation. Hernia. 2005;9(1):969.
7. Jeans S, William G, Stephenson B. Migration after open mesh plug inguinal hernioplasty:
a review of the literature. Am Surg. 2007;73(3):2079.
38. Patient with Groin Pain After Open
Inguinal Hernia Repair with Mesh
Jeffrey A. Blatnik and Ajita S. Prabhu
Chief Complaint
Right lower quadrant pain, status post six prior hernia repairs
History
The patient is a 51-year-old thin male with multiple prior inguinal
hernia operations with right lower quadrant abdominal pain described as
burning and at times stabbing and dull. Previously, he has had six
hernia operations on the same side. It began with an open inguinal hernia
repair with mesh at age 20 years to address preoperative groin pain radiat-
ing to his right leg, across his back, and down to his groin area.
Approximately 2 years later, he developed stabbing pain in the same
location upon routine lifting of objects that he did not consider to be
heavy. He underwent a second open repair with mesh at that time and is
uncertain as to whether his first mesh was removed. He again had resolu-
tion of his symptoms until 2 years later, when he had recurrence of the
same symptoms and underwent a third open exploration. He is unsure as
to whether mesh was placed at that time. Approximately 1 year afterward,
he developed an acutely incarcerated right inguinal hernia with obstruc-
tive symptoms. He was taken emergently for a fourth operation and does
not know if mesh was placed at that time. Due to the time period during
which these operations took place, operative reports were not available
for review. Three years later in 2010, the patient developed recurrent pain
radiating to his right leg, groin, and back. He had his fifth exploration via
an open incision. At that operation, he was noted to have an onlay poly-
propylene flat mesh on top of the external oblique aponeurosis, as well as

DOI 10.1007/978-3-319-21587-7_38
468 J.A. Blatnik and A.S. Prabhu
a polypropylene flat mesh on the floor of the inguinal canal, with a small
direct hernia recurrence. This was repaired primarily with permanent
suture. The onlay mesh over the external oblique aponeurosis was
resected, and the mesh on the floor of the canal was left in place. Finally,
in 2011 he had painful recurrence of his symptoms and was taken for
open right inguinal exploration with resection of all previously placed
mesh and permanent suture. The ilioinguinal nerve was not seen or iden-
tified. Notably, there was no hernia identified at the time of that operation
and therefore no new sutures were placed. This operation was compli-
cated by an immediate postoperative expanding hematoma for which he
was emergently explored. He had a brief reprieve from his pain postop-
eratively. He presented 2 years later with recurrence of his symptoms.
Physical Exam
He had multiple surgical scars in the right lower quadrant, a small
recurrence of his hernia, and palpable mesh in the subcutaneous space with
tenderness over the area. There was no hypesthesia or allodynia noted.
Imaging
Computed tomography scan of the abdomen and pelvis was obtained
that did not show an obvious recurrence.

As part of the workup for this problem, the patient was referred to a
pain management specialist who performed a comprehensive neurologic
exam. He did not feel that the pain was neuropathic in nature. The
patient was offered a transcutaneous electrical nerve stimulation unit as
a noninvasive measure for pain control. The patient did not pursue this
due to the cost and also the desire for a more definitive cure for his pain.
Diagnosis
The patient was considered to have a hernia recurrence (most likely,
again,) of his direct hernia. In addition, it was unclear if the mesh alone
was contributing to his symptoms. We did not feel that he suffered from
38. Patient with Groin Pain After Open Inguinal Hernia 469
any nerve injury or spermatic cord injury. Nor was there any evidence
for infection or balling up of the mesh, i.e., meshoma.
Operative Treatment
Once workup was completed, the patient was offered laparoscopic
exploration to address the recurrence of his inguinal hernia. Chronic groin
pain is not an uncommon complication after open inguinal herniorrhaphy,
with an incidence as high as 62.9 % described in some series [1]. A gener-
ally accepted definition for the term chronic groin pain is the presence of
pain in the groin region for greater than 3 months after surgery. This may
be further divided into neuropathic pain versus non-neuropathic pain.
Neuropathic pain may be related to injury to the ilioinguinal nerve, the
iliohypogastric nerve, the genitofemoral nerve, or (rarely) the lateral femo-
ral cutaneous nerve. Nerve injury may be mechanical in nature or other-
wise may be related to an adjacent inflammatory process such as granuloma
or excess fibrotic reaction or mesh encasement of the nerve structures [2].
For the patient discussed in this scenario, an extensive workup by a pain
management physician suggested a non-neuropathic source of pain, hence
the decision to take the patient to surgery. There was no role for nonopera-
tive intervention, as the pain was felt to be non-neuropathic in etiology.
We began with a transabdominal laparoscopic evaluation. This iden-
tified multiple loops of small intestine densely adhered to the hernia
mesh (Fig. 38.1). This finding was despite the fact that all of the
patients previous hernia repairs had been in an open fashion and pre-
sumably as an onlay, and per report, all mesh had been removed. These
adhesions were taken down sharply, and to avoid injury to the small
bowel, a portion of mesh was left adherent to the bowel. This dissection
exposed what appeared to be a plug mesh in his internal ring.
Due to the chronic, non-neuropathic nature of his groin pain, it was
felt that all previous mesh would need to be removed at this operation.
To facilitate subsequent hernia repair following mesh removal, we
began by creating a large, extraperitoneal flap. During this portion, we
encountered multiple pieces of prior mesh, all of which were removed
with a combination of sharp dissection and harmonic scalpel. Great care
was taken to avoid injury to the overlying skin, as the patient was very
thin, and there was not a significant amount of subcutaneous tissue.
Coopers ligament was identified and served as our inferomedial land-
mark, and dissection was continued laterally. The plug mesh was identi-
fied adherent to the vas deferens, as can often be expected. In the
Fig. 38.1. Densely adherent small intestine to prior hernia mesh in retroperito-
neal space.
complex re-operative setting, we discuss with the patient preoperatively

the potential for division of the vas deferens, as often this cannot be
preserved. When completing the inferior dissection of the plug, great
caution must be used, as it is in close proximity to the iliac artery and
vein (Fig. 38.2). The plug mesh was then removed through the umbili-
cal incision. We then turned our attention to removing the remainder of
the prior mesh. This was noted to involve the inferior epigastric vessels;
to prevent bleeding during this stage, the vessels were prophylactically
ligated with a clip. After removal of all of the prior mesh from the
abdominal wall, they were removed from the abdomen in a specimen
removal bag.
The patient was clearly left with a defect in the groin. We elected to
repair this with an extra-large piece of 3DMax Light Mesh (Bard,
Warwick, Rhode Island). This is a preformed, lightweight polypropylene
mesh with large pores. This was positioned in our extraperitoneal plane
and secured in place with selectively placed tacks into Coopers liga-
ment. In addition, it is our practice to secure the inferior portion of the
hernia mesh with fibrin glue in an effort to prevent recurrence below the
mesh. To prevent the mesh from contacting the viscera, it was covered
with our previously created peritoneal flap. Prior to completing the pro-
cedure, the portion of small bowel that was densely adhered to the mesh
was externalized through the umbilical incision to evaluate for any
potential injury and was ultimately oversewn.
38. Patient with Groin Pain After Open Inguinal Hernia 471
Fig. 38.2. The prior plug mesh is retracted medially to demonstrate its close
proximity to the underlying right iliac artery and vein.
The patient was admitted to the hospital for observation overnight.
He noted a marked improvement in his chronic pain symptoms. He was
discharged home, doing well, on postoperative day number one.
At 1-month follow-up, our patient reported that his groin pain had
completely resolved with no evidence of hernia recurrence on exam.

This outcome is similar with two other small case series evaluating
laparoscopic management of groin pain following inguinal hernia repair
[3, 4]. These studies report that all patients had some improvement in
pain symptoms, with the majority having complete resolution. Although
this patient had a successful outcome with resolution of his pain symp-
toms, this is not always the case, as often some patients will have some
minor ongoing complaints. Known complications of this operation
include recurrent pain or hernia, injury to the adjacent vasculature (infe-
rior epigastric or iliac artery/vein), injury to the vas deferens or other
spermatic cord contents (resulting in testicular pain or need for vasec-
tomy or orchiectomy), and injury to the genitofemoral or lateral femoral
cutaneous nerves with resultant neuralgia. In conclusion, laparoscopic
management of chronic groin pain following open inguinal hernia repair

can be technically challenging. However, it often results in symptom
improvement for the patient.
References
pain and quality of life following open inguinal hernia repair. Br J Surg. 2001;88(8):
11226.
2. Cunningham J, Temple WJ, Mitchell P, Nixon JA, Preshaw RM, Hagen NA. Cooperative
hernia study. Pain in the postrepair patient. Ann Surg. 1996;224(5):598602.
3. Rosen MJ, Novitsky YW, Cobb WS, Kercher KW, Heniford BT. Combined open and
laparoscopic approach to chronic pain following open inguinal hernia repair. Hernia.
2006;10(1):204.
4. Keller JE, Stefanidis D, Dolce CJ, Iannitti DA, Kercher KW, Heniford BT. Combined
open and laparoscopic approach to chronic pain after inguinal hernia repair. Am Surg.
2008;74(8):695700.
a Lichtenstein Hernia Repair
Shirin Towfigh
Chief Complaint
Right groin pain radiating to the base of the penis
History
The patient is a 65-year-old male, status post open onlay mesh repair
of his right inguinal hernia using polypropylene mesh in Lichtenstein
tension-free onlay method. He reports noting groin pain within the first
several weeks after surgery, with no improvement since then. He pres-
ents with 1 year of chronic right groin pain and 5 months of severe
debilitating pain. The pain is 10/10, ranging from 2/10 to 10/10. It is a
sharp, stabbing, hot pain like a big knife or hot poker. It is always
in the same area at the lateral edge of his groin wound and with time has
radiated farther and farther down his groin. He is now hypersensitive at
the right scrotum. He wears restrictive underwear to prevent tugging by
or swaying of the scrotum. He fidgets when he sits and does not wear
jeans, as the wrinkling of the stiff fabric causes pressure and pain when
he sits. He cannot sit on the toilet seat without pain. Walking is now an
ordeal, as is getting up to stand and bending. He cannot pick up a bar of
soap from the ground. He cannot raise his leg, such as to step over the
little bottom lip of his shower door, as this causes pain. He is best when
lying flat. He used to be an avid cyclist, but he can no longer cycle.
According to the operative report, the patient had an indirect inguinal
hernia. The onlay patch from a medium size plug and patch kit was used
as a keyhole mesh. It was sutured with 0 Ethibond sutures. The ilioin-
guinal nerve was identified throughout its course and protected.

DOI 10.1007/978-3-319-21587-7_39
474 S. Towfigh
Physical Exam
The patient was in discomfort while sitting at the edge of the chair.
He had a healed groin scar and no visible bulge. Palpation elicited 3+
tenderness at the internal ring and along the spermatic cord. A mass of
mesh was palpable laterally. He had 3+ hypesthesia and allodynia at the
right groin scar and scrotal skin. The testis was descended and without
associated tenderness or mass.
Imaging
Magnetic resonance imaging of the anterior pelvis, non-contrast, with
Valsalva and dynamic views demonstrated intact flat onlay mesh with no
hernia recurrence (Fig. 39.1). He has a significant varicocele on the
right. There is no inflammatory reaction noted around the mesh.
Diagnosis
The patient was diagnosed with ilioinguinal neuralgia. This was due
to direct injury at the time of his operation versus entrapment due to scar
or mesh. He had no other obvious causes for his postoperative pain,
including no evidence of hernia recurrence, infection, inflammation, or
meshoma. He was offered nonsurgical treatment as the initial modality
Fig. 39.1. MRI anterior pelvis, non-contrast, with Valsalva and dynamic views
demonstrated intact right inguinal hernia repair with no hernia recurrence. T2
axial view here shows intact flat onlay mesh (yellow arrow).
39 Patient with Groin Pain After a Lichtenstein 475
for cure. This includes a combination of nerve blocks and neuromodulat-

ing medications and anti-inflammatories. If these provide short-term
success, they are continued with the goals of long-term success. In our
experience, most patients who respond to local injections require 35
cycles of nerve blocks and tend to have weeks to months of pain-free
episodes after each block as well as overall reduction in their pain score.
Only those that have short-term response but no long-term cure are
offered surgical options.

I first offered the patient a diagnostic nerve block in the office, which
was performed with 0.5 % bupivacaine, injected medial and inferior to
the anterior superior iliac spine. This resulted in near-complete resolu-
tion of the patients pain. Wiping the area clean after the injection
resulted in no pain. As per our protocol among patients with purely
neuropathic pain, if they respond positively to local nerve blocks, they
are offered serial blocks, no more than every 2 weeks, as their primary
mode of treatment. The therapeutic nerve blocks include steroids (10 mg
Kenalog). The patient indeed had a very clear improvement with the
blocks. These were continued and resulted in reduction of his pain such
that he was able to return to work, which involved sitting and standing.
The scrotal sensitivity resolved. He did have continued pain along his
groin and would even pass out at times due to the pain.
The patient already was under the care of a pain management special-
ist. He did not tolerate duloxetine, due to rash, and did not tolerate gaba-
pentin due to its side effects. He was using Traumeel topically and 5 %
lidocaine patch with no major improvement in symptoms.
The patient did not wish to undergo an operation unless absolutely neces-
sary. After five cycles, the patient was agreeable to surgical exploration.
Operative Treatment
The patient was offered targeted ilioinguinal neurectomy. This was
performed in open fashion, anteriorly, with identification of the nerve as
it coursed anteriorly and just proximal to the lateral edge of the mesh.
476 S. Towfigh
The patients localized areas of pain were marked in the preoperative

area. This often helps intraoperatively with correlation of the pain with
the operative findings and also to help guide the procedure. The opera-
tion was performed under local anesthesia with sedation. The prior inci-
sion was reincised along its lateral portion. Once the external oblique
aponeurosis was identified, the lateral edge of the mesh was noted, as
was the greenish hue of Ethibond sutures. The fascia was incised and
lifted off of the mesh using a combination of blunt, sharp, and cautery
dissection. There were two sutures of Ethibond with multiple knots each
at the superolateral edge of the mesh. These were both removed. The
ilioinguinal nerve was identified entering this area on top of the internal
oblique muscle and under the mesh. This was dissected out proximally
and distally. The nerve seems to have tracked in the same region as one
of these sutures. Thus, most likely the patient had nerve entrapment of
the right ilioinguinal nerve with a laterally placed suture within the
muscle. The right ilioinguinal nerve was skeletonized proximally and
distally. It was tied off and transected distally at the level of the mesh
edge. It was then dissected proximally and injected with local anesthetic
proximally. A 3-0 Chromic tie was used to tie its end to reduce bleeding
from the neurovascular bundle. It was transected and sent to pathology
for identification. The stump of the nerve was further dissected and
implanted into a pocket of internal oblique muscle just deep to it. The
purpose of this is to help reduce the risk of postoperative neuroma. The
wound was then closed in layers.
The patient had complete resolution of his pain postoperatively. He
was followed up for 2 years and has not had any recurrence of his
symptoms.

Nerve injury at the time of Lichtenstein hernia repair is either due to
a technical error (e.g., direct injury, suture entrapment, manipulation,
and dissection of the nerve) or due to mesh folding or scar tissue with
39 Patient with Groin Pain After a Lichtenstein 477
resultant entrapment of the nerve nearby. In this case, inappropriately

placed suture, placed laterally along the mesh, entrapped the ilioinguinal
nerve as it coursed through the muscle layers.
The timing of onset of the pain (usually less than 6 weeks vs. after 6
weeks, respectively) can help determine the cause. In the case of direct
nerve injury at the time of procedure, such as due to manipulation, cau-
tery, etc., the application of an inflammatory mesh on top of the injured
nerve can prevent natural healing and result in progression toward neu-
roma and/or chronic pain. Imaging can help rule out meshoma and other
causes such as hernia recurrence and infection.
Nonsurgical options for neuropathic pain include the use of neuro-
modulating medications (e.g., gabapentin, duloxetine, tricyclic antide-
pressants), local anesthetics (topical creams, patches, direct nerve
blocks), and anti-inflammatory medications [nonsteroidal anti-inflam-
matory drugs (NSAIDs), steroids] or a combination therapy. If patients
are not cured from these modalities, then the injury is more severe and/
or is mechanical in nature, and more invasive therapies are indicated.
This includes nerve ablation (e.g., with alcohol, radiofrequency, cryoab-
lation) or surgical neurectomy.
In my experience, patients who respond to nerve blocks with more
than 6 h of complete pain relief are best suited for nonoperative manage-
ment. These patients are provided 35 cycles of blocks with bupivacaine
and Kenalog steroids, injected in the vicinity of the nerve proximal to
the site of injury. If the pain relief duration increases with each injection
cycle and the overall pain score reduces with each visit, then this is
considered a successful plan of care. At least 20 % of such patients will
never require surgical neurectomy.
Conclusion
Patients who undergo Lichtenstein hernia repair with mesh are at risk
for chronic pain; the cause of many of these occurrences is technical in
nature and thus preventable (Fig. 39.2) [1]. The surgeon evaluating the
patient should have a grasp of all the different technical errors that could
lead to such complications and rule them out as part of the workup.
478 S. Towfigh
Fig. 39.2. Diagram of left open inguinal dissection prior to onlay repair via
Lichtenstein technique. Green circles demonstrate areas of safe suture place-
ment, i.e., at or medial to the level of the internal ring. Red circles demonstrate
areas of unsafe suture placement, including no sutures at areas of visible nerves
and in muscle, as the ilioinguinal and iliohypogastric nerves may be traveling
within the muscle layers of the internal oblique prior to their emergence onto the
conjoint tendon. In general, it is safest not to place any sutures lateral to the
internal ring (Adapted from Chen and Amid [1], with kind permission of
Springer Science + Business Media).
Reference
1. Chen DC, Amid PK. Technique: Lichtenstein. In: Jacob BP, Ramshaw B,
editors. The SAGES manual of hernia repair. New York: Springer; 2013.
p. 4154.
Tissue Repair, Anterior Approach
Shirin Towfigh
Chief Complaint
Right groin pain after tissue repair
History
The patient is a 73-year-old male, status post classic Shouldice repair
of his right inguinal hernia 3 months earlier. Preoperatively he had a bulg-
ing hernia with scrotal extension, without significant pain. He now com-
plains of daily groin pain, 7/10, ranging from 2/10 to 9/10. This began 3
weeks postoperatively after an otherwise uneventful early recovery period
when he was feeling amazing. He now reports a feeling of tightness,
like a rubber band across his lower abdomen at the level of the repair.
He feels like he wants to pop out. The pain is at times burning, sharp,
shooting, or a dull constant pain at baseline. The pain radiates to the upper
inner thigh as a minor but irritating burning stinging pain. The pain also
radiates to his flank and he feels pain at his hip bone. He denies testicular
pain. He has swelling of the right groin that comes and goes. He also has
bloating and feels filled with gas. He has changed his diet, removed all
dairy, and takes daily probiotics, stool softeners, and anti-gas medication,
with no improvement. He denies constipation or straining.
Physical Exam
The patient gets up from sitting position with mild distress. His
entire lower abdomen seems a bit edematous and bloated. The right
groin has a healed incision and is edematous along the wound and its

DOI 10.1007/978-3-319-21587-7_40
480 S. Towfigh
periphery. He is 2+ tender along the entire groin area, nonspecifically.

There is no palpable mass or hernia recurrence. He has no hypesthesia
or allodynia in the region.
Imaging
Computed tomography scan performed 2 months postoperatively
demonstrated an intact repair without hernia recurrence. There were
marked edematous changes without fluid collection.
Diagnosis
The patient was diagnosed with postoperative pain from anterior tis-
sue repair, without evidence of neuropathy. He also had no evidence of
spermatic cord injury, which can also at times be seen with this repair.
His symptoms of increased pain and swelling are concerning for tearing
of the repair, with associated edema and pain. As this is a tension repair,
and the patient notably is an elderly male with a relatively large hernia,
it is possible that the Shouldice repair was too tight and his tissue is not
supportive of such a repair. There is no evidence of infection or hernia
recurrence at this time, so conservative management alone is indicated.

To address his inflammatory state and possible underlying tissue
tearing from a tight repair, the patient was recommended to begin local
treatment with ice as well as systemic treatment with nonsteroidal anti-
inflammatory drugs (NSAIDs). He was also educated to rest the groin,
similar to treatment for a sports hernia, until the area is healed. Once
healed, he should begin a physical therapy regimen to regain abdominal
core muscle strength and mobility at his hip joint.
Operative Treatment
If the patient does indeed prove to have a hernia recurrence in the
future, then he is eligible for repair, which I recommend be performed
with mesh. The patient initially did not wish to have mesh repair, as he
was concerned about the risk for postoperative groin pain.
40. Patient with Groin Pain After Tissue Repair 481

Tissue repairs are tension repairs by definition. The complications
associated with them may be due to direct injury at the time of operation
(e.g., nerve injury due to cautery, traction), missed hernia (e.g., femoral
hernia), too tight of a repair, or hernia recurrence. In the case of too tight
of a repair, as the repair is purely muscle/fascia, and without mesh
involvement, it is likely that this will gradually loosen with time. Local
therapies to reduce risk factors (e.g., constipation, chronic cough, weight
gain) for hernia recurrence can also help reduce pain and allow for
improved recovery from such a repair. Also, physical therapy and exer-
cise to improve mobility of the groin area (e.g., cycling) can help with
the rehabilitation. Surgical options should be expectant only and address
any hernia recurrence or irreversible causes for pain. It is notable that
nerve mobilization is necessary in most situations for tissue repair to
reduce risk of entrapment in the repair. This may theoretically increase
the risk of chronic pain of neuropathic nature. In most cases, however,
as there is no additional foreign body or inflammatory status, the patients
improve with time and there is no need for intervention [1].
Meta-analysis of 16 trials showed no major difference in chronic
pain with the Shouldice repair versus other open techniques [2]. It does
have a higher recurrence rate compared to mesh techniques, by a factor
of 3.80, but is considered to have a lower recurrence rate than other non-
mesh techniques. That said, the chronic pain after Shouldice repair is
significant, with over one third of patients having significant pain more
than 3 months postoperatively [1, 3, 4]. This is typically higher than
most mesh repairs, and so the clinician should evaluate these patients
and their recovery with different standards than he does with patients
who undergo open or laparoscopic repair with mesh. That said, the inci-
dence of chronic pain rapidly decreases with time and is infrequently
debilitating [1].
Conclusion
Patients who undergo tissue hernia repair are at risk for chronic pain,
but this is mostly due to a tight repair, missed hernia (e.g., femoral her-
nia), and/or hernia recurrence. Minor instances of nerve injury may heal
on their own, as may too tight of a repair.
482 S. Towfigh
References
1. Matthia W, Reinpold J, Nehls J, Eggert A. Nerve management and chronic pain after
open inguinal hernia repair. Ann Surg. 2011;254(1):1638.
2. Amato B, Moja L, Panico S, Persico G, Rispoli C, Rocco N, et al. Shouldice technique
versus other open techniques for inguinal repair. Cochrane Database Syst Rev.
2012;4:CD001543.
3. Kninger J, Redecke J, Butters M. Chronic pain after hernia repair: a randomized trial
comparing Shouldice, Lichtenstein and TAPP. Langenbecks Arch Surg. 2004;389(5):
3615.
41. Right Inguinal Hernia with Osteitis
Pubis: A Case Report of Osteitis Pubis
and Ipsilateral Inguinal Hernia
Naif A. Al-Enazi and Brian P. Jacob
Chief Complaint
Right groin discomfort
History
A 46-year-old male, otherwise healthy, had right groin pain, which
started 23 years previously and was not that bad at first, but became
slowly more pronounced over the years. Pain was described as discom-
fort, not radiated anywhere localized to the groin area. The pain started
suddenly after heavy exercise. It was intermittent, lasted a few seconds,
and then disappeared. It was aggravated by exercise and spontaneously
disappeared. No history of nausea, vomiting, diarrhea, or constipation.
No history of lifting heavy objects or trauma. He was nonathletic.
Allergy historyunremarkable
Past surgical historylipoma of back
Drug historynone
Past medical historyunremarkable
Social historynonsmoker, nonathletic
Review of Systems
Cardiovascularnormal
Respiratorybreathing well
Gastrointestinalunremarkable

DOI 10.1007/978-3-319-21587-7_41
484 N.A. Al-Enazi and B.P. Jacob
Neurologicalunremarkable
Genitourinary/renalunremarkable
Musculoskeletalunremarkable
Psychiatricnormal behavior
Focused Examination
BMI: 32 mg/kg2.
Abdomen: soft and non-tender.
Umbilicus: no hernias.
Left groin: no obvious hernia on exam.
Right groin: patient was examined in standing and lying position,
with and without Valsalva maneuver. A small reducible right inguinal
hernia was palpable when standing and coughing, and the patient did not
have any discomfort over this reducible bulge.
Right pubic bone and tubercle: mildly tender to palpation.
Left pubic tubercle: non-tender.
Symphysis: non-tender and stable to manipulation.
Rectus muscle: when flexed during sit-up maneuver, mildly uncom-
fortable over right tubercle insertion site only.
RIGHT Hip rotation: non-tender. RIGHT Leg elevation against
resistance to evaluate the flexors (flexion at hip joint): mildly uncom-
fortable over the right tubercle with this maneuver. Reproducible symp-
toms. RIGHT Leg extension (extension at the hip joint): non-tender and
no symptoms.RIGHT Adductor: mildly tender over the right tubercle
inseriton with right leg adduction, reproducible symptoms.right groin
pain with standing and squatting: NONE. RIGHT GROIN Sensory
exam: no numbness, tingling, or hypersensitivity along any of the nerve
distribution in the groins. rotation: non-tender.
Leg elevation against resistance to evaluate the flexors: mildly
uncomfortable over the right tubercle with this maneuver.
Leg extension: non-tender.
Adductor: mildly tender over the right tubercle with right leg
adduction.
Standing and squatting: non-tender.
Sensory exam: no numbness, tingling, or hypersensitivity along any
of the nerve distribution in the groins.
41. Right Inguinal Hernia with Osteitis Pubis 485
Workup
Magnetic resonance imaging (MRI) of the osseous pelvis with atten-
tion to the pubic symphysis showed that there was mild marrow edema
and subchondral remodeling at the pubic symphysis compatible with
osteitis pubis (Fig. 41.1). The adductor tendons were intact. The rectus
abdominis aponeurosis was intact as well. There was also a fat-contain-
ing right-sided inguinal hernia with direct and indirect component mea-
suring 3 cm (Fig. 41.2).
Diagnosis
While the reducible right inguinal hernia in this patient was obvious,
the patients history and physical examination gave high suspicion for
the clinical diagnosis of osteitis pubis as well. The symptoms of osteitis
pubis can be presented as any complaint in the groin or lower abdomen
[1]. Pain generally is localized over the symphysis and may radiate to
the groin, scrotum, perineum, medial thigh, hip, or abdomen [2].
Fig. 41.1. Osteitis pubalgia on MRI.

Fig. 41.2. Right inguinal hernia on MRI.
Physical findings for osteitis pubis can vary. It is important always to

consider any sport involved, as well as the chronicity of the conditions
[3]. Gradual onset of pelvic pain, with pubic symphysis tenderness, is
one of the features of osteitis pubis [4]. One great modality for the diag-
nostic investigation in detecting the osteitis pubalgia is MRI. The dif-
ferential diagnoses of chronic groin pain that can present similarly to
osteitis pubis include musculotendinous strain, osteomyelitis, inguinal
hernia, referred low back pain, intra-articular hip disease and genitouri-
nary disease, and adductor tendinopathy. Osteomyelitis of the pubic
symphysis is one of the diseases most commonly confused with osteitis
pubis [5], so clinical evaluation requires a careful synthesis of history
taking, physical examination, and appropriately directed investigation.
Discussion
Osteitis pubis, a rare condition, is characterized by pelvic pain local-
ized over the symphysis pubis, in the lower abdominal muscles or in the
perineum. The pain may radiate to the adductor region of the thigh, and
patients may describe painful adductor muscle spasms. Aggravating fac-
tors are walking and standing from a seated position.
Osteitis pubis, also known as pubalgia or sometimes mislabeled as
just athletic pubalgia, is one of the most chronic and debilitating syn-
dromes affecting athletes [6]. It is described as the pubic bone stress
injury occurring usually as a result of chronic overload or impaction

trauma [7].
Osteitis pubis is also considered as noninfectious, inflammatory dam-
age to the pubic symphysis and its supporting structures [8] anatomi-
cally. The pubic symphysis is mainly composed of fibrocartilage and is
a nonsynovial, nonvascular joint. The pubic symphysis is reliant on four
ligaments to maintain its supportive integrity. Most of the strength and
support arise from the superior and inferior ligaments, whereas the ante-
rior and posterior ligaments are of less supportive importance. The pel-
vic floor musculature, composed of the levator ani and coccygeus,
inserts posteriorly at the pubic symphysis. The pectineus, rectus abdomi-
nis, and oblique externus muscles, as well as the inguinal ligament,
insert near the superior portion of the pubic symphysis. The pubic rami
give rise to several muscle origins: adductor magnus, adductor longus,
adductor brevis, and gracilis. These muscles make up the adductors of
the hip [1].
The prevalence of osteitis pubis among the general population of
athletes ranges from 0.5 to 6.2 % [8, 9]. Although many different sports
may be associated with osteitis pubis, sports with a higher risk include
soccer, football, ice hockey, and rugby [9].
The etiology of osteitis pubis is unknown; repetitive trauma alone or
in conjunction with opposing shearing forces across the pubic symphy-
sis is likely the main contributing factor in many athletes [10, 11]. This
may be due to different types of movements, including rapid acceleration-
deceleration, kicking, and changes in direction.
Management
Nonoperativemanagement of osteitis pubis is similar to that of other
causes of chronic groin pain and consists mainly of rest, ice or heat,
and nonsteroidal anti-inflammatory drugs (NSAIDs) or other oral medi-
cation if patient can not take an anti-inflammatory medication. If these
initial modalities are not helpful after a defined trial period (3 weeks for
example), then the next intervention to consider would be glucocorti-
coid injections directly into the pubic symphysis or oral glucocorticoids
[12, 13]. Additional nonoperative interventions can then also
include physiotherapy focusing on core stability, muscle balance, and
rotational hip range of movement; and activity modification. The most
important lesson here is that if a patient has osteitis pubalgia and an
inguinal hernia, just repairing the hernia alone will not alleviate the
pubalgia pain. We therefore recommend initiating treatment for pubalgia

first and delaying a hernia repair until the pubalgia pain is better con-
trolled and the patient understands the difference between the hernia
pain and the pubalgia pains.
The main goal of physical rehabilitation is to strengthen and stabilize
the pelvis and pubic symphysis. Physical rehabilitation, usually for 68
weeks, has been found in multiple observational studies to be effective
in reducing pain among patients with osteitis pubis [14]. Conservative
measures have been shown to be effective in treating osteitis pubis, and
the expected duration of treatment before resolution should be around
23 months. A majority of the patients with osteitis pubis respond very
well to this modality of treatment. After the osteitis is improved or
resolved, the hernia repair can then be sought.
Conclusion
Osteitis pubis can be easily missed when patients complain of groin
pain and present with a simultaneous inguinal hernia. History and
physical examination should include a high index of suspicion. If the
diagnosis is suspected, the potential to make the diagnosis will increase,
and thus the surgeon and the patient may be able to prevent a case of
chronic groin pain that would otherwise be at risk for being associated
with an inguinal hernia repair. Usually, the treatment of choice for
patients with osteitis pubis is conservative, with rest, painkillers, and
physiotherapy or steroid injection. The healing process for most
patients is 68 weeks. In patients who have an obvious inguinal hernia
and osteitis, it is important to educate the patients about the osteitis and
its associated symptoms, treatment options, and outcomes before
repairing the inguinal hernia.
References
1. Hlmich P. Adductor-related groin pain in athletes. Sports Med Arthrosc Rev.
1997;5:28591.
2. Fricker PA. Osteitis pubis. Sports Med Arthrosc Rev. 1997;5:30512.
3. Ruane JJ, Rossi TA. When groin pain is more than just a strain: navigating a broad
differential. Phys Sportsmed. 1998;26(4):78103.
4. Holt MA, Keene JS, Graf BK, Helwig DC. Treatment of osteitis pubis in athletes.
Results of corticosteroid injections. Am J Sports Med. 1995;23(5):6016.
5. Pauli S, Willemsen P, Declerck K, Chappel R, Vanderveken M. Osteomyelitis pubis

versus osteitis pubis: a case presentation and review of the literature. Br J Sports Med.
2002;36(1):713.
6. Rodriguez C, Miguel A, Lima H, Heinrichs K. Osteitis pubis syndrome in the profes-
sional soccer athlete: a case report. J Athl Train. 2001;36(4):43740.
7. Gilmore J. Groin pain in the soccer athlete: fact, fiction and treatment. Clin Sports
Med. 1998;17(4):78793.
8. Batt ME, McShane JM, Dillingham MF. Osteitis pubis in collegiate football players.
Med Sci Sports Exerc. 1995;27(5):62933.
9. Johnson R. Osteitis pubis. Curr Sports Med Rep. 2003;2(2):98102.
10. Radic R, Annear P. Use of pubic symphysis curettage for treatment-resistant osteitis
pubis in athletes. Am J Sports Med. 2008;36(1):1228.
11. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandelbaum BR. Management of
(Performing athletes with abdominal or inguinal neuromuscular pain study group).
Am J Sports Med. 2000;28(1):28.
12. OConnell MJ, Powell T, McCaffrey NM, OConnell D, Eustace SJ. Symphyseal cleft
injection in the diagnosis and treatment of osteitis pubis in athletes. AJR Am J
Roentgenol. 2002;179(4):9559.
13. King JB. Treatment of osteitis pubis in athletes: results of corticosteroid injections.
Am J Sports Med. 1996;24(2):248.
14. Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the
pubic symphysis in athletes: a systematic review. Br J Sports Med. 2011;45(1):5764.
42. Patient with Chronic Pelvic Pain
Shirin Towfigh
Chief Complaint
Left groin pain and pelvic pain
History
The patient is a 41-year-old female with left groin and pelvic pain for
8 months. It first was felt when moving crates of files at work. The pain
started in the left groin and radiates up to the umbilicus and around her
back. She also has pain that radiates down her leg, mostly anterior thigh.
The pain is currently 10/10 and ranges from 6/10 to 10/10. It is a pinch-
ing, so sharp, shooting pain that occurs daily. Any pressure on the area
causes pain. This includes cuddling from her children, as she is also very
sensitive in the area. She wears skirts and dresses to work, as formal
pants and belts cause too much pain in the area. The pain is worse with
prolonged standing, sitting, coughing, laughing, sneezing, climbing
stairs, getting out of a car or bed, bending, and with crossing legs.
Sexual intercourse is painful. The pain is worse during her menses and
at the end of the day. She is best when lying flat. She has nausea when
the pain is at its worst.
The pain is severe and activity limiting. She has been to the emer-
gency room twice due to pain. She has been evaluated by her gynecolo-
gist as well as gastroenterologist and colorectal surgeon. Colonoscopy
was normal. She was sent to a pain management specialist, as she was
told she has muscle spasm. She underwent local injection, which
increased her level of pain.

DOI 10.1007/978-3-319-21587-7_42
492 S. Towfigh
Physical Exam
The patient was in no discomfort. She has a healed Pfannenstiel inci-
sion from her prior Cesarean section. There is 3+ tenderness with associ-
ated fullness at the internal ring. There is no visible bulge or reducible
mass. She has no hypesthesia and allodynia in the area.
Imaging
Pelvic ultrasound and abdominal ultrasounds were both nondiagnostic.
CT scan showed a small left inguinal hernia with fat content.
Diagnosis
The patient has an occult inguinal hernia based on history and physi-
cal examination that are suggestive but not diagnostic of a hernia and
then imaging which is diagnostic of a hernia. Her symptoms are not
suggestive of a gynecologic or gastroenterologic disorder, as she has
point tenderness at the internal ring and pain with activity that involves
engaging the abdominal muscles.
Operative Treatment
The patient was offered open versus laparoscopic repair. There was
a hint of possible femoral hernia on computed tomography (CT) scan,
and so laparoscopic repair was considered the best option. Operative
findings were of an indirect and femoral hernia. This was repaired with
mesh, with fixation to Coopers ligament, using TEP technique.
The patient had complete resolution of her pain as early as in the
postoperative recovery unit. She was followed up for 2 years and has not
had any recurrence of her symptoms.
42. Patient with Chronic Pelvic Pain 493

Occult inguinal hernias are more common among women but are often
overlooked as a cause for pelvic pain, as inguinal hernias are considered a
male disease. Symptoms are variable and may include pain radiating from
the groin to the labia, vagina, down the leg, and around the back. The physi-
cal examination finding that is highly specific for such a hernia is point
tenderness at the internal ring. In fact, early studies show this to be found in
98100 % of all occult hernias, and ilioinguinal neuralgia symptoms were
noted in 63 % (Tables 42.1 and 42.2) [1]. In our study, the finding of point
tenderness at the internal ring meant inguinal hernia was between 13% and
25 % more likely to be the correct diagnosis in women with chronic pelvic
pain, when correcting for BMI, age, dysmenorrhea, and radiating pain [2].
The overall positive predictive value of occult hernia when tenderness was
elicited on groin examination was 74 %. The sensitivity was 60 % and
specificity was 88 %. All other typical findings, such as a visible bulge,
reducible mass, or palpable defect, are often not found.
Table 42.1. Preoperative symptoms in 192 cases of nonpalpable inguinal her-

nias (from Spangen and Smedberg [1], with kind permission from Springer
Science + Business Media).
Type of inguinal pain No.
Dull, gnawing pain 190
Neuralgic pain only 2
Combined dull and neuralgic pain 136
Pain, radiating from the groin to the ipsilateral
Thigh 101
Flank 62
Lower abdomen 33
Pain accentuated by
Physical exertion 176
Menstruation 19
Mental stress 3
Table 42.2. Clinical findings in 192 cases of occult inguinal hernia (from Spangen
and Smedberg [1], with kind permission from Springer Science + Business Media).
Finding No.
Tenderness corresponding to the deep inguinal ring upon palpation 192
during a Valsalva maneuver
Hyperalgesia of the skin corresponding to the distribution 121
of the ilioinguinal nerve
494 S. Towfigh
Imaging is often required to confirm the diagnosis prior to commit-

ting the patient to surgical exploration and repair. Ultrasound and mag-
netic resonance imaging (MRI) are found to be good options, and CT
scan is considered to be a poor option for the pelvis. In our study, ultra-
sound has a 100 % positive predictive value and 0 % negative predictive
value [3]. Thus, if an ultrasound is negative, and symptoms and physical
examination are suggestive of inguinal hernia, then MRI (not CT scan)
is recommended as the next modality [3, 4]. MRI has a 95 % positive
predictive value and 85 % negative predictive value. MRI is 91 % sensi-
tive and 92 % specific for findings of occult inguinal hernia. On the
other hand, among patients who underwent CT scan with negative find-
ings, 91 % had occult hernias notable on MRI.
On operative exploration, the patient has a fat-containing hernia
defect. This is typically preperitoneal fat only, without peritoneal
involvement, i.e., no hernia sac. Thus, intraperitoneal examination by
laparoscopy, without takedown of the peritoneum and fat to visualize the
fascia itself, may provide a false-negative result.
Conclusion
Inguinal hernia can cause chronic pelvic pain. The absence of a her-
nia on examination should not rule out inguinal hernia as the cause of
pain. A complete history and physical examination, followed by imaging
(ultrasound or MRI), are necessary to rule out inguinal hernia as the
cause of pain. Surgical treatment may provide immediate cure.
References
1. Spangen L, Smedberg SG. Nonpalpable inguinal hernia in women. In: Bendavid R,
Abrahamson J, Arregui ME, Flament JB, Phillips EH, editors. Abdominal wall hernias:
principles and management. New York: Springer; 2001. p. 6259.
2. Saad CA, Kim DS, Towfigh S, Solnik MJ. Inguinal hernia as a cause of chronic pelvic
pain: a key sign to make the diagnosis (abstract). J Min Invasive Gynecol. 2014;21
Suppl 6:S76.
3. Miller J, Cho J, Michael MJ, Saouaf R, Towfigh S. Role of imaging in the diagnosis of
occult hernias. JAMA Surg. 2014;149(10):107780.
4. Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role
of radiology in the diagnosis of occult inguinal hernia. Surg Endosc. 2013;
27(1):118.
43. Thoracolumbar Syndrome
James A. Rydlewicz and Dean J. Mikami

Thoracolumbar syndrome (TLS) is a very rare but real etiology of
lower back pain and referred chronic groin pain. The diagnosis is often
by exclusion, and based primarily on history and physical examination
alone, TLS is a challenge to diagnose and treat, but should be part of the
groin pain differential diagnosis. Distal sensory nerves that originate
from the posterior primary rami of the thoracolumbar spinal nerves
T12L2 can be irritated without any obvious magnetic resonance imag-
ing (MRI) or X-ray findings, thus increasing the challenge of making the
diagnosis. Treatment should initially be aimed at physical therapy and
rehabilitation modalities. Pain management specialists can then inject
the trigger points. Outcomes after surgical intervention have not been
well documented.
Introduction
Patients who present with groin pain may be experiencing referred
pain from a spinal pathology. Robert Maigne first described thoracolum-
bar syndrome in 1974; it is sometimes called Maignes Syndrome [1].
The thoracolumbar junction is comprised of the T1011, T1112, and
T12L1 vertebrae. The dermatomes T10L2 are responsible for the
referred pain that patients experience [2]. Patients usually complain of
low back pain, but can also have ipsilateral gluteal and groin pain.
Thoracolumbar syndrome is defined by a dysfunction of the thoraco-
lumbar junction referring pain in the corresponding dermatomes of
T10L2. In particular, T12 and L1 are specifically located in the
groin region, and they emerge at the level of the thoracolumbar junction.

DOI 10.1007/978-3-319-21587-7_43
496 J.A. Rydlewicz and D.J. Mikami
Low back pain may also be involved with groin pain, or groin pain can
be an isolated complaint [2]. T12 is the transitional vertebra of the spine
where the thoracic facet joint meets the lumbar facet joint. It is believed
that the thoracolumbar facet joint irritation is the cause of the pain. This
irritation causes unilateral pain to the distribution of the posterior pri-
mary rami of the lower thoracic and upper lumbar nerve roots [3].
Clinical Manifestations
Low back pain is the most common complaint of individuals with
thoracolumbar syndrome and usually starts with a rotational twisting
motion. The pain is usually unilateral, located in the sacroiliac or low
lumbar region and may radiate to the lateral thigh. Pain is often made
worse with extension and certain positions. Patients may also complain
of lower abdominal, groin, pubic, or testicular pain. Patients describe the
pain as a deep aching sensation, which is commonly mistaken for
intestinal, urologic, or gynecologic disorders [4]. These clinical
signs correlate with T12L1 spinal nerve root innervations (Fig. 43.1).
Fig. 43.1. T12L1 thoracolumbar nerve root compression with referred pain.
43. Thoracolumbar Syndrome 497
The posterior ramus supplies the subcutaneous tissue of the lower waste
and buttocks. The anterior ramus supplies the lower abdomen and groin
[5]. Patients with TLS may also have other etiologies causing groin pain,
in addition to the TLS, thus adding complexity to pinpointing TLS as
one of the sources of discomfort.
Physical Examination
Physical exam begins with examination of the spine with the patient
in a prone position. Lateral pressure on the spinous processes of T9L3
should elicit unilateral pain. The compression should be performed in
both a right and left movement. Direct compression over the affected
facet will elicit the same tenderness (Fig. 43.2). The posterior iliac crest
should then be palpated to identify point tenderness. Rubbing the crest
in an up-and-down motion should elicit pain at a point usually 7 cm
from the midline. The pain should be sharp in nature. This point is called
the posterior iliac crest point; it is where the irritated cutaneous branches
of T11L1 are compressed [3] (Fig. 43.3).
The pinchroll test is then performed to test for hyperalgesia of the
skin and subcutaneous tissues of the gluteal and iliac crest region.
Referred pain accompanies hyperalgesia and thickening of the skin.
The test is performed by grasping a fold of skin between the thumb and
forefinger and rolling the tissue in a controlled manner. The involved side
should elicit tenderness compared to the opposite side [4] (Fig. 43.4).
Fig. 43.2. Point pressure over iliac crest.

Fig. 43.3. Anatomical position of the L1L3 as it transverses the iliac crest.
Fig. 43.4. Pinchroll test.

43. Thoracolumbar Syndrome 499
Groin pain should be examined with standard inguinal examination

to rule out inguinal hernia. Thoracolumbar syndrome has two clinical
features that are characteristic: a positive pinchroll test and tenderness
on the superior aspect of the pubis. Palpation of the periosteum of the
pubis should cause tenderness on the affected side. The pinchroll test
should be performed in a supine position in the inguinal area [2].
Workup and Diagnosis

Plain films of the thoracolumbar region should be obtained to rule out
gross segmental instability. Computed tomography (CT) and MRI of the
spine can evaluate for masses, disk herniation, spinal stenosis, and frac-
tures. CT scan of the abdomen can be useful to rule out intra-abdominal
pathology. Thoracolumbar syndrome is diagnosed clinically and most
radiological studies will be normal [6].
Clinical criteria for diagnosis include (1) a positive pinchroll test,
(2) a positive posterior iliac crest point, (3) localized tenderness over the
affected thoracolumbar segment, and (4) tenderness in the facet joints at
the affected level [3]. A diagnostic nerve block can also be performed to
confirm the diagnosis either at the bedside or with fluoroscopic guid-
ance. The needle is inserted over the painful facet about 1 cm from the
midline. Lidocaine 1 % is injected around the joint and laterally around
the dorsal ramus. One can also inject lidocaine at the posterior iliac crest
point. The pain should be gone within minutes of injection [2].
Treatment
Treatment of thoracolumbar syndrome is directed at the vertebral
column. Spinal manipulative therapy directed at the correct thoracolum-
bar posterior joint is a first-line treatment. Manipulation is a forced
movement applied to the joint and is contraindicated in severe osteopo-
rosis [2]. If manipulative therapy does not cause relief of symptoms,
then injections of corticosteroids around the painful facet joint and
posterior iliac crest may help. Nonsteroidal anti-inflammatory agents,
massage, and physical therapy have also been shown to be helpful.
Surgical treatment is rarely indicated. Concern for nerve entrapment as
the cause of the problem and failure of medical management would be
an indication for surgery and nerve release [4].
Conclusion
Low back pain with associated groin pain can be caused by referred
pain for irritation of the thoracolumbar facet joints. A detailed history
and complete groin and spine exam are essential to diagnose thoraco-
lumbar syndrome. Once diagnosed, spinal manipulative therapy or
injection of trigger points is the best treatment option.
References
1. Maigne R. Origine dorso-lombaire de certaines lombalgies basses. Rles des
articulations interapophysaires et des branches postrieures des nerfs rachidi-
ens. Rev Rhum. 1974;41(12):7819 (article in French).
2. Maigne JY. Thoracolumbar junction and thoracolumbar spinal pain syndromes.
Socit Franaise de Mdecine Manuelle, 1996. http://www.sofmmoo.com/
english_section/4_thoracolumbar_junction/thoracolumbar_junction_aus-
tralie.htm. Accessed 16 Mar 2015.
3. Proctor D, Dupuis P, Cassidy JD. Thoracolumbar syndrome as a cause of low-
back pain: a report of two cases. J Can Chiropr Assoc. 1985;29(2):713.
4. Maigne R. Low back pain of thoracolumbar origin. Arch Phys Med Rehabil.
1980;61:38995.
5. Kim SR, Lee MJ, Lee SJ, Suh YS, Kim DH, Hong JH. Thoracolumbar junc-
tion syndrome causing pain around posterior iliac crest: a case report. Korean
J Fam Med. 2013;34(2):1525.
6. Fortin JD. Thoracolumbar syndrome in athletes. Pain Physician. 2003;6(3):
3735.
44. Patient with Referred Hip Pain
Shirin Towfigh
Chief Complaint
Right groin pain, like a tearing sensation at my groin crease.
History
The patient is a 41-year-old male with chronic right groin pain. He
has had a full workup at major academic institutions, including evalua-
tion by gastroenterologists and pain management specialists, and has
undergone colonoscopy, endoscopy, and injections, with no improve-
ment in his pain. His main complaint is a tearing sensation at the right
groin crease. It radiates from the groin to his anterior superior iliac spine
(ASIS). It also radiates down his leg and into his thigh. He denies pain
radiating around to his back or any hip pain. He admits that the pain is
deep and not at the surface of his groin. The pain is worse with activi-
ties. It is not better when lying flat. He has pain when stepping into the
car on the driver side. He also notes a hip click on that side. When the
pain is at its peak, he walks with a limp to protect himself from the pain
and prefers not to bear weight on that right leg. It is painful to lie on his
right side. He prefers to lie on his contralateral side in fetal position. He
denies groin bulge. He has no testicular pain.

DOI 10.1007/978-3-319-21587-7_44
502 S. Towfigh
Physical Exam
No visible bulge or palpable hernia defect in the right groin.
Nonspecific tenderness 2+ at the right groin, at the internal ring region.
Non-tender ASIS, hip area, pubic bone. Pain with passive flexion and
internal rotation of the right hip.
Imaging
Magnetic resonance imaging (MRI) of the pelvis was ordered to evalu-
ate for inguinal hernia. It showed suggestion of hip anterior acetabular
labral tear, with increased signal at acetabulum (Fig. 44.1), as well as CAM-
type femoroacetabular impingement (FAI).
Diagnosis
Right hip labral tear with FAI.
Fig. 44.1. MRI of the pelvis, non-contrast, T2 axial view. Right anterior acetabu-
lum with intermediate linear increased intensity signal, suggestive of labral tear
(yellow arrow). Also, concomitant osseous bump at femoral head-neck junction
suggestive of CAM-type femoroacetabular impingement (yellow asterisk). MR
arthrogram is indicated.
44. Patient with Referred Hip Pain 503
Treatment
The patient was referred to an orthopedic specialist for evaluation
and treatment. MR arthrogram confirmed the diagnosis. He underwent
joint injection, with resolution of his pain. He is scheduled for
arthroscopic surgery.

Hip disorders, especially labral tears, may present with groin pain. A
detailed history and physical examination are key to help differentiate
their diagnosis from other diagnoses, such as inguinal hernia. In fact, it
is not uncommon for a patient to have an inguinal hernia at the same
setting of a hip disorder. It is important to correctly diagnose the cause
of the patients groin pain and to provide treatment focused on that
disorder. In my practice, I often see patients who undergo elective
inguinal hernia repair, with no improvement in their preoperative
symptoms. Workup proves that their preoperative symptoms were
indeed due to another pathology, such as a hip disorder, and their ingui-
nal hernia was asymptomatic. A poor outcome would be to have a
complication from the elective inguinal hernia repair while at the same
time the patients main cause of preoperative pain was due to the hip
disorder, thus altogether complicating the patients plan of care, out-
come, and recovery.
Key elements in the history can help differentiate hip disorders from
groin pain. With hip disorders, the pain is often not relieved with lying
flat; there may be a limp or difficulty of weight bearing on the ipsilateral
leg. Many patients with hip disorders describe pain as wrapping around
the ASIS, like the letter C, cupping their thumb and fingers at their
waist. The pain is often deeper than expected and lower than expected
for an inguinal hernia. Also, a sensation of tearing or pulling is often
described, as opposed to a dull or sharp pain. Activities that are remark-
ably painful include an adduction, such as stepping into or out of a car
or sitting cross-legged on the floor. Many patients report a hip click or
popping sensation. On physical exam, passive flexion and adduction,
with internal rotation, elicit pain and limitation in movement.
504 S. Towfigh
Conclusion
Hip disorders such as labral tear, may present with groin pain. Their
distribution of pain can be similar to that of an inguinal hernia, with
groin pain radiating down the leg and around the back and worsening
with activities. Key questions in the history can help differentiate a hip
disorder from that of an inguinal hernia. Remember that patients with
inguinal hernias may have a primary hip problem. A hip X-ray and MRI,
preferably a dedicated hip MR arthrogram, are diagnostic. See Chap. 8,
for a full review and discussion on this very important topic.
45. Value-Based Clinical Quality
Improvement for Chronic Groin Pain
After Inguinal Hernia Repair
Bruce Ramshaw
Introduction
Improving the value of patient care has become the challenge for
healthcare in the twenty-first century. In healthcare, value should be
defined by quality measures, patient safety and satisfaction, and the
costs of care for a defined care process throughout the patients entire
cycle of care. Until recently, there have been no examples of patient care
based on defined care processes and collected outcome measures that
determine value. However, publications from business experts have
proposed a model for patient care that would allow for defining, measur-
ing, and improving value [13]. There have also been recent guidelines
and a book chapter describing these concepts applied to healthcare [4, 5].
Continuing to provide patient care in a model designed in the nineteenth
century, using the principles of reductionist science, evolved from the time
of the Renaissance, is no longer adequate. Our current system structural
design for modern patient care includes the hospital model with hierar-
chy, bureaucracy, and departmental silos, causing fragmentation in care
that is becoming more inefficient as complexity increases [6, 7]. Another
system structure for providing patient care is the individual physician
model, which is also not sufficient in light of the exponential increase in
medical knowledge [8]. Both core structures for providing patient care are
inadequate given the increasing complexity of patient care and the
increasing pace of change in our world in general. A complex systems
science view of healthcare, which is based on principles that describe
complex phenomena demonstrated in systems characterized by nonlinear
interactive components, allows us to simplify patient care by designing
care around definable patient groups, diseases, and problems [9].

DOI 10.1007/978-3-319-21587-7_45
506 B. Ramshaw
The information generated by the care processes can be used to improve

the outcomes of care over time. This continuous improvement of the
patients entire cycle of care has the potential to lead to improved qual-
ity, safety, and patient satisfaction at the same time that costs are low-
ered, resulting in improved value [1, 2].
The clinical quality improvement (CQI) program described in this
chapter demonstrates an attempt at process improvement for patients
with chronic groin pain after inguinal hernia repair. With chronic groin
pain after inguinal hernia repair becoming a more common and some-
times devastating problem, there is an opportunity to significantly
improve the outcomes for this group of hernia patients and decrease the
costs of care for this patient group, thus increasing overall value.
Traditionally, improvements in patient care have been dependent on
established clinical research tools such as prospective randomized con-
trolled studies. However, using traditional research tools for a complex
dynamic processsuch as for a patient with chronic pain after hernia
repairwith inherent uncontrollable variables can be inadequate to
improve value for patients. Recently, principles of CQI have been intro-
duced to improve clinical care. The value of applying these principles
has already been established for a portion of a patients cycle of care:
reducing central line infection, for example [10]. Implementing the prin-
ciples of CQI for the entire cycle of care for patients who develop
chronic pain after abdominal wall (inguinal and ventral) hernia repair
has not yet been demonstrated. A comparison between traditional clini-
cal research and CQI is presented in Table 45.1.
Methods: Developing a CQI Program for Patients

with Chronic Pain After Hernia Repair
Using principles of complex systems science and tools such as CQI
programs and nonlinear data analytics (such as predictive analytics), we
can define a variety of patient groups who had abdominal wall hernia
disease and related complications, such as chronic pain after hernia
repair. We have constructed a diverse hernia team to serve the needs of
this patient group. Based on feedback from former patients and review of
current literature, a dynamic care process is defined for the entire cycle
of care, from the moment of first symptom or contact until full return to
a maximum quality of life, with ongoing contact for long-term follow-up.
One step in the process is to determine the factors involved in producing
various outcomes. In reviewing the literature, two sources have produced
Table 45.1. Comparison between traditional research and CQI (with the kind permission of Surgical Momentum, LLC).
Traditional clinical research Value-based clinical quality improvement
Intent Testing of hypotheses Improving value
Traditional clinical research Clinical quality improvement
Pro Con Comparison
Pre-market FDA requirement Costly and lengthy Not currently acceptable for pre-market
Human subjects research Appropriate ethical Costly, limited ability Not ethically appropriate in current environment
(potential risk to patient) protections to interpret value
Post-market surveillance Might help determine Costly and lengthy Appropriate mechanism for post-market surveillance
harmful devices because information is gathered in real time in the
real clinical world with no change in patient care
Clinical research Traditionally known and Costly, rarely answers Ideal for real-world clinical research. Over time, can
accepted research clinical questions lead to improved value of care and opportunities
mechanism adequately to define unmet clinical needs
CQI project Known research Costly, wasteful, Ideal, as long as it is applied to the whole process of
mechanism may be unethical, care, or if applied to a subprocess, the outcomes
limited ability to of the whole process are measured concurrently
interpret value
Off label use/obtain May be industry initiated Costly and lengthy May be appropriateclinician initiated, no increased
additional indications (depending on risks to risk to patient
the patient)
Traditional clinical research Clinical quality improvement
Patient consent Disclosed to patient that they are participating Disclosed to patient that CQI is a natural part of their
in a defined clinical research project care and that information collected will be used
45. Value-Based Clinical Quality Improvement for Chronic Groin
primarily to improve the patient care process

for future patients
507
508 B. Ramshaw
Table 45.2. Preoperative and postoperative factors that can contribute to the
development of chronic pain after hernia repair.
Preoperative factors Postoperative factors
Pain greater than 1 month Pain
Repeat surgery Post-op radiation
Psychological vulnerability Neurotoxic chemotherapy
Anxiety Depression
Females Psychological vulnerability
Younger age Anxiety
Workers compensation Neuroticism
Inefficient diffuse noxious inhibitory control
Table 45.3. Factors that can contribute to

the development of chronic pain after hernia
repair and increase the vulnerability to pain.
Having English as a second language
Race and ethnicity
Income and education
Sex and gender
Age group
Geographic location
Military veteran status
Cognitive impairments
Surgical patient
Cancer patient
End of life
patient-related factors that contribute to the development of chronic pain

after surgery. These factors are listed in Tables 45.2 and 45.3 [11, 12].
Patients are offered a variety of choices for treatment (including non-
operative management) of their chronic pain after hernia repair. Most
patients have already sought and received many nonsurgical treatments
prior to seeking a surgical option for their chronic pain. The surgical treat-
ment choices include a diagnostic laparoscopy with attention to the pres-
ence of intra-abdominal adhesions, the presence of interstitial and hidden
hernias, and any foreign body such as mesh, tacks, sutures, etc. that may
be contributing to the entrapment or irritation of nerves and potentially
contributing to inflammation and chronic pain. A review of the current
evidence helped to establish the dynamic care processes. In all cases, the
patient and family are included in a shared decision process. Information
is provided by the hernia team, including the director of patient care man-
agement, other patient care specialists, and a surgeon who is experienced
45. Value-Based Clinical Quality Improvement for Chronic Groin 509
with the surgical treatment for this problem. A set of patient education
documents is given to the patient and family and includes a basic educa-
tion summary for this problem, a group of frequently asked questions
(FAQs) generated by former patients for the entire cycle of care, and a
copy of a book chapter on this problem with a description of surgical
treatments. Patients and family members are encouraged to do their own
research, to talk with other patients, and to consider other opinions,
including from other surgeons who are considered experts in this area.
In this model, we also define outcome measures that determine the
value of care (quality, safety, satisfaction, etc.). These measures are
obtained based on the subjective and objective input from a multidisci-
plinary hernia team, including the patient and family. As part of CQI, the
hernia team enters into a data-sharing contract that allows the de-
identified patient information to be shared with others who could add
value to the process of interpreting the data and might contribute ideas
for improved care. In addition to the core hernia team members, business
operations specialists, engineers, and associates from the manufacturers
of drugs and devices used in the care of this patient group can potentially
contribute ideas and knowledge to improve the outcomes for this CQI
program. As a part of the CQI program, a group of volunteer patient and
family members, surgical residents, medical students, and other general
surgeons may also participate at various times to add their perspective to
the improvement process. This can occur through participation at regu-
larly scheduled CQI meetings. The primary objective of this CQI pro-
gram is for the improvement of value for the patient within the local care
process. Secondary goals may include sharing this de-identified data and
analysis with hospitals, other physicians, patients, medical device com-
panies, regulatory bodies, and others within the healthcare value stream.
Implementing CQI as a part of the actual patient care process allows for
the coordination of care and quality improvement efforts to be exempt
from the strict requirements of the Health Insurance Portability and
Accountability Act (HIPAA), and the effort is not required to go through
an Institutional Review Board (IRB) process [13].
The process of developing a CQI program for patients with chronic
pain after hernia repair will initially be limited to those hernia practices
that regularly treat this patient group. However, the data and analytics
that are generated from these specialized hernia programs can be shared
with any surgeon, hospital, or person with chronic pain after hernia
repair that could benefit from access to this information. A sample work-
sheet that could be used to generate a CQI program for this condition is
presented in Fig. 45.1.
510 B. Ramshaw
Determining What Matters
Patient Care Process Definition Worksheet
Surgical Category Procedure

Chronic pain after hernia repair Laparoscopic and open operation to treat pain
Process Variables Worksheet
What Matters Specific Factors and Data Additional Comments

Elements
Do patient demographics Yes
matter?
Age (DOB)
If so, what patient variables? Gender (M/F)
BMI (Ht, Wt, Calc BMI)
Smoker (Current/Former)
Controlling personality (Y/N)
Workers Comp (Y/N)
Active lawsuit (Y/N)
Do symptoms matter? Yes Capture the duration of the

symptoms and time of onset
after hernia repair
If so, what symptoms? Active wound infection (Y/N)
Active mesh infection (Y/N)
Pain level
Ability to do normal activities
Ability to work
Functional assessment
Do pre-op tests matter? No
If so, what tests?

Do medical history variables Yes
impact the disease process?
If so, which medical history Emotional complexity

variables? (low, medium, high)
Medical complexity
(low, medium, high)
History of psychological disease
(Y/N)
Prior treatment for pain (list)
Do surgical history variables Yes
impact the disease process?
If so, which surgical history # of recurrent hernias (for this

variables? hernia)
# Prior abdominal surgeries
(include all hernia repairs)
History of mesh infection (Y/N)
History of wound infection (Y/N)
Are specific meds pertinent? Yes
If so, which meds? Current opioid use (drug, dose,

frequency)
For history of present illness, Effect on quality of life:
what questions are important to - ability to work
answer? - ability to exercise
- ability to do leisure activities
What intra-op specific variables Date of surgery

matter? (age at time of surgery)
Procedure:
What questions are important? Intraoperative nerve block:
R/L
Bilateral
Type
Who performed surgery?

Who performed TAP block?
What intra-op process deviations i.e., inadvertent bladder injury

could occur?
Fig. 45.1. A sample worksheet to generate a CQI program for chronic pain after
hernia repair.
Post-op hospital stay/ Discharge Length of stay (days)

variables ICU stay
Y/N
# Days
Pain medication (convert to
morphine equivalent):
IV/IM:
Dil
Morph
Dem
PO
Dil 2 mg
Perc 5
Loritab 7.5
Roxicet 10
PACU information: time (min),
opioid use (morphine equivalents)
Post-op List possible Respiratory

complications Treatment
Transfer to ICU
Intubation (# days intubated)
Bleeding
Wound complication
Minor
Moderate
Major
Pneumonia
Pulmonary effusion
Treatment
PE
Ileus
NG Tube
Delayed D/C
Cardiac
Arrythmia
MI
Other
List
Post-op clinic visit Pain at rest
Short term (0-90 days) recovery Pain while active
variables? Functional assessment
Complications:
Wound (minor, moderate, major)
Re-Hosp
Reason
Patient satisfaction:
Happy with cycle of care (Y/N)
Improvement suggestions
Any patient safety issues (list)
Ability to return to work
(Y/N, Y-full, part)
Ability to return to leisure
(Y/N, Y-full, part)
Any other issues?
Post-op clinic visit Pain at rest

Long term (90+ days) recovery Pain while active
variables? Functional assessment
Complications:
Re-Hosp
Reason
Recurrence
Chronic pain
(Degree of improvement)
Patient satisfaction:
Happy with cycle of care (Y/N)
Improvement suggestions
Any patient safety issues (list)
Ability to return to work
(Y/N, Y-full, part)
Ability to return to leisure
(Y/N, Y-full, part)
Any other issues?
Costs for entire cycle of care
Fig. 45.1. (continued)

512 B. Ramshaw
Discussion
This chapter attempts to describe the principles of CQI and nonlinear
statistical analytics applied to the entire cycle of care for patients with
chronic groin pain after hernia repair. The point of CQI is not to prove
or disprove a direct cause and effect with various process improvement
interventions but to define, measure, and improve the value of care for
patients. Implementation of ideas for process improvement is one way
to attempt to improve outcomes that define value.
Another way to attempt to improve value is to analyze the data that
is generated from real patient care to attempt to predict outcomes of
treatment, termed predictive analytics [14, 15]. Predictive analytics is
the practice of extracting information from existing data sets in order to
determine patterns and to predict future outcomes and trends. Other
nonlinear statistical methods such as factor analysis can produce
weighted correlations (positive and negative). This analytical tool can
help determine what factors contribute the most to outcomes. By identi-
fying the factors that are important to producing the outcomes, ideas for
process improvement can be generated. Another important concept to
foster improvement will be the opportunity to develop multiple collabo-
rations across organizations. Each team that is applying CQI for a
patient process, such as management of patients with chronic pain after
hernia repair, will develop different process improvement ideas and
generate a pool of data. By pooling data and sharing ideas, there will be
the opportunity to prevent overlearning, the tendency for a single team
functioning in isolation to stop improving.
Traditional research methods such as prospective randomized con-
trolled trials are producing diminishing returns in a world that is changing
faster and faster. As with Newtonian principles applied to physics, tradi-
tional linear research and statistical methodologies are incomplete when
applied to the real world of patient care. With a robust understanding of
complex systems science, it is appropriate and necessary to apply more
complete nonlinear scientific tools, such as CQI and nonlinear statistical
methods, to our patient care. Instead of attempting to prove or disprove a
hypothesis, value-based CQI is implemented to improve value to the
patient. Traditional clinical research defines inclusion and exclusion cri-
teria, primary outcomes, and length of the study. CQI has no inclusion or
exclusion criteria, has many outcome measures, and never ends.
The use of CQI for improving patient care has been supported by
healthcare law since the HIPAA law in 1996. These principles were again
supported with the Patient Safety and Quality Improvement Act of 2005.
The need for human subjects research protections and the use of IRB
processes have been challenged; when true CQI efforts are implemented,
there is a clear distinction when compared to human subjects research
that does require an IRB process. True CQI is focused on local process
improvement and utilizes evidence-based medicine interpreted by the
clinical team, ideally including the patient and family in a shared deci-
sion process. CQI is not appropriate for pre-market studies, for interven-
tions that could clearly increase risks for patients, or for efforts that
intend to produce generalizable knowledge as a priority, rather than local
process improvement as a priority. The intent to publish is not sufficient
to classify the effort as human subjects research. This information about
the distinction between human subjects research and CQI is clearly pre-
sented in the FAQ format on the US Health and Human Services website
[13]. It should be noted that the results of a CQI project in one local
environment do not necessarily apply to another, different local environ-
ment. Local environmental variation can produce different patient results
from the same process improvement intervention.
Summary
The use of CQI applied to the entire cycle of care for improving
value-based outcomes is a complex systems solution for healthcare. The
implementation of CQI is facilitated by implementing a multidisciplinary
hernia team, by learning how to design dynamic clinical processes, by
learning how to interpret data and data analyses, by learning how to gen-
erate and implement ideas for process improvement, and finally, by
developing a patient and family committee to assist with the hernia team
process improvement ideas. Future plans include adding a process activ-
ity-based cost model so that true value for the entire cycle of care can be
measured and adding additional collaborative hernia teams in other loca-
tions so that knowledge can be shared and data can be pooled to define
patterns and subpopulations from larger data sets, termed big data.
To our knowledge, this is the first publication demonstrating the use
of CQI for patients with chronic pain after hernia repair. Additional
prospective randomized controlled studies are not adequate or appropri-
ate for this type of real-world attempt to improve patient value, because
they are designed for hypothesis testing and generalizable knowledge,
rather than for attempting to improve patient value in a local clinical
environment. Continuing to refine processes, define value-based out-
comes, and apply complex system data analytics has the potential to
514 B. Ramshaw
improve the value of care delivered in each local environment where

these principles are implemented. Additional sites applying CQI and
complex systems data analytics will be necessary to allow collaborations
that will produce sustainable improvement of value for patients with
chronic pain after hernia repair.
References
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tems design for care and improvement. In: Jacob BP, Ramshaw B, editors. The
SAGES manual of hernia repair. New York: Springer; 2013. p. 318.
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(International Endohernia SocietyIEHS)-part 1. Surg Endosc. 2014;28(1):229.
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care, education and research. Washington, DC: The National Academies Press; 2011.
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of the Australian and New Zealand College of Anaesthetists and Faculty of Pain
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& FPM; 2010.
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research. 2015. http://answers.hhs.gov/ohrp/categories/1569. Accessed 20 Apr 2015
14. Mayer-Schnberger V, Cukier K. Big data: a revolution that will transform how we
live, work and think. London: John Murray; 2013.
15. Siegel E. Predictive analytics: the power to predict who will click, buy, lie, or die.
Hoboken, NJ: Wiley; 2013.
46. Patient Care Manager Perspective
on Chronic Groin Pain After Hernia
Repair
Brandie Forman and Bruce Ramshaw
Introduction
Where should one begin in defining patient-centered care for those
suffering from chronic groin pain after hernia repair? Identifying and
caring for the medical needs of a patient should certainly be at the center
of the focus of the caregivers in any medical or surgical facility. State-
of-the-art equipment and procedures, with highly trained physicians and
nurses, are aimed at meeting the medical needs of every patient. To
assume, however, that patient-centered care can and will result solely
from the use of specialized equipment and the presence of dedicated
physicians and nurses creates the potential for overlooking many impor-
tant patient needs and fails to achieve true patient-centered care. The
need for such care is especially important in dealing with more complex
patients such as those who have chronic pain.
True patient-centered care begins with the broadest possible defini-
tion of a patients needs. To limit that definition to a medical condition
requiring specific medical or surgical procedures may overlook subordi-
nate needs that can rise to overshadow the medical need. Patient-
centered care must begin by understanding the total situation from the
patients perspective. This involves meticulous care in communicating
with the patient as early as possible in the cycle of care and maintaining
that communication far beyond the end of the clinic visit or the hospital
stay. This communication must be aimed at establishing the highest level
of understanding possible.
The communicator must be able to listen as intently as she speaks.
What does a particular question or absence of a question suggest about

DOI 10.1007/978-3-319-21587-7_46
516 B. Forman and B. Ramshaw
the patients understanding of the entire situation? Why was there such
a long pause after your last explanation before the patients next ques-
tion? Did the patient really understand what was being explained?
Instead of simply answering questions, the communicator must also ask
appropriate questions to identify the level of the patients understanding
and to be sure that there are no gaps or holes in that understanding.
Such patient-centered communication must extend beyond the indi-
vidual seeking and receiving care and must also include the family
members who will be involved in the preparation for the care, who will
be waiting as the procedure takes place, and who will be providing com-
fort and assistance for the patient following the clinic visit and/or surgi-
cal procedure. Communication with the patients support system can
also identify factors that could be of benefit or could be detrimental to
the treatment of chronic pain. For example, our team has observed in
some cases that a controlling female influence (mother and/or spouse)
for an adult male suffering from chronic pain after hernia repair can
predict a more challenging recovery and potentially a less successful
outcome. This factor currently observed by our hernia team is poten-
tially related to outcomes. Factors such as this will need to be evaluated
in a factor analysis to determine the weighted correlation to various
outcomes for a more objective evaluation.
The Role of the Patient Care Manager

The role of the patient care manager in the clinical team is to provide
true patient-centered care by facilitating all levels of communication.
The patient care manager must become the communicator who creates
the environment that will identify the total needs of the patientinclud-
ing the patients family/support systemand who will coordinate meet-
ing those needs in an appropriate manner with the entire clinical team.
At the same time, the patient care manager and the clinical team must be
able to transfer critical information from the medical team to the patient
in a manner that will ensure that the ongoing needs of the patient will be
met. Listening, explaining, and understanding are the key ingredients in
facilitating the dynamics of this exchange.
As previously mentioned, this communication process must begin at
a very early stage. In order to ensure proper patient-centered care in a
program treating patients with chronic groin pain, the appropriate clear-
ances must be obtained from primary care physicians or referring medi-
cal specialists in such areas as pulmonology, cardiology, and other
46. Patient Care Manager Perspective on Chronic Groin Pain 517
specialized fields. The patient must be informed of the various alterna-

tives for travel to and from the medical facility. Possible needs and alter-
natives must be explored for convenient accommodations for patient and
family members before, during, and following the planned treatment,
test, or procedure at the medical center. The patient must be aware of the
specific paperwork required for employers, insurance providers, and oth-
ers with whom the patient is connected. The patient care manager and the
clinical team must be aware of and actively considering these needs in
order to provide all of the information needed by the patient as soon as
it is required. The viewpoint required for all of this is that of the patient.
The clinical team should be thinking, What does the patient need?
Obviously, the situation of some patients suffering with chronic pain
after hernia repair may be more complex than just one individual patient
seeking help. Manipulation, opioid abuse, secondary gain, and a number
of issues, both conscious and subconscious, may be present and can
inhibit the relationship between a patient and the clinical team and
inhibit a patients potential to improve.
It is very important for the patient care manager and clinical team to
confront any of these issues. But it is also important that the confronta-
tion be done with empathy and love, not with judgment. Instead of going
into a relationship with defenses up, our clinical team attempts to engage
every patient with empathy. However, if this is abused, we do put up
defenses as needed.
Shared Decision Process

As the medical team identifies the treatment options, there is likely to
be a need for some interpretation for the patient and the patients family.
While the medical team may well deal on a daily basis with medical
situations identical with or at least similar to those of a particular patient,
in most cases the patient has never dealt with such a situation before
and/or has difficulty understanding the options due to the presence of
chronic pain. The patient care manager and the clinical team must be
able to take the medical terminology and the explanation of symptoms,
outcomes, and ongoing treatment options and break them down in such
a way that the patient can understand their true significance. One cannot
assume that the patient understands; there must be patient and family
assurance based on the clear and concise communication process by the
clinical team. The patient care manager and the clinical team must learn
to think like the patient in order to provide the facilitation required to be
certain that the patients needs have been clearly identified and met as
much as possible.
The Operation and Postoperative Care

During a surgical procedure, the patient care manager and the clinical
team must become the coordinators who remove the vacuum of doubt
that can surround those awaiting the outcome of the procedure. This is
not a hand-holding process, but rather a clear effort to offer complete
information regarding the processes taking place beyond the doors of the
operating room. The questions must be addressed. The answers must be
complete. The next step should be foreseen and explained. Never
should there be the assumption that the less said the better. In most
cases, more information is needed rather than less. This is one clear
example of the patients needs extending beyond the operating room and
including those who are waiting nervously to see what happens next.
The patient care manager and the clinical team must be available and
responsive to that part of the patient that is in the waiting room while the
surgery is taking place.
During the postoperative period, and even after discharge from the
hospital, communication must continue if the patients needs are to be
met. The clinical recommendations must be transferred to the patient
and to the family in such a way that they understand what is included in
the postoperative protocol and what is expected of them. Communication
between caregivers must also be completed to assure that the patients
needs are met. Once again it is the patient care manager and the clinical
team who must facilitate all of this communication.
The role of the patient care manager and the clinical team during the
transition from the surgical facility to the next level of carewhether to
a rehabilitation center, another care facility, or to the patients homeis
particularly important. There must be assurance that all paperwork and
other orders for medical follow-up are completed correctly and in a
timely fashion. The patient and the medical team must be assured that
care has been taken to ensure proper handling of this next level of care.
Once again, communication among all who are involved in the care is
critical. The patient care manager and the clinical team must be directly
involved in all of this transfer of information. For patients with chronic
groin pain, this often includes communication with not only families but
also physicians in other locations. Developing relationships with the
support and caregivers in the patients hometown, often at a great
distance, is another important role for the patient care manager.
Following discharge from the hospital, there must be no assumption

that the care is complete or that all needs of the patient have been met.
The patient care manager and the clinical team must make follow-up
calls to be sure the recovery is taking the proper track. Additional clinic
visits must be arranged and the patient made aware of the importance of
those visits. If long-term care is required, the terms and basis for that
care must be carefully set forth to assure that the ongoing needs of the
patient are met. For patients on chronic opioid medications, the patient
care manager often facilitates communication and pain management
with a pain specialist near the patients home.
Patient-Centered Care for the Entire Cycle of Care

Patient-centered care involves approaching every element of the
entire process (medical, surgical, social, emotional, etc.) from before the
initial clinic visit (first contact) to the final and ultimate end of the cycle
of care from the patients perspective. How the patient perceives the
care received may very well determine whether or not the treatment was
successful. Thinking like the patient, talking like the patient, and even
feeling like the patient are essential elements in providing patient-
centered care.
The subject of patient-centered care is more critical in the mind of
the patient and the patients family than it can ever be to a caregiver or
administrator at a medical facility. That is the foundation, in fact, of the
entire concept of patient-centered care. Viewing medical care and
treatment from the perspective of the patient and the patients family
may well clarify the reasoning behind a method of care that focuses on
more than the medical condition of the patient but also on the patients
emotions and psyche as he/she prepares for, undergoes, and follows up
his/her own care. There are some specific behavioral patterns that are
essential for the caregiver to follow in order to be sure the patient is truly
at the center of the care given. This pattern from the perspective of the
patient, and the spouse, sibling, parents, or offspring of the patient,
involves seven specific and overlapping proceduresto listen, to under-
stand, to question, to instruct, to listen, to reinforce, and to reassure.
Obviously, as you read these seven items, you notice that listening is
included twice, indicating that it is the central and most important ele-
ment to ensure that the entire care process is successful in the mind of the
patient. Listening is the first element in the care cycle for the care team.
As the patient comes forward and attempts to explain his/her condition,
listening involves more than just hearing words and understanding symp-
toms. Listening is crucial to the process of recognizing the mind-set of

the patient as he/she attempts to describe not only his/her condition but
also what he/she has encountered prior to this phase of care in attempting
to deal with the condition. The terminology that the patient uses will
probably not be medically correct, so listening to the complete story from
the patient involves getting into the patients mind and understanding
what he/she is trying to say and what he/she is feeling. By listening to
hundreds of chronic patients suffering after hernia repair, we have heard
of several patterns:
The patient did not do research or think much about the decision
to have the repair. The surgeon said it was no big deal.
The patient feels stupid for not doing more research.
The patient expresses the wish that he/she had known more
about what was going into their body (e.g., that a mesh was
being placed and what type of mesh it would be).
After surgery, the surgeon would not listen, refused to acknowl-
edge that the patient was in pain, said that the cause was not the
mesh or the operation and that the pain was all in your head,
and told the patient not to come back.
Understanding involves the process of leaving the caregivers medi-
cal knowledge in the office and being able to put oneself into the posi-
tion of the patient. There are a wide variety of emotional and
psychological reactions on the part of most patients, as well as the physi-
ological reactions to their medical condition. Fear, confusion, intimida-
tion, uncertainty, and misinformation are some of the more obvious
characteristics of many patients. Being placed in a medical institution
whether a doctors office, a medical clinic, an emergency room, or
hospital roomis very uncomfortable for many. For the caregiver, this
environment is their normal workday setting. For the patient, however,
it is like a foreign land. Not only is the setting uncomfortable, the lan-
guage they hearwords that they cannot pronounce, with meanings that
are either vague or completely unknownfurther creates a sense of
mystery and increases the likelihood of confusion and intimidation. In
order for caregivers to be able to deal effectively with the patient and
center their care on the total needs of the patient, they must understand
where the patient isin a strange place, surrounded by strange words,
and attempting to deal with a situation they may not understand at all.
The caregivers understanding of the patient involves much more than
recognizing and treating the medical symptoms; it involves relating to
them as their equal and not their superior.
Understanding the patient in chronic pain after hernia repair includes

various patterns with severe impact on the quality of life for the patient
and their loved ones. These patterns include:
Learned helplessness that can lead to a lack of hope, depression,
and contemplation of suicide.
Lack of validation of their pain and suffering. Many patients
have stated that they wished that they had cancer so that friends,
family, and others would show more empathy.
Strain on relationships, especially a spouse.
Significant posttraumatic stress syndrome and other emotional
effects similar to those seen in torture victims.
Confusion or difficulty understanding what has happened to
them and how to explain it to others.
Anger toward the surgeon who did the initial hernia repair or oth-
ers who may have been involved in the process, and more recently
anger toward the mesh company (which may in great part be due
to potential financial gain through product liability lawsuits).
One of the best ways for the caregiver to grow from listening to
understanding is to ask pertinent questions. These questions will, obvi-
ously, involve exploration of the medical condition of the patient, but
they must also probe the understanding, the level of fear, the sense of
intimidation, and the confusion that the patient is enduring. By recogniz-
ing what issues are present, there can be a foundation to care for the
patients total needs. As the caregiver asks questions that probe the areas
of the patients understanding, confidence, and uncertainty, there will
develop a bond that will enable the patient to feel more comfortable
about the care being offered. They will become more open both to ask-
ing the right questions without fear of being ridiculed by one who is
wiser than they are and also to applying the instructions the caregiver
offers about their condition, the care they are receiving, and the follow-
up care upon leaving the medical facility.
As the listening, understanding, and questioning take place, a shared
decision process about the best course of action for the patient often
happens naturally. This is a uniquely individual process. Some go
through the process quickly and others more slowly. The goal of the
shared decision process is for the patient and family to feel that they
have made a decision that is right for them so that they are confident
moving forward with implementation of that shared plan.
The final part of the process of patient-centered care is reassurance.
This may well take place after the treatment is concluded. The follow-up
conversations or other contact with the patient will help the patient to
have the assurance that the care received was necessary, timely, and as
complete as possible. Even though the results of the procedure may be
obvious to the medical team, one must never assume that those results
are obvious to the patient. Going the extra mile in explaining after the
fact what has happened, what is involved in the recovery and post-care
period, and what the patient should expect as a long-term result of the
treatment can prove invaluable to the patient as he or she looks back at
what has occurred and forward to what is to come.
For patients with chronic inguinodynia after hernia repair who
undergo another operation to attempt to relieve pain, it is common for
them to need reassurance for several months after surgery. The acute
surgical inflammation can lead to times when the patient feels the pain
is as bad or worse than ever. This can even occur in patients who gain
total pain relief eventually. However, this healing process can take
months or even years.
Summary
The role of a patient care manager and the use of patient-centered
care in the mind of the patient is the only care that should be offered.
By involving the elements outlined here in the care process, the patient
who has chronic pain after a hernia repair can feel throughout the care
process and following the care process that they have been effectively
and efficiently cared for.
Suggested Reading
1. Baker SK, Bank L. Im sorry to hear that: real life responses to patients 101 most
common complaints about health care. Gulf Breeze FL: Fire Starter Publishing; 2008.
ISBN 13: 978-0974998657.
2. Diering SL. Love your patients! Improving patient satisfaction with essential behaviors
that enrich the lives of patients and professionals. Blue Dolphin: Nevada City, CA;
2004. ISBN 13: 978-1577331414.
3. Frampton SB, Charmel PA, editors. Putting patients first: best practices in patient-
centered care. 2nd ed. San Francisco: Jossey-Bass; 2008. ISBN 13: 978-0470377024.
4. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, editors. Through the patients
eyes: understanding and promoting patient-centered care. San Francisco: Jossey-Bass;
2003. ISBN 13: 978-0787962203.
47. Workers Compensation:
An Occupational Perspective on Groin
Pain, Including Psychosocial Variables,
Causality, and Return to Work
Joseph S. Pachman and Brian P. Jacob
Introduction
Groin pain and inguinal hernias are a frequent cause of lost work time
[1]. Despite the fact that elective inguinal hernia repair is a commonly
occurring surgery, there is surprisingly little evidence-based guidance
available regarding return to work, causality determination, and psycho-
social variables that impact post-herniorrhaphy functional recovery [2].
These issues are of particular relevance to disability insurance payers,
such as workers compensation carriers, which are contractually respon-
sible for medical treatment, as well as indemnity payments for lost wages
that are the result of a workplace injury. Especially since this financial
responsibility may extend for years, there is an interest in addressing
any potentially contributory comorbid conditions that might result in a
more expeditious return to work. In addition to the fiduciary responsibil-
ity to accurately assess causation, there is an incentive to identify all of
the factors that may have contributed to an injury, so that appropriate
prevention practices can be applied as related to future claims.

DOI 10.1007/978-3-319-21587-7_47
524 J.S. Pachman and B.P. Jacob
Evidence and Recommendations

There is significant variability in recommendations regarding return
to work post-herniorrhaphy [2]. Survey data suggest that when the
occupational job demands involve heavy lifting, return to work recom-
mendations vary from a few days to as long as 3 months post-op [3].
There is evidence that post-herniorrhaphy recommendations for early
return to work and unrestricted activity are more likely to result in func-
tional recovery [4]. There is good evidence that return to full duty work,
even with high physical demands, should generally not exceed 30 days and
this time should generally be even less with laparoscopic surgery [2]. Even
in the case of more conservative recommendations for return to work with
physical demands that include frequent lifting of greater than 25 lbs., dis-
ability of more than 68 weeks is not supported by available evidence [5].
Return to Work
In most cases, return to work recommendations can include time-
limited initial work restrictions (e.g., sedentary work). These recommen-
dations should never be based on the patient report of job availability,
but instead upon sound medical judgment regarding work capacity.
Even if accommodated work is not available, this determination is occu-
pational, not medical. Furthermore, there is a good deal of evidence that
early return to work, even with appropriate time-limited restrictions,
reduces long-term disability [6].
In general, workers compensation carriers are motivated by expedi-
tious return to work, quality outcomes, appropriately limited use of pre-
and postoperative opiate analgesics, and the absence of recurrence.
Regarding the latter, the available evidence suggests that there is no
difference related to recurrence in the case of early return to work fol-
lowing elective inguinal repair [6]. Not surprisingly, self-employed post-
herniorrhaphy patients have been found to return to work sooner than
those patients who are receiving disability benefits [7]. There is also
evidence that workers compensation patients report a greater duration
of pain and disability post-herniorrhaphy as compared to patients who
are receiving group health benefits [8].
47. Workers Compensation: An Occupational Perspective 525
Psychosocial Variables
Much of the variation in disability following hernia repair appears to
be a function of psychosocial variables. Jones et al. [2] found that apart
from age, educational level, income level, occupation, symptoms of
depression, and the expectation for return to work accounted for nearly
two thirds of the variance in return to work. These authors found that
depression significantly delayed return to work in this setting. Pars [9]
emphasized the importance of preoperative expectations, as well as cul-
tural and motivational issues related to return to work post-herniorrhaphy.
The inflection point as related to likely prolonged disability in workers
compensation appears to be 3 months absence from work [10].
Pain as Basis for Disability Decision

If pain alone is considered to be an ambiguous indication for surgery,
this subjective report is even more unclear when used as a basis for dis-
ability decisions. There is some evidence that at least 36 % of post-
herniorrhaphy patients will report some degree of chronic pain and that
this is more likely if there was a history of prior chronic pain [11]. It is
reasonable to hypothesize that a history of prior workers compensation
claims would similarly be a predictor of chronic post-herniorrhaphy
pain, and this may be worth considering in preoperative evaluation. It is
also worth noting that opiate analgesics can be a particular concern
when there is a claim of work-related pain, with regard to the potential
for diversion, medication misuse, and prolonged disability [12].
Catastrophizing
Tripp and Nickel [13] have emphasized the role of catastrophizing
as related to chronic groin pain and increased disability. Shaw et al. [14]
have demonstrated that this psychosocial variable can significantly
impact the duration of disability. In this case, catastrophizing refers to
misattribution and exaggeration of physiological experiences of groin
pain. There is emerging evidence that pain catastrophizing can be effec-
tively mitigated [15]. For example, although a complete discussion of
these issues is beyond the scope of this chapter, informing the patient
that some time-limited postoperative pain is often evidence of tissue
healing and repair incorporation, can reduce negative affect and improve
outcome perception [16].
Causality
Physicians treating patients with groin pain will occasionally be
asked by a workers compensation carrier to render an opinion regarding
causality. The issue here is whether the payer for the groin pain treatment
is more appropriately the workers compensation or the group health
carrier. There is often a motivation by patients to shift this responsibility
to the workers compensation system, given the absence of a deductible
or required co-pay. The rate of reimbursement to physicians and hospi-
tals in workers compensation can vary greatly from state to state.
In most jurisdictions, causality refers to the predominant cause of the
symptoms and findings, in this case, groin pain. Usually the question
relates to an estimation of causality as related to (greater than 50 %)
medical probability (i.e., is the groin pain, more likely than not, the
result of the workplace injury or the result of other unrelated pro-
cesses?). However, it is worth noting that the causation threshold in
different state workers compensation systems can vary.
The question of causality, i.e., whether or not an inguinal hernia may
be attributed to a single work-related strenuous lifting event, or even to
recurrent strenuous activity, is often a source of litigation. However,
despite the large number of claims in this area, there is little evidence to
support work-related causality [1]. There is increasing support for the
fact that inguinal hernias are more likely related to a congenital or
acquired connective tissue weakness [17]. For example, the available
evidence does not support an increased risk of developing an inguinal
hernia among laborers [18]. It is also interesting to note that inguinal
hernias are unusual occurrences in weight lifters [1]. As Hendry et al.
further point out, in the work setting, it is likely that when a hernia diag-
nosis follows a specific lifting or strenuous event, the event in question
has merely brought forward the occurrence of a hernia, and it would
most likely have occurred anyway around a similar time (p. 362). In
this respect, the hernia is analogous to a myocardial infarction that hap-
pened to occur at work, but was more likely than not the result of under-
lying atherosclerosis, not the occupational related event. There is also no
evidence to support a relationship between a single or even recurrent
strenuous work-related (or nonwork-related) event and subsequent her-
nia recurrence [1].
Maximal Medical Improvement

Physicians who are treating injured workers with groin pain might on
occasion be asked to comment on maximal medical improvement
(MMI). MMI is not necessarily related to a prescribed post-hernia repair
time, for example, but rather to that point at which little or no further
improvement is anticipated (more likely than not) and treatment gains
appear to have plateaued. When an injured worker is determined to be
at MMI, a physician might also be asked to provide a permanency rat-
ing. This rating of permanent impairment will help to determine the
amount of benefits for the patient by the workers compensation or dis-
ability insurance carrier. For example, usual successful hernia repair
would be expected to result in a 0 % impairment rating. A patient who
reports an absence of pain but for whom there is a recurring groin pro-
trusion with increased abdominal pressure, and for whom there are some
appropriate lifting restrictions (and surgery declination), would receive
an impairment rating of 10 %. In the case of ongoing pain due to docu-
mented residual nerve entrapment, or in the case of recurrent inguinal
hernias that are only partially reducible despite repeated surgical repair,
it is advised that the American Medical Associations Guides to the
Evaluation of Permanent Impairment be referenced [19], as these deter-
minations are less straightforward.
Conclusion
In summary, there is increasing evidence that groin pain and inguinal
hernias are not usually related to workplace injuries, that disability dura-
tion is often overestimated, and that chronic groin pain and herniorrha-
phy recovery are in part related to psychosocial variables, some of
which are modifiable. Disability and subjective reports of chronic pain
are disproportionally higher among workers compensation patients.
Workers compensation carriers are generally interested in value. If a
hernia surgeon is able to document improved outcomes and decreased
recurrence rate, there is often an opportunity for a preferred referral
relationship (that is not necessarily related to reimbursement).
Workers compensation can be arcane. Although it is described as a
single system, in reality, it is a complex set of often challenging rules
and regulations that vary from state to state. If case-specific questions
arise, a treating physician can consider engaging the carrier medical
director to help clarify.
Disclosure Dr. Pachman is the Regional Medical Director, Liberty Mutual

Group; the views expressed here do not necessarily reflect the views of Liberty
Mutual.
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Index
A American College of Radiology

Abnormal uterine bleeding (ACR), 186
(AUB), 170 Ankylosing spondylitis, 93
Acellular extracellular dermal Anterior inferior iliac spine
matrix mesh, 412 (AIIS), 76
Acetabulum, 75, 81, 82, 84, 96 Anterior superior iliac spine
Acetaminophen (APAP), 223, (ASIS), 76
225, 228 Anticonvulsants, 389
Acute epididymitis, 126 Antidepressants, 389
Acute pain management, 216224 Antineuropathic agents, 301
acetaminophen, 223 Appendix testis, torsion, 125
clonidine, 223 Appropriateness, 186
corticosteroids, 222 Arthritis, 264
gabapentinoids, 222 Athlete, CGP
ketamine, 224 diagnosis, 487
local anethetics, 216221 history, 485486
NSAIDs, 221 MRI, 486487
opioids, 223 nonoperative management
Acute scrotum, 119 options, 487489
Adductor longus (AL), 6668, operative treatment, 490491
413414, 420, 494, 513 outcomes, 491496
Adductor tendonitis, sports hernia physical examination, 486
clinical outcome, 513516 postoperative course, 491
complications, 516 Athletic pubalgia, 62, 6466,
diagnosis, 509 6872, 413
history, 507508 occult hernia
nonoperative management, defintion, 62
509511 diagnosis, 62
operative management, 511513 imaging, 62, 64
physical examination, 508 treatment, 64
workup, 508509 osteitis pubis
Adductor tenotomy, 104, 494, 513 clinical features, 64
Adenomyosis, 167 diagnosis, 65
Adhesions, 170 genitofemoral nerve, 69
Alcocks canal, 143 ilioinguinal nerve
Alpha-blocker therapy, 134 entrapment, 68
Alpha-2 receptor agonists, 223 inguinal nerve entrapment, 68
American College of Obstetricians nerve entrapment syndromes,
and Gynecologists, 159 7172

DOI 10.1007/978-3-319-21587-7
532 Index
Athletic pubalgia (cont.) Cauterization, 438

obturator nerve entrapment, Cephalosporin, 436
70, 71 CGP. See Chronic groin pain (CGP)
physical exam, 65 CGSCP. See Chronic groin and
radiographic evaluation, 66 scrotal content pain
treatment, 66 (CGSCP)
(see Sports hernia) Chlamydia trachomatis, 126
Atraumatic mesh fixation, 428 Chocolate cysts. See Endometrioma
Autoimmune disorders Chronic epididymitis, 129
clinical outcomes, 481 Chronic groin and scrotal content
magnetic resonance imaging, 479 pain (CGSCP)
nonoperative management anatomy, 387388
options, 478479 embryology, 386
operative treatment, 479480 evaluation and management,
patient histroy, 477478 388, 389
physical exam, 478 physical examination, 388
postoperative course, 481 prevalence, 385
Avascular necrosis, 9596, 191, 264, 265 treatment, 388390
two-hit theory, 385, 386
varicocelectomy, 394396
B Chronic groin pain (CGP), 119, 120,
Back and neck, 112, 113 127129, 131132, 336,
neoplasm 338339, 347351, 485496,
leisions, 112 525, 529534, 537539
treatment, 113 after hernia repair, 334
spondylolisthesis, 111, 112 (see also Clinical quality
Benign nerve sheath tumors, 112 improvement (CQI))
Bilateral athletic pubalgia, 487 after inguinal hernia repair,
Bioactive prosthetic materials 337, 557
(BPM), 408, 409 clinical quality improvement
cross-linked/non-cross-linked, 411 portion, 351
inguinal hernia repair, 412413 development factors, 336
mammalian source, 410 hernia team, 348
sports hernias, 413415 interaction with clinical
tissue of origin, 411 manager/care
Biologic mesh, 414, 415 coordinator, 351
Bisphosphonate therapy, 90, 95 invasive nonsurgical
Bolus wound infusion, 229 options, 339
Border nerves, 302, 305 multimodal perioperative
Botulinum toxin (Botox), 151, 401 management, 348350
BPM. See Bioactive prosthetic noninvasive treatment
materials (BPM) options, 338339
Bupivacaine, 71, 414, 441, 501, 511, prevention, 347348
513, 532, 534 systems science solution,
348351
after tissue repair
C diagnosis, 538
Cam-type impingement, 82, 83 history, 537
Catastrophizing, 587 imaging, 538
Index 533
nonoperative management, 538 post-vasectomy pain

operative treatment, 538 syndrome, 131
outcomes, 539 testicular mass, 127
physical examination, 537 varicocelectomy, 128
in athlete surgical options, 339
diagnosis, 487 sutures, 337
history, 485486 types, 334336
MRI, 486487 Chronic inguinal neuralgia, 446
nonoperative management Chronic inguinal pain, 283
options, 487489 Chronic pain, 135137
operative treatment, 490491 after hernia repair (see Patient
outcomes, 491496 care manager)
physical examination, 486 conservative measures, 135
postoperative course, 491 epididymectomy, 136
autogenous and mesh repairs, 472 microsurgical spermatic cord
causes, 336337 neurolysis, 135
etiology of, 467 orchiectomy, 137
fixation devices, 337, 470471 vasovasostomy, 135
foreign body reaction, 466 Chronic pelvic pain (CPP), 159167,
incidence, 333 170176
Lichtenstein hernia repair clinical findings, 551
diagnosis, 531 CT scan, 550
history, 529 diagnosis, 550
imaging, 530 operative treatment, 550
nonoperative management, 532 outcomes, 551, 552
operative treatment, 532 patient history, 549
outcomes, 534 pelvic and abdominal
physical examination, 530 ultrasounds, 550
postoperative course, 533 physical examination, 550
lightweight vs. heavyweight postoperative recovery, 550
mesh, 469470 preoperative symptoms, 551
mesh, 337, 466, 468469 in women
operative management, adenomyosis, 167
340345 adhesions, 170
perceptions, 467468 comorbid pain conditions, 175
postoperative endometriosis,
complications, 346 162167
management, 345346 functional pain syndrome, 161
outcome, 465 history, 160
preoperative management, 340 laparoscopy, 161, 162
risk factors, 465466 myofascial pain, 171
spermatic cord and testicular neurosensory pain, 173
causes ORS, 173
epididymal causes of scrotal PCS, 172
pain, 129 prevalence, 159
hydrocele, 128 psychological factors, 176
pelvic pain syndrome, 132 vaginal cuff pain, 174
post-inguinal herniorrhaphy Chronic pelvic pain syndrome
testicular pain, 131132 (CPPS), 132134
534 Index
Chronic post-herniorrhaphy groin IASP, 18, 20

pain, 235 interventional therapy, 22, 23
Chronic postoperative inguinal pain intravenous medication, 22
(CPIP), 275277 patient report, 19
algorithmic approach, 272 pharmacological treatment, 20
diagnostics, 273 reflex sympathetic dystrophy and
etiology, 271 causalgia, 18
mesh removal, 278 topical medications, 22
multidisciplinary approach, 280 Complex systems science, 567, 568, 574
neuropathic pain Computed tomography (CT). See
neurolysis, 276 also Radiography (X-ray)
recurrence, 277 inguinal hernia repair, 524
triple neurectomy, 275 intravenous contrast material, 190
orchialgia, 279 and radiography comparison, 185
timing, 273 radiation dose, 185
Chronic scrotal pain, 129 Congestive epididymitis, 396
drug-induced epididymitis, 130 Continuous wound infusion, 228
granulomatous epididymitis, 130 Corticosteroids, 222, 229
idiopathic chronic epididymitis, 130 Coxa saltans externa, 261
lesions of epididymis, 131 COX-2-selective NSAIDs, 225
Chronic scrotal pain syndrome C-reactive protein (CRP), 89
(CSPS), 120, 123, 133, 134 Cross-linking, 411
Chronic testicular pain, 119, 131, Cyclo-oxygenase (COX) enzymes, 221
133, 135
Clinical quality improvement (CQI),
567571, 574 D
complex systems science, 567, Deaver retractor, 515, 516
568, 574 Deeply infiltrating endometriosis
complexity, 567 (DIE), 164, 167
dynamic care process, 568 Deep somatic pain, 335
healthcare, 567 Defecatory dysfunction, 134
healthcare law, 574 Degenerative spondylolisthesis, 112
hernia team, 571 Depression, 503
inguinal hernia repair, 568 Dermatome mapping, 310, 312, 313,
nonlinear data analytics, 568, 574 316, 323
traditional clinical research, classification, 317, 320
568, 569 postoperative pain, 309
treatment, 570 technique description, 311
Clonidine, 223, 229 Dermatome Mapping Classification
Comorbid pain conditions, 175 (DMC), 317, 318, 320
Complementary alternative Dermatome mapping test (DMT),
medicine (CAM), 338 310, 319, 320
Complex regional pain syndrome Dilated vein, isolation and ligation, 395
(CRPS) type I and type II Discogenic pain, 262
chemical findings, 19 Drehmanns sign, 80
chronic pain, 17 Drug-induced epididymitis, 130
classification, 18 Dynamic MR, 288
clinical management, 19, 21 Dysmenorrhea, 161
definition, 18 Dyspareunia, 160, 163, 171, 174
Index 535
E Foreign body reaction, 466, 481, 482

EndoCare CryoProbe, 400 Fourniers gangrene, 125
Endometrioma, 164
Endometriosis, 150, 162
diagnosis, 164 G
inflammation, 164 Gabapentin, 222, 229, 389
symptoms, 163 Gate control theory, 160
therapies, 165 Genital branch of genitofemoral
Endoscopic retroperitoneal triple nerve (GFN), 357
neurectomy, 276 Genital nerve in inguinal canal,
Endoscopic transperitoneal 363, 365
pudendal neurolysis, 155 Genitofemoral nerve (GFN), 69,
Enhanced or extended view TEP 123, 302, 303, 329, 459, 461
(eTEP) technique, 437 Gluteus medius tendonitis, 100101
Epididymal innervation, 123 Gonococcal infections, 88
Epididymectomy, 136 Granulomatous epididymitis, 130
Epididymis lesions, 131 Greater trochanteric bursitis, 101
Epidural anesthesia, 227 (see also Iliopsoas bursitis)
Erythrocyte sedimentation rate Greater trochanteric pain syndrome
(ESR), 89 (GTPS), 260
European Association of Urology Groin hernia, 460
(EAU), 120 Groin pain, 3, 2835, 4146, 184191,
External oblique aponeurosis, 194, 196, 200, 202
tears in, 511 adductor sprain, 4
arthritis and avascular
necrosis, 264
F documentation, 37
FABER test, 104 extra-articular causes, 260
Femoral hernia, 83, 132 FAI, 265
Femoral neck, 75, 88, 9193 femoral neck stress fractures, 266
Femoral neck stress fractures, 266 first-line treatments, 300
Femoroacetabular impingement fluid collections, 283, 286, 287
(FAI), 8284, 265, 562 GTPS, 260
Fibrin glue technique, 428 hip instability, 266
Fibromyalgia, 161 hip pathologies, 4
clinical outcomes, 481 hip synovitis and septic
magnetic resonance imaging, 479 arthritis, 265
nonoperative management history
options, 478479 C sign, 29, 30
operative treatment, 479480 causes, 28, 29
patient histroy, 477478 movements and activities, 28
physical exam, 478 osteitis pubis, 30
Ficat scoring system, 95 sports hernias, 30, 31
Field block, 221 iliopsoas pathology, 263
Fixation, CGP, 470471 imaging, 183210
Flexible CO2 laser computed tomography/
instrumentation, 392 radiography, 184191
Focused inguinal examination, evaluation of occult hernias,
sports hernia, 486 205, 210
536 Index
Groin pain (cont.) therapeutic options, 304

magnetic resonance, 191, total hip replacement, 266, 267
194, 196 Groin, neuroanatomy of, 356
modalities, 183205
nuclear, 202
ultrasound, 200, 202 H
inguinal hernia repair, 5 Hematoma, 284, 438
Internet, 3 Hernia Trialists, 469
interventional targets, 301 Herniated disc, 111
intra-articular causes, 263, 264 Hip, 78105
localizing options, 303 abductors, 76
lumbar spine disease, 262 anatomy, 75
mesh complications, 285, 288290 arthroscopic surgery, 562
nerve compression/entrapments, 4 avascular necrosis
neurectomy, 7 diagnostic examination, 95
neurologic complications, 292, 294 differential examination, 95
neuropathic pain, 5 physical examination, 95
nociceptive pain, 5 presentation, 95
office-based local nerve blocks, 6 treatment/referral, 95
osteitis pubis, 262 defintion, 561
physical examination diagnosis, 562
height and weight, 31 dysplasia, 8687
hip joint injury, 3335 femoroacetabular impingement
iliohypogastric, ilioinguinal, cam-type impingement, 82
and genitofemoral nerve, 33 diagnostic examination, 82
leg muscles, 32 differential examination, 83
palpation, 3132 physical examination, 82
paraspinal muscles, 32 pincer-type impingement, 82
valsalva/cough, 32 presentation, 82
primary groin pain, 6 treatment/referral, 84
primary inguinodynia gluteus medius tendonitis
athletes, 42 diagnostic examination, 101
femoral hernias, 42 differential examination, 101
gynecologic causes, 44 physical examination, 100
inguinal hernias, 41 presentation, 100
lumbar disc herniation, 43 treatment/referral, 101
spermatic cord, 43, 44 greater trochanteric bursitis
testicular causes, 43, 44 diagnostic examination, 102
pubic bone, 4 physical examination, 102
pubic ramus fractures, 262 presentation, 101
radiographic studies, 36 treatment/referral, 102
risk factors, 300 hip dysplasia
secondary groin pain, 3, 6 diagnostic examination, 86
secondary inguinodynia physical examination, 86
inguinal hernia repairs, 45 treatment/referral, 87
lumbar spine, 46 history of pain, 76
second-line treatments, 301 imaging, 562, 564
TAPP approach, 6, 293, 295 inflammatory arthritis
TEP, 293 diagnostic examination, 94
Index 537
physical examination, 94 septic

presentation, 93 diagnostic examination, 89
treatment/referral, 94 differential examination, 89
instability, 266 physical examination, 89
labral tear presentation, 88
diagnostic examination, 85 treatment/referral, 90
differential examination, 86 snapping hip syndrome
magnetic resonance diagnostic examination, 98
arthrogram, 85 differential examination, 98
physical examination, 85 physical examination, 98
presentation, 85 presentation, 97
treatment/referral, 86 treatment/referral, 98
lateral femoral cutaneous stress fracture
neuralgia diagnostic examination, 91
diagnostic examination, 99 differential examination, 91
differential examination, 100 physical examination, 91
physical examination, 99 presentation, 90
presentation, 99 treatment/referral, 92
treatment/referral, 100 synovitis, 265
muscle sprain/strain transient osteoporosis
diagnostic examination, 103 diagnostic examination, 96
differential examination, 103 differential examination, 97
physical examination, 103 physical examination, 96
presentation, 102 presentation, 96
treatment/referral, 103 treatment/referral, 97
occult fracture Human toll of
diagnostic examination, 88 inguinodynia, 467
physical examination, 87 Hydrocele
presentation, 87 definition, 128
treatment/referral, 88 pediatric herniorrhaphy, 129
osteoarthritis pediatric hydrocelectomy, 129
arthroplasty, 82 treatment of adult, 129
diagnostic examination, 80 Hydrodissection of residual nerve
differential examination, 80 fibers, 393, 394
physical examination, 79 Hysterectomy, 165, 174
presentation, 78
radiological study, 80, 81
treatment/referral, 82 I
young ones, 80 IBS. See Irritable bowel syndrome
outcomes, 563 (IBS)
physical evaluation, 76 Idiopathic inflammatory
physical examination, 562 epididymitis, 130
range of motion, 76, 77 Iliohypogastric and ilioinguinal
sacroiliac joint pain nerve block, 303
diagnostic examination, 104 Iliohypogastric nerve (IHN), 123,
differential examination, 105 302, 329, 447, 459
physical examination, 104 anatomy, 357
presentation, 104 identification and neurectomy,
treatment/referral, 105 363, 364
538 Index
Ilioinguinal nerve (IIN), 123, 302, BPM, 412413

329, 446, 447, 459 chronic groin pain
anatomy, 357 (see Chronic groin pain
entrapment, 68 (CGP))
identification and neurectomy, 363 computed tomography, 524
Ilioinguinal neuralgia, 531 diagnosis, 525
Ilioinguinal neurectomy, 449451 history, 523524
Iliopsoas bursitis, 102 mesh use for, 465, 467
Iliopsoas tendinitis, 263 mesh vs. non-mesh
Iliopubic tract, 247 methods, 468
Inflammatory agents, 482 nonoperative management
Inflammatory arthritis, 9394 options, 524
Inguinal canal operative treatment, 525527
anterior wall, 9, 10 outcomes, 527528
external ring, 11 physical exam, 524
fascial layers, 9, 10 postoperative course, 527
femoral ring, 13 recurrence rates after, 355
genitofemoral nerve, 13 surgery, 435
iliohypogastric nerve, 12 tissue repairs
ilioinguinal nerve, 13 Bassini, 233
internal ring, 9, 11 McVay, 233
neuroanatomy and intraoperative Shouldice, 233
variations, 14 treatments, 51
preperitoneal fascia, 11, 12 infection-based therapies, 237
sympathetic nerves, 13 mesh and suture removal, 238
Inguinal hernias, 215, 225227, 229, NSAIDs, 237
233, 237, 238, 457, 465, RFN, 238
529531, 537 surgical interventions, 238
chronic post-herniorrhaphy groin triple neurectomy, 239
pain, 235 worsening symptoms, 50
complications, 235 Inguinal herniorrhaphy, 233, 235
diagnosis, 50 Inguinal nerve block, 219
disadvantage, unilateral Inguinal nerve entrapment, 68
laparoscopic, 51 Inguinal neuroanatomy, 356, 358
epidemiology/etiology, 49, 50 Inguinodynia, 132, 283, 317, 371,
mesh-based repairs, 234 449, 519
physical exam, 50 after mesh repair, 468
recurrences development, 355
anterior and posterior (see Groin pain)
approach, 326 incidence, 467
anterior approach, 329 Injection-based therapies, 237
evaluation, 327 Instillation, 221
posterior approach, 330 International Association for the
postoperative pain, 325, 326 Study of Pain (IASP),
risk factors, 327 18, 274
surgical options, 328 Interstitial cystitis (IC), 134,
treatment, 328 161, 482
repair, 470, 568 Intra operative pain management,
approach for, 472 226, 227
Index 539
anesthetic technique Lateral femoral cutaneous nerve,

general anesthesia, 227 302, 303
local anesthesia, 226 Lateral femoral cutaneous
nonrecommended neuralgia, 99100 (see also
intraoperative, 227 Meralgia paresthetica)
systemic analgesia Left groin nerves, 342, 343
acetaminophen, 227 Left groin pain
ketorolac, 227 diagnosis, 487
Invasive nonsurgical options, for history, 485486
chronic groin pain, 339 MRI, 486487
Irritable bowel syndrome (IBS), 134, nonoperative management
161, 482 options, 487489
Isthmic spondylolisthesis, 112 operative treatment, 490491
physical examination, 486
postoperative course, 491
K LeggCalvPerthes disease, 31
Ketamine, 224, 229 Levator syndrome, 148
Ketorolac, 226 Levonorgestrel intrauterine system
(LNG-IUS), 170
Leydig cells, 387
L Lichtenstein hernia repair, 529534
Labral tear, 8486, 265 diagnosis, 531
Labrum, 75, 82, 84, 85 history, 529
Laparoscopic inguinal hernia imaging, 530
repair, 252 nonoperative management, 532
Laparoscopic retroperitoneal triple operative treatment, 532
neurectomy approach, 381 outcomes, 534
dissection, genitofemoral nerve physical examination, 530
trunk over psoas muscle, postoperative course, 533
374 Lichtenstein repair, 234, 242
genitofemoral nerve trunk over Lichtenstein technique, 423
psoas muscle, 378 Lightweight mesh, 426
iliohypogastric and ilioinguinal Lipoma
nerve trunks, 374, 377 diagnosis, 56
lateral femoral cutaneous nerve epidemiology/etiology, 55, 56
trunk, 374, 378 treatment, 56
lumbar plexus, 374, 376 Local anesthesia
patient positioning, 373 bolus wound infusion, 229
subcostal nerve trunks and 12th continuous wound infusion, 228
rib, 374, 377 Local anesthetics
trocar placement and operative definition, 216218
positioning, 373, 374 epinephrine, 226
ureter, iliac artery vs. field block, 221
genitofemoral nerve trunk, inguinal nerve block, 219
375, 379 instillation, 221
Laparoscopic technique, 494 plus epinephrine, 227
Laparoscopic triple neurectomy, 241 plus instillation, 227
Laparoscopic uterosacral nerve preoperative pain
ablation (LUNA), 174 management, 225
540 Index
Local anesthetics (cont.) Mood disorder, 176

pre-peritoneal instillation of, 227 MRI. See Magnetic resonance
transversus abdominis plane imaging (MRI)
block, 219 Multimodal pain therapy, 215, 219, 221
Lumbar disc degeneration, 109 acetaminophen, 223
Lumbar spine disease, 262 clonidine, 223
Lumbar stenosis, 110 corticosteroids, 222
gabapentin, 222
ketamine, 224
M local anesthetics, 218
Magnesium, 229 field block, 221
Magnetic resonance imaging (MRI) inguinal nerve block, 219
adductor tendonitis, sports instillation, 221
hernia with, 508 transversus abdominis plane
arthrogram, 85 block, 219
autoimmune disorders, 479 NSAIDs, 221
bilateral athletic pubalgia with, 487 opioids, 223
CGP in athlete, 486487 Mumps orchitis, 126
contrast agents, 196 Muscle relaxation, 436
and CT comparison, 199 Muscle sprain/strain, presentation, 102
dynamic, 194 Myofascial pain, 171
fibromyalgia, 479, 480 Myopectineal orifice, polypropylene
intravenous, 196 mesh reinforcement, 492
Maximal medical improvement
(MMI), 589
Meralgia paresthetica, 99 N
Mesh and suture removal, 238 Nantes criteria, 148, 149
Mesh complications, 285 Neisseria gonorrhoeae, 126
Mesh migration, 521 Neoplasm, 112
Mesh placement, 342, 344 Nephrolithiasis, 126
Mesh plug, 521 Nerve fiber, 391
Mesh reaction, 285, 481 Nerve injury, mechanisms, 356
Mesh removal, 278, 341, 342, 526 Nerve stimulation, 303, 305
Mesh-based repairs, 234 Neural innervation, 387
Meshoma, 272, 273, 276, 278, 289, 502 Neural plasticity, 335
Mesh-related chronic pain, 466 Neurectomy, 453457, 502
lightweight vs. heavyweight, pain after, 458
469470 pragmatic, 448451
studies evaluation, 468469 prophylactic, 446448
Metalloproteases, 90 selective, 454, 455, 457460
Methylprednisolone, 509 triple, 456, 460461
Microcryoablation, 400 Neurofibromas, 112
Microsurgical denervation, 135 Neurolysis, 305
Microsurgical spermatic cord Neuroma, 283
neurolysis, 135 Neuromodulation, 304
Microsurgical targeted denervation Neuropathic pain, 132, 274, 300,
of spermatic cord 334, 335, 356, 360361, 371,
(MDSC), 390 379, 525
Migraines, 161 Neuroplasticity, 335
Index 541
Nociceptive pain, 274, 299, 334, 356, Osteoarthritis (OA), 7882

371, 379 Ovarian remnant syndrome
Nociceptors, sensitization of, 335 (ORS), 173
Noninvasive treatment options,
338339
Non-neuropathic pain, 132 P
Nonsteroidal anti-inflammatory Pain, definition, 299
drugs (NSAIDs), 82, 101, Painful bladder syndrome (PBS),
126, 221, 228, 237 149, 161
Nuclear imaging, 202 Parasympathetic fibers, 123
Paravertebral nerve block, 227
Patient care manager, 577582, 584
O communication, 578
Obturator nerve entrapment, 70 entire cycle of care, 581, 582, 584
Occult fracture, 8788 operation and postoperative
Occult hernia, 205 care, 580, 581
Occult inguinal hernia patient-centered care, 577
definition, 52 role, 578, 579
diagnosis, 53, 54 shared decision process, 579
epodemiology/etiology, 51, 52 Patient-centered care, 577
treatment, 54 Pediatric herniorrhaphy, 129
Open autogenous Shouldice Pediatric hydrocelectomy, 129
repair, 469 Pelvic congestion syndrome (PCS), 172
Open inguinal hernia repair Pelvic floor tension myalgia, 148149
computed tomography, 524 Pelvic ultrasound, 479
diagnosis, 525 Pelvis
history, 523524 fractures, 263
nonoperative management T2-weighted axial oblique image
options, 524 of, 509, 510
operative treatment, 525527 T2-weighted sagittal image of,
outcomes, 527528 509, 510
physical exam, 524 Percocet, 501, 503, 504
postoperative course, 527 Perioperative pain management,
Open triple neurectomy, 276 224227, 229
Operative management, 520522 anesthetic technique, 226
Opioids, 223, 300 clonidine, 229
Orchialgia, 279 corticosteroids, 229
Orchiectomy, 137 gabapentin/pregabalin, 229
Orchitis, 126 ketamine, 229
Osteitis pubalgia, 543 magnesium, 229
Osteitis pubis, 262 nonrecommended intraoperative
diagnosis, 543544 strategies, 227
MRI, 543 preoperative, 225
nonoperative management, 545 gaba agonists, 226
patient history, 541542 local anesthetics, 225
physical examination, 542 nonrecommended
physical rehabilitation, 546 strategies, 226
prevalence, 545 systemic analgesics, 225
pubic symphysis, 545 systemic analgesia, 227
542 Index
Peripheral nerve entrapment, 107 recovery from, 504

Peripheral nerve field stimulation, 305 revisional surgery, 503504
Peripheral pain generators, 162 Postherniorrhaphy inguinodynia
Permanency, 589 chronic pain after preperitoneal
Persistent postoperative pain hernia repair, 364, 365
(PPP), 420 classification, 356
Photoelectric effect, 184 open triple neurectomy,
Physical therapy, 338 362364
Piezoelectricity, 200 postherniorrhaphy orchialgia, 365
Pincer-type impingement, 82, 83 surgical results, 366367
Pinchroll test, 557, 558 surgical risks, 362
Plain radiographs, 508 timing and patient selection,
Platelet-rich plasma (PRP), 415 361362
Plug and patch repair Postherniorrhaphy orchialgia, 365
complications, 522 Postherniorrhaphy pain, 453, 461
diagnosis, 520 Post-inguinal herniorrhaphy
history, 519 testicular pain, 131132
nonoperative management, 520 (see also Inguinodynia)
operative management, 520522 Postoperative pain management,
outcomes, 522 228229, 299
physical exam and workup, 520 acetaminophen, 228
Polypropylene mesh reinforcement, nonrecommended strategies, 228
myopectineal orifice, 492 NSAIDs, 228
Polypropylene meshes, 426 strong opioids, 228
Pool therapy, 82 weak opioids, 228
Portal for Rare Diseases and Post-vasectomy pain syndrome
Orphan Drugs, 143 (PVPS), 131, 136
Positron emission tomography Pragmatic neurectomy, 424,
(PET) scan, 481 448451
Post vasectomy pain, 396400 Pregabalin, 389
Posterior hernia surgery, 245254 Preperitoneal hernia repair, chronic
anatomy, 246 repair after, 364, 365
differential diagnosis Presacral neurectomy (PSN), 174
location, 249 Primary inguinal hernia repair
timing and nature, 249 technique
type of pain, 249 anesthesia selection, 421
workup, 249 fixation of mesh, 427
differential diagnosis, 248249 lightweight vs. heavyweight
glue fixation, 252 mesh, 426, 427
mesh repair, 245247, 249251, 254 nerve identification, 424426
prevention, 252 open anterior vs.
treatment, 250252 preperitonealapproach,
Postherniorrhaphy chronic 421423
pain, 355 polypropylene mesh, 426
Post-herniorrhaphy groin pain postoperative therapy, 428
depression, 503 preoperative patient selection,
description, 502503 419420
patient experience, 499505 Prolene Hernia System (PHS), 423
preoperative experience, 500501 ProleneTM Hernia System, 289
Index 543
Prophylactic neurectomy, 446448 transischiorectal pudendal

PRP. See Platelet-rich plasma (PRP) neurolysis, 154
Pseudotumors, 267, 268 transperineal pudendal
Pubalgia. See Osteitis pubis neurolysis, 154155
Pubic inguinal pain syndrome vaginal mesh implantation, 155
(PIPS), 420 Pulsed radiofrequency (PRF), 304
Pubic ramus fractures, 263
Pudendal nerve blocks, 152
Pudendal nerve entrapment R
(PNE), 144 Radiation dose assessment, 186
Pudendal nerve motor terminal Radicular pain, 262
latency (PNMTL) Radiofrequency neurolysis
testing, 147 (RFN), 238
Pudendal neuralgia, 146155 Radiography (X-ray)
causes of, 144, 146 appropriateness criteria, 186
definition, 143 and CT, 185
diagnosis and groin pain, 184
magnetic resonance RAVV. See Robotic-assisted
imaging, 148 microsurgical
MRI, 147 vasovasosectomy
Nantes criteria, 149 (RAVV)
patient history, 146 Rectus abdominis (RA),
physical examination, 147 508510
PNMTL testing, 147, 148 Repetitive shear, 108
quantitative sensory Retroperitoneal genitofemoral
threshold testing, 147 nerve trunk, 365, 366
differential diagnosis Retroperitoneal neuroanatomy,
endometriosis, 150 357, 359
painful bladder syndrome/ Return to work, 586
interstitial cystitis, 149 Revisional surgery, 87
pelvic floor tension myalgia, Rheumatoid arthritis, 483
148149 Rheumatoid arthritis (RA), 93
vaginismus, 150 Right rectus avulsion, with
vulvar vestibule, 150 secondary cleft, 488
vulvodynia, 150 Robotic targeted MDSC
dorsal clitoral/penile innervates, (RTMDSC), 391393
143, 144 Robotic-assissted microsurgical
etiology, 144, 145 vasoepididymostomy
prevalence, 143 (RAVE), 397400
symptoms, 145 Robotic-assisted microsurgical
treatment vasovasostomy (RAVV),
botulinum toxin injections, 151 396397
endoscopic transperitoneal anterior muscular anastomosis, 398
pudendal neurolysis, 155 involution
pharmacotherapy, 151, 152 vasoepididymostomy, 399
physical therapy, 151 posterior luminal anastomosis, 397
pudendal nerve blocks, 152 vas muscularis to
transgluteal pudendal epididymal adventitia
neurolysis, 153, 154 approximation, 399
544 Index
S epidemiology, 120
Sacroiliac (SI) joint dysfunction, Spermatic cord nerve blocks, 390
107109 Spermatocele, 131
Sacroiliac (SI) joint pain, 104 Spinal anesthesia, 227
Sarcoidosis, 130 Spine and back, 107111
Schwannomas, 112 herniated disc, 111
Scrotal wall layers, 387 lumbar disc degeneration, 109
Selective neurectomy, 454, 455, lumbar stenosis, 110
457460 sacroiliac (SI) joint dysfunction
Selective norepinephrine receptor physical examination, 108
inhibitors (SNRIs), 301 presentation, 107
Self-gripping Parietene Progrip treatment, 108
mesh, 427 surgical vs. nonsurgical
Semmes-Weinstein monofilament approach, 110
test, 450 Spine disease, 262
Septic arthritis, 265 Spine patient outcome study
Septic hip, 8890 (SPORT), 110
Sertoli cells, 387 Spondylolisthesis, 111
Shared decision process, 579 degenerative, 111
Short-tau inversion recovery isthmic, 111
(STIR), 191 spondylolysis, 111
Shouldice repair, 537539 Sports hernia, 83, 485496, 507516,
Single nerve resection, 235 (see Athletic pubalgia)
Small intestine submucosa (SIS), with adductor tendonitis
repair with, 414 clinical outcome, 513516
Snapping hip syndrome, 9798 complications, 516
Somatic pain, 334 diagnosis, 509
Spermatic cord and testicular causes, history, 507508
125129, 131, 132 nonoperative management,
acute groin pain 509511
acute epididymitis, 126 operative management,
appendix testis, 125 511513
Fourniers gangrene, 125 physical examination, 508
nephrolithiasis, 126 workup, 508509
orchitis, 126 left groin pain
physical examination, 125 diagnosis, 487
testicular torsion, 125 history, 485486
treatment, 125 MRI, 486487
anatomy, 123 nonoperative management
chronic groin pain options, 487489
hydrocele, 128 operative treatment, 490491
pelvic pain syndrome, 132 outcomes, 491496
post-inguinal herniorrhaphy physical examination, 486
testicular pain, 131132 postoperative course, 491
post-vasectomy pain postoperative protocol, 493
syndrome (PVPS), 131 Stinchfield test, 80, 261
scrotal pain, 129 Stress fractures, 9092, 266, 267
testicular mass, 127 Strong opioids, 228
varicocele, 128 Superficial pain, 335
Index 545
Surgical interventions, 238 physical examination, 555, 556

Surgisis, 408 point pressure over iliac crest, 556
Sutureless technique, 428 T12L1 thoracolumbar nerve
Sympathetic fibers, 123 root, 555
Synovial fluid, 84, 89 treatment, 558
Synthetic meshes, 408 Tissue repair, 537539
Systemic lupus erythematosus diagnosis, 538
(SLE), 93, 483 history, 537
imaging, 538
nonoperative management
T options, 538
T2-weighted axial oblique image, of operative treatment, 538
pelvis, 509, 510 outcomes, 539
T2-weighted sagittal image, of pelvis, physical examination, 537
509, 510 Total hip replacement, 266
Targeted denervation Total joint arthroplasty, 94
flexible CO2 laser Totally extraperitoneal (TEP)
instrumentation, 392, 393 technique hernia repair,
standard robotic instrumentation, 64, 245, 246, 254, 293, 471
392 Transabdominal preperitoneal
Temporomandibular joint disorder (TAPP) hernia repair, 6,
(TMJ), 161 64, 245, 246, 254, 293, 295,
Tenotomy, 10.1007/9783319 436, 437, 441, 469
215877_36#ITerm49, 513 athlete, CGP in, 490
TENS. See Transcutaneous electrical Coopers ligament, 440
neural stimulation (TENS) cord structures, 438
TEP hernia repair, 436, 437, 441 distal sac, 439
Coopers ligament, 440 laparoscopic anatomy, 436
cord structures, 438 large peritoneal flaps during, 437
distal sac, 439 lipomatous structures, 439
laparoscopic anatomy, 436 low-weight mesh, 440
lipomatous structures, 439 macroporous lightweight
low-weight mesh, 440 polypropylene mesh, 521
pain prevention pain prevention
cephalosporin, 436 cephalosporin, 436
postoperative pain, 437 postoperative pain, 437
preoperative pain, 436 preoperative pain, 436
postoperative pain postoperative pain, 441
surgical techniques and proximal dissection, 439
types, 441 Transcutaneous electrical nerve
proximal dissection, 439 stimulation (TENS),
Testicular innervation, 123 229, 338
Testicular mass, 127 Transgluteal pudendal
Testicular torsion, 125 neurolysis, 153
Thoracolumbar syndrome Transient osteoporosis, 9697
anatomical position, 557 Transinguinal preperitoneal repair
clinical manifestations, 554 (TIPP) technique, 423
definition, 554 Transischiorectal pudendal
diagnosis, 556 neurolysis, 154
546 Index
Transperineal pudendal neurolysis, Value-based CQI. See Clinical

154155 quality improvement
Transvaginal ultrasound (TVUS), (CQI)
164, 170 Varicocele, 128
Transversus abdominis plane (TAP) Varicocelectomy, 128, 394396
block, 220 Varicoceles, 394
Trendelenburg gait, 260 Vas deferens, 366, 368
Tricyclic antidepressants (TCAs), 301 Vasectomy reversal, for post
Triple neurectomy, 239241, 329, vasectomy pain,
372, 381, 456, 460461 396400
laparoscopic retroperitoneal Vasoepididymostomy, 135
approach, 373375 Vasovasostomy, 135
limitations, 372 (see Vasoepididymostomy)
outcomes, 380 Visceral pain, 334
preoperative workup, 372 Visual analog scale (VAS), 449
Triple neurectomy approach, Vulvar vestibulitis syndrome, 150
375, 377 Vulvodynia, 150, 161
Trochanteric bursitis, 100, 260
Tuberculosis, 130
W
Wallerian degeneration, of
U peripheral nerves, 385
Ultrasound, 200, 202 Weak opioids, 228
guidance, 303 Workers compensation
transducer, 200, 202 catastrophizing, 587
causality, 588
disability, 585, 587
V MMI, 589
Vaginal cuff pain, 174 psychosocial variables, 587
Vaginismus, 150 return to work, 586

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Brian P. Jacob David C.

The SAGES Manual

Brian P. Jacob, MD, FACS

Bruce Ramshaw, MD, FACS

Shirin Towfigh, MD, FACS

Videos can also be accessed at http://link.springer.com/book/

ISBN 978-3-319-21586-0 ISBN 978-3-319-21587-7 (eBook)

Library of Congress Control Number: 2015953840

Springer Cham Heidelberg New York Dordrecht London

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business

Inguinal hernia repair is one of the most common operations done by

St. Louis, MO, USA L. Michael Brunt, MD

Part I Primary Groin Pain

1 Introduction to Primary and Secondary Groin Pain:

10 Groin Pain Etiology: Spermatic Cord

Part II Secondary Groin Pain

15 Chronic Groin Pain Following Anterior Hernia Surgery ....... 211

22 Management of Inguinal Hernia Recurrences

Part III Current Debates

27 The Role of Bioactive Prosthetic Material

Part IV Case Reports and Patients Perspectives

33 Foreign Body Reaction, Fibromyalgia,

45 Value-Based Clinical Quality Improvement

Index ............................................................................................... 531

David S. Edelman, MD, FACS

Gregory J. Mancini, MD, FACS

David B. Renton, MD, MSPH, FACS

Brian P. Jacob, David C. Chen, Bruce Ramshaw,

If dedicated inguinodynologists already existed and were easily

Springer International Publishing Switzerland 2016 3

include chronic relapsing appendicitis or diverticulitis, IBD, adhesions,

femoral, direct, and indirect spaces can be carefully examined for

Irmina Anna Gawlas and Warwick J. Peacock

Boundaries of the Inguinal Canal

Fascial Layers and the Inguinal Rings

Springer International Publishing Switzerland 2016 9

Lateral cutaneous Genitofemoral

Femoral branch Interior epigastric vessels

Table 2.1. Structures of the inguinal canal.

Obturator n. Vas deferens

Genital branch of Bladder

Fig. 2.3. Axial illustration of preperitoneal planes.

incorrect placement in the parietal preperitoneal space is a potential

Anatomical Course and Innervation

abdominal wall, eventually passing through external oblique about

Anatomy of the Femoral Ring

Variations in Neuroanatomy and Intraoperative

Payam Vahedifar and Evish Kamrava

Springer International Publishing Switzerland 2016 17

possibility of complex regional pain syndrome (CRPS). In these

Complex Regional Pain Syndrome

disproportionate to the degree of the usual course and symptoms of the

Clinical Management of CRPS

nerve blockade plateaus, other treatments should be considered.

therapy, and restorative therapy in order to avoid a full-blown case of

9. Farah BA. Ketorolac in reflex sympathetic dystrophy. Clin Neuropharmacol. 1993;