Surgical Management of Chronic Groin Pain
Chronic groin pain remains a significant source of morbidity for patients following inguinal hernia repair. For patients refractory to conservative therapies, operative intervention may be considered. The operative technique selected depends upon the natu
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20
Alexandra M. Moore, Parviz K. Amid, and David C. Chen
20.1 Introduction
20.2 Nonoperative Approach
Widespread adoption of tension-free inguinal hernia repair techniques and the routine use of mesh prostheses have dramatically lowered rates of inguinal hernia recurrence [1]. However, with improvement in recurrence rates, chronic groin pain following inguinal hernia repair has emerged as one of the most significant causes of postoperative morbidity, with rates as high as 63 % in some studies [2, 3]. This pain is moderate to severe in 6–8 % of post-herniorrhaphy patients [4]. With 800,000 inguinal hernia repairs completed in the USA every year and a conservative estimated risk of chronic groin pain causing an adverse effect on daily life between 0.5 and 0.6 %, it can be estimated that 4000–48,000 patients develop severe, debilitating chronic groin pain every year [5–9]. The risk of developing chronic groin pain is independent of the method of hernia repair and post-inguinal herniorrhaphy inguinodynia preceded the era of mesh repairs [6, 10, 11]. Chronic groin pain can be classified as either nociceptive, neuropathic, somatic, or visceral. Nociceptive pain is due to tissue injury, meshoma, or inflammation and is typically a dull, deep, and constant pain localized over the entire groin. In contrast, neuropathic pain is due to direct damage to the inguinal nerves and can be constant or intermittent, often radiates, and is characterized by negative sensory symptomatology. In clinical practice, there is often significant overlap between nociceptive and neuropathic pain, making accurate diagnosis of the etiology of groin pain difficult. Somatic pain typically manifests localized tenderness which is maximum at the pubic tubercle, commonly caused by periosteal anchoring of mesh [12]. Visceral pain may be due to intestinal complications or involvement of the spermatic cord and is typically manifested by gastrointestinal complaints or sexual dysfunction.
Nonsurgical modalities for the treatment of chronic groin pain include pharmacologic, behavioral, and interventional therapies. Pharmacologic therapies for nociceptive pain due to tissue inflammation include NSAIDs and steroids, but neither of these is sustainable in the long-term treatment of chronic pain. Pharmacologic therapies for neuropathic pain include GABA analogues (gabapentin and pregabalin), SNRIs, and TCAs [13]. There is no firm evidence to support the use of one over another [14]. Opioids and tramadol are considered second-line treatments for neuropathic pain and should be avoided in the long term, but may be necessary for acute exacerbations. There is no solid evidence supporting the use of topical analgesics such as lidocaine or capsaicin, but they have minimal morbidity and cost and a trial is reasonable [15, 16]. Interventional treatment options include nerve blocks, neuroablative techniques, and neuromodulation. Nerve blocks of the ilioinguinal and iliohypogastric nerves can be used both diagnostically and therapeutically, though there is conflicting
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