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Classifying Postherniorrhaphy Pain Syndromes FollowingElective Inguinal Hernia Repair M. J. A. Loos Æ R. M. H. Roumen Æ M. R. M. Scheltinga Ó Socie´te´ Internationale de Chirurgie 2007 Chronic postherniorrhaphy pain is diverse in Chronic pain following elective inguinal hernia repair is origin. The aim of our study was to classify post- common. Approximately 14%-54% of patients still expe- herniorrhaphy pain syndromes following elective inguinal rience some degree of inguinal pain several years after ‘‘successful’’ surgery Moreover, up to 21% of pa- tients are functionally impaired in work or leisure activities inguinal hernia repair performed between January 2000 ]. As many as 1% of individuals suffering from pain and August 2005 received a questionnaire evaluating after open repair are eventually referred to a specialized chronic inguinal pain (visual analog scale, VAS 0–10).
pain clinic, as are 0.4% after laparoscopic hernia repair Patients with moderate to severe pain complaints (VAS Efforts have been made to clarify the etiology of these score ‡ 3) were invited for an interview and an outpatient postoperative pain syndromes using pain descriptors in questionnaires ]. In such studies, neuropathic symp- A total of 2,164 cases underwent an elective tomatology was more often described than non-neuropathic hernia repair and received the questionnaire; 1,766 indi- descriptors, suggesting a significant nerve-related contri- viduals responded (response rate: 81.6%). Moderate to bution to pain. However, this result allows for only a severe pain was present in 211 patients (11.9%). Follow-up limited insight into underlying causes. A complete physical was performed in 148 patients. Three separate groups of examination, possibly supported by additional testing, may diagnoses were identified. Group I: neuropathic pain provide answers in the quest for a correct diagnosis and (n = 72) indicating inguinal nerve damage; group II: non- tailored treatment regimens. The aim of the present study neuropathic pain (n = 40) due to an array of diagnoses was to classify postherniorrhaphy pain syndromes follow- including periostitis (n = 18) and recurrent hernia (n = 13); ing elective inguinal hernia repair.
and group III: a tender spermatic cord and/or a tight feelingin the lower abdomen (n = 43).
Conclusions Chronic pain following elective hernia re- pair is common and diverse in etiology but may allow for a classification contributing to the development of tailoredtreatment regimens.
Some authors have attempted to classify inguinal pain afterhernia repair [, In the present study it was decided tomake a distinction between neuropathic and non-neuro- This study was presented at the Annual Meeting of the British Hernia pathic (nociceptive) causes of pain, as suggested by Amid Society in Nottingham, November 2006.
Neuropathic pain is characterized as an activity-induced M. J. A. Loos (&) Á R. M. H. Roumen Á sharp pain, located in proximity to the inguinal scar. The pain frequently radiates toward the scrotum, labium, and/or upper Department of Surgery, Ma´xima Medical Centre, PO Box 7777, inner thigh. Upper body stretching or twisting and/or De Run 4600 Veldhoven, The Netherlandse-mail: [email protected] hip joint flexing may cause pain from nerve traction or compression. Physical examination often reveals signs of a Eligible patients were contacted and invited to come to the disturbed neurophysiological equilibrium including hypo- Surgical Outpatient Department for a standardized interview esthesia, hyperesthesia, or allodynia. A distinct trigger point and physical examination. Current pain intensity was then situated in or close to the scar may cause pain following tested once again, using the VAS-scoring procedure.
stimulation, e.g., after palpation. A local anesthetic nerve Patients received a local injection of 10 cc lidocain (1%) block can possibly act as a diagnostic and (temporary) if the combination of the patient’s history and the physical therapeutic agent. The complex of symptomatology is examination (trigger point) suggested pain of neuropathic thought to be caused by entrapment of ilioinguinal, ilio- origin. If a non-neuropathic origin of pain was suspected, hypogastric, or genital branches of the genitofemoral nerves.
the treatment approach depended on the suggested diag- Suture material, staples or tacks, perineural fibrosis, and nosis. For instance, if a periostitis was diagnosed, patients prosthetic material have all been implicated, as has acci- received a local injection containing 5 cc lidocaine and dental iatrogenic nerve damage, possibly causing a neuroma.
40 mg methylprednisolone acetate 40 mg/ml (Depo- In non-neuropathic causes of inguinal pain after hernia MedrolÒ), a corticosteroid, at the site of maximal pain repair, other conditions are responsible for symptomatol- intensity. Following a 10-min equilibrium period after ogy including residual/recurrent hernias, hip pathology, injection, the regimen’s efficacy was evaluated by a VAS and periostitis pubis, among others. In such cases, all score. Additional imaging techniques including ultrasound, nerves are intact. These definitions of the neuropathic and computed tomography (CT) scans, or magnetic resonance non-neuropathic causes of pain are applicable in the fol- imaging (MRI) were performed if deemed necessary.
The study was conducted at the Ma´xima Medical Centre,a teaching hospital serving approximately 350,000 inhab- Figure describes patient inclusion. A total of 211 patients itants in the Eindhoven and Veldhoven region, the (11.9%) were eligible for the study, as dictated by a Netherlands. Patients were eligible for study if they re- VAS-score ‡ 3. Sixty-three patients did not visit the out- ported moderate or severe pain (visual analog scale patient department for reasons stated in Figure leaving [VAS] ‡ 3; range: 0 = no pain, 10 = unbearable pain) as 148 patients (8.4%) for analysis. The mean age of partic- identified by a recent questionnaire study (Fig. ) ipants was 40 years, and the majority were male (87.2%; Table 1 Clinical characteristics of patients (n = 148) who visited Table 2 Pain characteristics of 148 patients who visited the outpa- the outpatient department based on a high pain score (VAS ‡ 3) tient department for pain following inguinal hernia repair Postoperative inguinal pain comparable or worse Time of onset after surgery, median [range] Values in parentheses are percentages, unless otherwise specified TEP total extraperitoneal; TAPP transabdominal preperitoneal Table ). Most hernia operations were done by open techniques (76.4%, mainly Lichtenstein), and about one quarter of patients (23.6%) treated using a laparoscopic method (total extraperitoneal [TEP], 12.8%; transabdomi- The pain history of the study population is given in Table . Almost 90% reported groin pain prior to correc- tive surgery. However, the present postoperative pain level was judged comparable or worse by half of the patients. In almost every case the pain had started directly after sur- gery, and its severity was considered by 28 patients (18.9%) to be progressive. More than half of the patients were constantly suffering from pain. Other chronic pain syndromes (chronic headache, low back pain, etc) were Overall, 26 male patients (20.2%) reported a bothersome or even incapacitating sensation during or after ejaculation, Values in parentheses are percentages, unless otherwise specifieda which was frequently described as ‘‘burning’’ or ‘‘stab- VAS-score as measured at outpatient department bing.’’ One patient mentioned a bothersome feeling of Chronic pain syndromes: chronic headache, back pain, rheumatoid arthritis, fibromyalgia, irritable bowel syndrome mechanical obstruction during ejaculation. Most of thesepatients (16/26) were contending with neuropathic paincomplaints as well. Eighteen men complained of increasing diagnosed in 95 patients, whereas hyperesthesia was present inguinal pain during an erection. Testicular pain was men- in 11 cases. No patient showed signs of allodynia.
tioned by 17 patients. Not all patients with testicular pain hadejaculatory complaints, or a painful erection. A direct post- operative onset of impotence was mentioned by 3 patients.
A classification including different causes of pain is pro- Findings on physical examination are listed in Table vided in Table Pain was judged to be neuropathic in nearly Inspection revealed bulges in 8.8% of patients. Palpation half of the patients (n = 72; 46.5%). They all complained of identified a distinct trigger point in or around the scar in the an activity-induced sharp pain combined with a trigger point nearly half of patients (46.6%). Moreover, the pubic tubercle and signs of a neurophysiological disequilibrium. Eleven was painful in 12.2% of patients. Neurophysiological patients showed hyperesthesia. All patients were offered a abnormalities were frequently observed. Hypoesthesia was peripheral nerve block with 10 cc lidocaine, and 51 patients Table 3 Physical examination and treatment of 148 patients who Non-neuropathic causes of pain were detected in forty individuals. In 18 patients a periostitis pubis was diag- nosed. On examination their pain was clearly situated on the pubic tubercle, possibly as a result of an incorrectly positioned deep suture. Eight patients with a suspected periostitis received an injection with lidocaine and corti- costeroids in tissue overlying the painful periosteum for diagnostic purposes. All eight participants reported pain reduction of more than 50% on their VAS-score. An injection was refused by 10 patients, because of reasons Periostal injection (Lidocain/corticosteroids) Thirteen recurrences and one femoral hernia were diagnosed, some with the help of an ultrasound or CT scan.
Seven patients had a contralateral inguinal hernia as well.
Values between parentheses are percentagesa In an 18-year-old soccer player bilateral adductor tendinitis Significant pain reduction defined as > 50% VAS reduction after was diagnosed. One 45-year-old woman with painful andlimited hip endorotation suffered from an iliopectinealbursitis. She regained persistent full pain-free motion of the Table 4 Classification of chronic inguinal pain in 148 patients afterelective inguinal hernia repair hip after an intrabursal injection with lidocaine and corti-costeroids.
including hip osteoarthritis, referred lumbosacral pain, and urological problems, were referred to specialists (n = 6) who confirmed these diagnoses at a later stage.
Group III: pain possibly related to spermatic cord Forty-three patients (27.7%) could not be identified on the basis of an existing classification. For the most part, these patients described their pain as ‘‘aching’’ in the absence of a specific trigger point. The spermatic cord was often diffusely tender in those patients who had undergone the hernia repair via an anterior approach. Similarly, in selected cases the mesh inserted during laparoscopic surgery produced a tight aching feeling in the lower abdomen, especially duringexercise. In most cases no neurophysiological abnormalities were present. Combining pain history, physical examina- tion, and additional tests, 155 diagnoses could be made in Seven patients were diagnosed with two separate conditions 148 patients. In 7 patients a second cause for the pain was a Ilioinguinal, iliohypogastric, genitofemoral nerve present: periostitis (n = 5), hernia recurrence (n = 1), and ipsilateral adductor tendinitis (n = 1).
agreed to proceed with this treatment. The remainder of thegroup declined the treatment, 14 patients because they did not consider their pain serious enough, 2 because they hadpreviously received a successful nerve block; 2 because they The issue of unraveling the dilemma of long-term moderate had contraindications (e.g., bleeding disorders), and 3 be- to severe postherniorrhaphy pain is not new ]. However, cause they were afraid of needles. Eighty percent of all pa- to our knowledge this is the first study in which a large tients receiving a local block (n = 41) reported pain relief cohort of patients was examined at the outpatient depart- (VAS scores > 50% lower). Pain relief was not attained in ment to clarify the underlying mechanisms responsible for the remaining 10 patients. In one patient meralgia pares- pain following hernia repair. A similar but smaller study was conducted by Cunningham et al. in 1996 []. In that study a subset of 10 patients referred to a pain clinic with tight aching feeling in the lower abdomen (after laparo- persisting pain was investigated 2 years after inguinal re- scopic procedures). Compression by scar tissue or prosthetic pair. The authors proposed three distinct pain syndromes; material may explain this type of groin pain Compro- somatic (n = 9), neuropathic (n = 1), and visceral (n = 1).
mised musculotendinous structures might play a roll as well.
The first one was judged as a ligamentous pain syndrome It remains unclear if venous congestion contributes to pain caused by suture insertion in the iliopubic tract and peri- in this group of patients. Overall pain intensity is less pro- osteum. The second syndrome was neuralgic and caused by nounced than that reported by the neuropathic pain group, inguinal sensory nerve damage, whereas a third complex although most patients experienced some limitation in daily was associated with ejaculation pain. They concluded that activities. Except for pain medication, no treatment was severe pain syndromes following hernia repair are most available for them. We suggest naming this type of pain commonly somatic in origin. Similar groups of patients ‘‘funiculodynia,’’ as this syndrome is mainly characterized were identified in the present study. Pain of neuropathic by pain in structures surrounding the spermatic cord.
origin was suspected in nearly half of the patients and was Prevalence, etiology, and treatment of genital compli- confirmed by nerve block in 28% of all patients. If one cations following hernia repair including erectile and extrapolates these results to the initial patient population ejaculatory pain are largely unknown. In a recently pub- encompassing 1,766 individuals, one could cautiously as- lished Danish questionnaire study 3% of younger male sume that at least 4% of all corrected inguinal hernias are patients with inguinal hernia repair exhibited pain during associated with nerve entrapment or damage. Previous sexual activity and subsequent sexual dysfunction ]. In authors have estimated a similar prevalence, varying be- the present study dysejaculation was reported by one of tween 3% and 5% [Chronic nerve irritation should be every five male patients. Several pathophysiological considered an important cause of moderate or severe mechanisms have been suggested, among them intraoper- chronic pain after inguinal hernioplasty.
ative nerve damage, dysfunction of periurethral structures Another well-known source of postherniorrhaphy pain is involved in ejaculation, or encasement of the spermatic periostitis of the pubic tubercle [A too deeply posi- cord caused by scar tissue. This is supported by anecdotal tioned suture aimed at medially affixing the mesh may reports on patients with dysejaculation in which dissection cause inflammation and chronic irritation. In the examined of twisted fibrotic spermatic cords combined with an ilio- cohort, one in every eight patients experienced pain while inguinal neurectomy provided total pain relief ]. Be- exerting digital pressure on the pubic tubercle. This pain cause of the high incidence of such complaints and the syndrome can be avoided by careful placement of suture sparse literature, more research on the etiology and treat- material by the surgeon, ideally sparing the bone’s peri- ment of dysejaculatory conditions after inguinal hernio- osteal layers. An injection with a local anesthetic and corticosteroids in painful periosteum can be tried as the Over 30% of all patients reported suffering from other first line of treatment, as this was effective in a substantial chronic pain syndromes as well. A correlation between the number of our patients. Surgical suture removal must be onset of postherniorrhaphy pain and other pain syndromes has been described in the hernia literature, and it may be When a patient presents with residual pain following due to genetic and psychosocial factors ]. Patients with hernial repair, a recurrent hernia is often the only diagnosis a tendency to develop chronic pain are more susceptible to that surgeons consider and rule out. Although relatively infrequent in the present study, 13 patients did have such a Classifying postherniorrhaphy pain syndromes may allow recurrence. This number approximates the 1% of the initial for tailored treatment regimens. The first step in a protocol 1,766 patients used in our previous questionnaire study.
for treatment of postherniorrhaphy neuralgia, described by The recurrence rate is probably higher because asymp- Lichtenstein nearly two decades ago, consisted of primary tomatic and mildly symptomatic recurrences remain diagnosis and treatment by injections []. Surprisingly, in the present study a single diagnostic nerve block with lido- A variety of additional musculoskeletal problems were caine led to long-term (> 1 month) pain reduction in 25% of observed in the remainder of the patients with recurrent our patients, confirming the therapeutic potential of such pain, including iliopectineal bursitis, adductor tendinitis, injections. Although it is known to occur, the phenomenon of and referred low back pain. These pain syndromes are very permanent or long-term cure following injection of short likely the secondary result of postural and functional acting anesthetics is not well understood ]. If (repeated) changes in the presence of persisting inguinal pain. How- injection therapy fails, the second step might be operative ever, a third group of 43 individuals demonstrated a clearly transsection ]. After early reports, it was suggested by distinct history and physical examination. They presented Amid that transsection should include all three groin nerves, with a tender spermatic cord (after open mesh repair) or a and the procedure was named ‘‘triple neurectomy’’ Because of central and peripheral communication and pos- 3. Nienhuijs SW, Boelens O, Strobbe LJA. (2005) Pain after ante- sible involvement of all three nerves, a maximal length of rior hernia repair. J Am Coll Surg 200:885–889 4. Callesen T, Bech K, Kehlet H. (1999) Prospective study of ilioinguinal, iliohypogastric, and genitofemoral in both chronic pain after groin hernia repair. Br J Surg 86:1528–1531 directions should be transsected and removed.
5. Poobalan AS, Bruce J, King PM, et al. (2000) Chronic pain and Reports on the effect of the mesh on nerves and chronic quality of life following open inguinal hernia repair. Br J Surg pain in hernia repair are scarce. According to a recent animal 6. Page B, Paterson D, Young D, et al. (2002) Pain from primary study, inserted mesh may lead to an inflammatory and inguinal hernia and the effect of repair on pain. Br J Surg fibroblastic response resulting in adhesions and mechanical entrapment of adjacent nerve fibers and structures such as the 7. Hindmarch AC, Cheong E, Lewis MPN, et al. (2003) Attendance spermatic cord ]. Whether these mesh-related nerve at a pain clinic with severe chronic pain after open and laparo-scopic inguinal hernia repairs. Br J Surg 90:1152–1154 changes are responsible for any pain sensation is unknown.
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