Genital Branch Research Articles

Stronger Evidence for Small Fiber Sensory Neuropathy in Restless Genital Syndrome: Two Case Reports in Males

Restless genital syndrome (ReGS) is characterized by unwanted, unpleasant genital sensations, restless legs, and/or overactive bladder, as well as neuropathy of the dorsal nerve of the clitoris. So far, ReGS has only been reported in females. To report the occurrence of ReGS in two males. Two males with unwanted genital sensations presented in our clinic. In-depth interview, routine and hormonal investigations, electro-encephalography, magnetic resonance imaging of brain and pelvis, manual examination of the pubic bone, and sensory testing of genital dermatomes were performed. In both males, conventional transcutaneous electrical nerve stimulation was applied bilaterally at the pudendal dermatome. Oral report, questionnaire on frequency and intensity of restless genital feelings, restless legs, overactive bladder, and satisfaction with the transcutaneous electrical nerve stimulation (TENS) treatment. ReGS in a 74-year-old male manifested as unpleasant genital sensations of being on the edge of an orgasm with overactive bladder, in the absence of erection and ejaculation. Genital sensory testing elicited bilateral points of static mechanical hyperesthesia in the pudendal dermatome. Manual examination of the dorsal nerve of the penis (DNP) elicited the genital sensations. TENS application resulted in a 90% reduction of genital sensations and complaints of overactive bladder syndrome (OAB). ReGS in a 38-year-old male manifested as unwanted and unpleasant spontaneous ejaculations and complaints of OAB. Genital sensory testing elicited bilateral points of static mechanical hyperesthesia in the pudendal dermatome. Manual examination of the DNP elicited the genital sensations. TENS application had no effect on genital complaints and complaints of OAB. ReGS is not a typical female disorder as it also affects males. This notion and the finding of typical sensory abnormalities of the genital end branches of the pudendal nerve in males and females--as previously reported--provides strong evidence for Small Fiber Sensory Neuropathy as a common cause of ReGS.

Free-living dorylaimid nematodes from nature reserves in Costa Rica. The genus Oriverutus Siddiqi, 1971 – species with simple uterus

AbstractThree Costa Rican species with a simple uterus, two new and one known, belonging to the genus Oriverutus are described. Descriptions, measurements and illustrations are provided. A detailed study of O. asaccatus, including SEM pictures, is presented and its diagnosis emended; O. sturhani is regarded as its junior synonym. Oriverutus costaricensis sp. n. is distinguished by its body 1.07-1.24 mm long, lip region offset by constriction and 14-15 μm broad, odontostyle 23.5-24 μm long, neck 277-353 μm long, pharyngeal-expansion 125-179 μm long or 45-51% of total neck length, cardia asymmetrical, a dorsal cell mass present at level of pharyngo-intestinal junction, female genital system amphidelphic, V = 45-48, tail conical and slightly bent dorsad at the end (42-43 μm long, c = 25-29, c′ = 1.7-1.8), and males unknown. Oriverutus hemihystera sp. n. is characterised by its body 0.92-1.17 mm long, lip region offset by shallow depression or almost continuous and 10-11.5 μm broad, odontostyle 22-24 μm long, neck 280-330 μm long, pharyngeal expansion 115-138 μm long or 41-43% of total neck length, female genital system amphidelphic but anterior genital branch reduced, V = 43-45, tail conical and slightly bent dorsad at the end (62-65 μm long, c = 15-18, c′ = 3.1-3.4), and males unknown.

Free-living dorylaimid nematodes from nature reserves in Costa Rica. The genus Oriverutus Siddiqi, 1971 – species with specialised uterus

Three Costa Rican species with a simple uterus, two new and one known, belonging to the genus Oriverutus are described. Descriptions, measurements and illustrations are provided. A detailed study of O. asaccatus, including SEM pictures, is presented and its diagnosis emended; O. sturhani is regarded as its junior synonym. Oriverutus costaricensis sp. n. is distinguished by its body 1.07-1.24 mm long, lip region offset by constriction and 14-15 μm broad, odontostyle 23.5-24 μm long, neck 277-353 μm long, pharyngeal-expansion 125-179 μm long or 45-51% of total neck length, cardia asymmetrical, a dorsal cell mass present at level of pharyngo-intestinal junction, female genital system amphidelphic, V = 45-48, tail conical and slightly bent dorsad at the end (42-43 μm long, c = 25-29, c′ = 1.7-1.8), and males unknown. Oriverutus hemihystera sp. n. is characterised by its body 0.92-1.17 mm long, lip region offset by shallow depression or almost continuous and 10-11.5 μm broad, odontostyle 22-24 μm long, neck 280-330 μm long, pharyngeal expansion 115-138 μm long or 41-43% of total neck length, female genital system amphidelphic but anterior genital branch reduced, V = 43-45, tail conical and slightly bent dorsad at the end (62-65 μm long, c = 15-18, c′ = 3.1-3.4), and males unknown.

Ultrasound-guided Nerve Blocks for Post-hernia Repair Pain

Ultrasound-guided Nerve Blocks for Post-hernia Repair Pain

Sportsmen’s Groin—Diagnostic Approach and Treatment With the Minimal Repair Technique: A Single-Center Uncontrolled Clinical Review

Context:Sportsmen’s groin, also called sports hernia and Gilmore groin, is one of the most frequent sports injuries in athletes and may place an athletic career at risk. It presents with acute or chronic groin pain exacerbated with physical activity. So far, there is little consensus regarding pathogenesis, diagnostic criteria, or treatment. There have been various attempts to explain the cause of the groin pain. The assumption is that a circumscribed weakness in the posterior wall of the inguinal canal, which leads to a localized bulge, induces a compression of the genital branch of the genitofemoral nerve, considered responsible for the symptoms.Methods:The authors developed an innovative open suture repair—the Minimal Repair technique—to fit the needs of professional athletes. With this technique, the circumscribed weakness of the posterior wall of the inguinal canal is repaired by an elastic suture; the compression on the nerve is abolished, and the cause of the pain is removed. In contrast with that of common open suture repairs, the defect of the posterior wall is not enlarged, the suture is nearly tension free, and the patient can return to full training and athletic activity within a shorter time. The outcome of patients undergoing operations with the Minimal Repair technique was compared with that of commonly used surgical procedures.Results:The following advantages of the Minimal Repair technique were found: no insertion of prosthetic mesh, no general anesthesia required, less traumatization, and lower risk of severe complications with equal or even faster convalescence. In 2009, a prospective cohort of 129 patients resumed training in 7 days and experienced complete pain relief in an average of 14 days. Professional athletes (67%) returned to full activity in 14 days (median).Conclusion:The Minimal Repair technique is an effective and safe way to treat sportsmen’s groin.

Influence of nerve identification and the resection of nerves ‘at risk’ on postoperative pain in open inguinal hernia repair

Surgical strategy regarding nerve identification and resection in relation to chronic postoperative pain remains controversial. A central question is whether nerves in the operation field, when identified, should be preserved or resected. In the present study, the hypotheses that the identification and consequent resection of nerves 'at risk' have no influence on postoperative pain has been tested. A single-centre study was conducted in 525 patients undergoing Lichtenstein hernioplasty. One surgeon (364 operations, Group A) consequently resected nerves 'at risk' for being injured and nine surgeons (161 operations, Group B) adhered to the general routine of nerve preservation. All cases were ambulatory surgery on anaesthetised patients and the groups were similar with regard to age, body mass index (BMI) and preoperative pain. Self-reported pain at 3 months was recorded on a 10-box visual analogue scale (VAS). The identification and resection of nerves were continuously registered. Statistical calculations were performed with Fisher's exact test and ordinal logistic regression. There was no significant difference in the number of identified nerves in the two groups of patients (iliohypogastricus, P = 0.555; ilioinguinalis, P = 0.831; genital branch, P = 0.214). However, the number of resected nerves was significantly higher in Group A for the iliohypogastric nerve, P < 0.001, but not for ilioinguinalis, P = 0.064, and genital branch, P = 0.362. Non-identification of the ilioinguinal nerve correlated to the highest level of self-reported postoperative pain at 3 months. Patients in Group A, who had nerves 'at risk' resected from the operation field, reported significantly less postoperative pain at 3 months, P = 0.007. This register study confirms the importance of nerve identification. Nerve resection strategy with the consequent removal of nerves 'at risk' gives a significantly better outcome in Lichtenstein hernioplasty.

Guitartia tridentata n. gen., n. sp. (Monhysterida: Xyalidae) and Macrodontium gaspari n. gen., n. sp. (Chromadorida: Microlaimidae), free-living marine nematodes from the Caribbean Sea

AbstractTwo new genera of free-living marine nematodes are described from the muddy bottom of Cienfuegos Bay, Caribbean Sea. Guitartia n. gen. (Xyalidae, Monhysterida) is characterised by three long tooth-like structures in the stegostom, second and third circle of anterior sensilla separate and posterior genital branch of the female restricted to a long post-vulvar sac. The type species is Guitartia tridentata n. gen., n. sp. Within the Xyalidae, Guitartia n. gen. is morphologically close to Amphimonhystrella, Cobbia, Elzalia, Scaptrella and Valvaelaimus, all being characterised by sclerotised structures in the stoma and transverse striation of the body cuticle. Main features for discrimination are the type of stoma structure, the shape and relative size of amphidial fovea, the presence of a post-vulvar sac and gubernacular apophyses and the absence of terminal setae on the tail. Macrodontium n. gen. (Microlaimidae, Chromadorida) is characterised by a heavily sclerotised stoma with one large dorsal tooth and two smaller subventral teeth, sexual dimorphism in size and position of the amphidial fovea and males with a single anterior testis. The type species is Macrodontium gaspari n. gen., n. sp. Within the Microlaimidae, Macrodontium n. gen. is similar to the genera Acanthomicrolaimus and Bolbolaimus due to sclerotised stoma and presence of large dorsal tooth. The new genus is similar to Aponema in sexual dimorphism in the size of the amphidial fovea, monorchic males, presence of a gubernacular apophysis and conico-cylindrical tail shape. Morphological characters of diagnostic value within the family are the ornamentation of the body cuticle, relative length of cephalic sensilla, stoma sclerotisation and number of testes.

INGUINAL HERNIOPLASTY

Introduction: Chronic pain following inguinal hernia repair is becoming a significant clinical problem, involving increased numberof patients and surgeons. Much controversy exists regarding treatment. Elective division of the nerves has been proposed to reduce the riskof chronic post operative pain. O b j e c t i v e s : To evaluate the effectiveness of elective neurectomy during open hernia mesh repair, in reducingpostoperativ pain. Materials a n d m e t h o d s : Settings: All patients admitted in SUN department of surgery, Allied Hospital Faisalabad wereincluded in study. Study was started after the approval of synopsis on with inguinal hernia 2n d Feb, 2007 to Aug, 2007.100 patients of inguinalhernias were divided into 2 groups, 50 in each group i.e. group A &amp; group B. The last patient was registered in the first week of July,convenience nonprobability sampling was used for location of patients in two groups. Results: On day one the pain was assessed in the twogroups i.e. Group A and group B (convenience non probability sampling technique used for patient grouping).It was found to be absent in 24/50(48 %) and 18/50 (36 %), mild in 10/50 (20 %) and 12/50 (24 %), it was moderate in10/50 (20 %) and 10/50 (20 %) and was severe in 6/50(12%) and 10/50 (20%) in the two groups respectively. One week after operation, in groups A and B, respectively, pain assessed with the useof the 4-point verbal scale was absent in 45 patients (90%) and 37 patients (74%), mild in 3/50 (6%) and 4/50 (8%), moderate in 2/50 (4%) and6/50 (12%), and severe in none and 3/50 (6%). Postoperative pain was not correlated with the presence of preoperative pain, and no correlationwas evidenced in the 2 subgroups. One month after operation, follow-up visits were performed in group A patients and group B patients. Inparticular, pain was absent in 46/50 (92%) patients in group A and 41/50 (82%) patients in group B. It was mild in 2 (6%) and 6/50 (12 %),moderate in 2/50 (4%) and 2/50 (4 %) none of the patients with elective neurectomy had pain at follow up of one month and 1 (2 %)one patientwithout elective neurectomy had pain. The numbness was assessed by checking sense of touch around the operated area. The difference foundbetween the 2 groups with respect to the presence of numbness was 15/50 (30 %) and 7/50 (14%) in the two groups i.e. group A and groupB respectively at day 1 and 12/50 (24%) and 7/50 (14%) at follow up of one week and it was 5/50 (10%) and 2/50(4%) at one month in the twogroups. C o n c l u s i o n s : When performing lichtenstein inguinal hernia repair, routine ilioinguinal, iliohypogastric and genital branch ofgenitofemoral nerves neurectomy is a reasonable option.

Anatomical Variations of the Lumbar Plexus: A Descriptive Anatomy Study with Proposed Clinical Implications

This study used dissection of 34 lumbar plexes to look at the prevalence of anatomical variations in the lumbar plexus and the six peripheral branches from the origin at the ventral roots of (T12) L1-L4 to the exit from the pelvic cavity. Prevalence of anatomical variation in the individual nerves ranged from 8.8–47.1% with a mean prevalence of 20.1%. Anatomical variations included absence of the iliohypogastric nerve, an early split of the genitofemoral nerve into genital and femoral branches, an aberrant segmental origin for the lateral femoral cutaneous nerve, bifurcation of the lateral femoral nerve prior to exiting the pelvic cavity, bifurcation of the femoral nerve into two to three slips separated by psoas major muscle fibers, the presence of a single anterior femoral cutaneous nerve rather than the normal presentation of two separate anterior femoral cutaneous branches, and the presence of an accessory obturator nerve. Comparison with relevant research literature showed a wide variation in reported prevalence of the anatomical variations noted in this study. Clinical implications and directions for future research are proposed.

Feasibility study of three-nerve-recognizing Lichtenstein procedure for inguinal hernia

Inguinal nerve identification during open inguinal hernia repair is associated with less chronic postoperative pain. However, most Dutch surgeons do not identify all three inguinal nerves when carrying out this procedure. The aim of this study was to evaluate the feasibility of a nerve-recognizing Lichtenstein hernia repair and to measure the extra time required for surgery Forty patients with primary inguinal hernia were operated on following the nerve-recognizing Lichtenstein hernia repair by four experienced hernia surgeons from four different Dutch teaching hospitals. The additional time needed to identify each individual nerve was recorded, and iatrogenic nerve injuries and anatomical characteristics were registered. Identification of the iliohypogastric and ilioinguinal nerves was each performed within 1 min. Identification of the genital branch of the genitofemoral nerve was notably more difficult but could usually be performed within 2 min. Identification of the cremasteric vein, running parallel to the genital branch, was less comprehensive. The incidence of major anatomical variations was low. Twenty-five per cent of ilioinguinal nerves, however, could not be identified. In five patients inguinal nerves were damaged iatrogenically during standard manoeuvres of the Lichtenstein hernia repair. Three-nerve-recognizing Lichtenstein hernia repair is feasible and non-time consuming if the surgeon has appropriate anatomical knowledge. In view of the low incidence of major anatomical variations, knowledge of standard inguinal nervous anatomy should be adequate. This procedure could enable the surgeon to prevent or recognize iatrogenic nerve damage and offer an opportunity to perform deliberate neurectomy as an alternative to accidental nerve injury.

Ways of the parasitism origin in the phytonematode orders Tylenchida and Aphelenchida

The following principal features of the plant parasitic nematode evolution are listed and illustrated. Phytonematodes have been originated from saprotrophic nematodes (bacterio- and mycotrophic ones), firstly plant hosts and later insect vectors were consequently included in their life cycle. The speciation factors were changing depending on the stage of evolution of the host–parasite relationships. In the primitive plant parasitic nematode taxa the species divergence is associated with the soil-climatic conditions; in the most advanced taxa of the sedentary phytonema todes the co-evolution with their plant host taxa took place; in the nematode taxa associated with insect vectors the insect families served as the speciation factors for nematodes. At the key steps of the host-parasite relations evolution, similar adaptations appeared independently in different phylogenetic lines. In transition to endoparasitic feeding, the stylet enforced and the lobe of the enlarged pharyngeal glands was formed. As the adaptations to the migratory endoparasitism in plant tissues, posterior part of the female body shortened and the posterior genital system branch located there, reduced in the postembryogenesis. In the sedentary endoparasitic nematodes the topic and trophic relations with plant hosts were developing independently (incoherently) in different phylogenetic lines. But all sedentary phytonematodes have common features: the specialized infective juvenile stages were differentiated in the life cycle; the diameter of adult female body, occupied with a hypertrophied genital system with mature eggs containing infective juveniles, has been increased significantly. In insect-vectored nematode taxa the special dispersal entomophilic stages were differentiated in the life cycles by two different phylogenetic lines: in one line the transmission juvenile stages (dauerlarvae) were formed, in the second line – the inseminated but not egg-producing transmission females were arisen. The parallelisms in development of similar adaptations indicate the general principles and tendencies of the plant parasitic nematode evolution.

Microsurgical Denervation of the Spermatic Cord for Chronic Orchialgia: Long-Term Results From a Single Center

We assessed the long-term efficacy, complications and patient perceptions of microsurgical denervation of the spermatic cord in the treatment of chronic orchialgia. Microsurgical denervation of the spermatic cord was performed on 95 testicular units in 79 men (mean age 40.3 years, mean duration of pain 62 months, 16 bilateral) for chronic orchialgia. Conservative management failed in all, and patients were evaluated with an extensive medical history and physical examination. To be a candidate for microsurgical denervation of the spermatic cord each man would have responded either completely or partially to spermatic cord block (greater than 50% decrease in pain) and had no identifiable reversible etiology. Postoperative pain rating scales (0 to 10) were used to determine efficacy. Mean followup was 20.3 months (range 1 to 102 months) and complete, durable relief was noted in 67 (71%) testicular units, partial relief in 17 (17%), and unchanged in 11 (12%). No patients reported worse pain. Complications included testicular atrophy without hypogonadism in 2 patients, superficial wound infection in 2, hydrocele in 2 and an incisional hematoma in 1. Microsurgical denervation of the spermatic cord is a minimally invasive, effective and durable management option for treatment of chronic orchialgia refractory to medical management, preserving the physiological function and psychological role of the testes.

(222) Treatment of Genitofemoral Neuralgia After Laparoscopic Inguinal Herniorrhaphy with Fluoroscopically-Guided Tack Injection

Nerve entrapment syndromes involving the genital branch of the genitofemoral nerve, the ilioinguinal nerve, or the iliohypogastric nerve occur in an estimated 1–2% of conventional, open herniorrhaphies [3], and can also occur with laparoscopic herniorrhaphies [1]. A 48-year-old man with a recurrent right-sided inguinal hernia underwent a laparoscopic hernia repair using Prolene mesh and titanium tacks. Two weeks post-operatively, the patient spontaneously developed severe, intermittent, lancinating pain in a genitofemoral nerve distribution. Infection and recurrent hernia were ruled out. Treatment with non-steroidal anti-inflammatory drugs, muscle relaxants and ilioinguinal nerve blocks using traditional anatomic landmarks were unsuccessful. A focal point of tenderness at the inferolateral portion of the pubic ramus was investigated under fluoroscopy and was found to be directly overlying a surgical tack. Palpation over this site produced a Tinel's sign reproducing the patient's pain. A diagnostic injection using local anesthetic was performed at this site. The patient was pain-free for two months following the injection. When the pain returned, the injection was repeated using local anesthetic with corticosteroid, using the same fluoroscopically-guided technique. The patient has been asymptomatic since that time. Laparoscopic hernia repair may pose increased risk of nerve injury than conventional hernia repair [1]. With a conventional repair the nerves at risk are generally visible and may be dissected free, thus avoiding nerve injury. In contrast, with the laparoscopic repair the staples are placed preperitoneally and the nerves cannot be visualized. In a patient with suspected nerve entrapment syndrome following laparoscopic hernia repair, injection therapy may be effective treatment. As illustrated in this paper, fluoroscopy can be useful during physical exam and as an aid in localizing and for performing the injection. If an injection offers significant but transient relief, surgical removal of the staple or neurectomy at a site proximal to the lesion may be indicated [2].

The Role of Peripheral Nerve Surgery in the Management of Painful Chronic Wounds: Indications and Outcomes

Patients with chronic wounds caused by healing problems often present with chronic pain at the site. Proper wound care with or without appropriate reconstruction usually addresses both the wound and its associated pain. However, wounds occasionally remain painful despite successful reconstruction, particularly when they are complicated by an underlying condition. These patients frequently develop a disabling chronic pain condition despite the application of current treatment modalities. The authors used a novel approach to manage this difficult clinical situation, by addressing the sensory nerve supply to the affected wound region. Five women and two men with intractable chronic pain despite wound reconstruction underwent surgery and were followed for a mean period of 27 months (range, 8 to 40 months). The involved sensory nerve was identified preoperatively by physical examination, confirmed by nerve block, and then surgically excised and implanted into adjacent muscle. Each patient's pain reduction, ambulation status, and quality-of-life improvement were evaluated. The involved nerves included the ilioinguinal, lateral femoral cutaneous, sural, saphenous, superficial peroneal, and deep peroneal nerves, and the genital branch of the genitofemoral nerve. All seven patients reported significant pain reduction (p < 0.0001), improved ambulation (p < 0.0001), and improved quality of life (p < 0.0001), as evaluated at last follow-up (mean, 27 months). This study suggests that an additional treatment modality in the management of chronic wounds can be considered for patients with disabling pain. As an adjunct to other interventions, this novel application of peripheral nerve surgery can critically improve symptoms in selected patients with intractable chronic wound pain.

Bladder activation by selective stimulation of pudendal nerve afferents in the cat

Bladder contractions evoked by pudendal nerve stimulation in both spinal intact and spinal transected cats support the possibility of restoring urinary function in persons with chronic spinal cord injury (SCI). However, electrically evoked bladder responses in persons with SCI were limited to transient contractions at relatively low pressures. This prompted the present study, which presents a detailed quantification of the responses evoked by selective stimulation of individual branches of the pudendal nerve at different stimulation frequencies. In spinal intact cats anesthetized with α-chloralose, selective frequency-dependent electrical activation of the sensory (2 Hz ≤ f ≤ 50 Hz), cranial sensory ( f ≤ 5 Hz), dorsal genital ( f ≥ 20 Hz) and rectal perineal ( f ≤ 10 Hz) branches of the pudendal nerve evoked sustained bladder contractions dependent on the stimulation frequency. Contractions evoked by selective electrical stimulation resulted in significant increases in voiding efficiency compared to bladder emptying by distension-evoked contractions ( p ANOVA < 0.05). Acute spinal transection abolished reflex bladder contractions evoked by low frequency stimulation of the cranial sensory or rectal perineal branches, whereas contractions evoked by high frequency stimulation of the dorsal genital branch remained intact. This study presents evidence for two distinct micturition pathways (spino-bulbo-spinal vs. spinal reflexes) activated by selective afferent pudendal nerve stimulation, the latter of which may be applied to restore bladder function in persons with SCI.

Nerve management during open hernia repair

Peroperative identification and subsequent division or preservation of the inguinal nerves during open hernia repair may influence the incidence of chronic postoperative pain. A systematic literature review was performed to identify studies investigating the influence of different types of nerve management. Based on three randomized studies the pooled mean percentage of patients with chronic pain after identification and division of the ilioinguinal nerve was similar to that after identification and preservation of the ilioinguinal nerve. Two cohort studies suggested that the incidence of chronic pain was significantly lower after identification of all inguinal nerves compared with no identification of any nerve. Another cohort study reported a significant difference in the incidence of chronic pain in favour of identification and facultative pragmatic division of the genital branch of the genitofemoral nerve compared with no identification at all. The nerves should probably be identified during open hernia repair. Division of and preservation of the ilioinguinal nerve show similar results.

Nerve‐Identifying Inguinal Hernia Repair: A Surgical Anatomical Study

Pain syndromes of somatic and neuropathic origin are considered to be the main causes of chronic pain after open inguinal hernia repair. Nerve-identification during open hernia repair is suggested to be associated with less postoperative chronic pain. The aim of this study was to define clinically relevant surgical anatomical zones facilitating efficient identification of the three inguinal nerves during open herniorrhaphy. Through dissection of 18 inguinal areas of embalmed and unembalmed human cadavers, identification zones were developed for the inguinal nerves (in particular for the genital branch of the genitofemoral nerve). The iliohypogastric nerve was identifiable running approximately horizontally and ventrally to the internal oblique muscle perforating the external oblique aponeurosis at a mean of 3.8 cm (range 2.5-5.5 cm) cranially from the external ring. When present, the ilioinguinal nerve was identifiable running ventrally and parallel to the spermatic cord, dorsally from the aponeurosis of the external oblique muscle. Identification of the genital branch of the genitofemoral nerve was more comprehensive. The course of the genital branch is laterocaudal at the level of the internal inguinal ring. Based on the newly defined identification zones, peroperative identification of all inguinal nerves is possible. Further research is warranted to assess clinical feasibility of these zones and to evaluate the influence of (facultative) division, preservation or omittance of the identification of inguinal nerves on the incidence of chronic pain.

Anatomical significance of the nerve to the pyramidalis muscle: A morphological study

Characteristics of the nerve to the pyramidalis muscle (NPy), including its origin, course and distribution, were observed (macroscopically) in detail in the present study. The spinal segments that give rise to the nerve vary considerably and involve Th12-L2. The course and distribution of the nerve also vary widely. The NPy is given off from one of the following: (i) the anterior cutaneus branch (Rca) of the intercostals nerve; (ii) the ilioinguinal (li) nerve; or (iii) the genital branch (Rg) of the genitofemoral nerve. The NPy can be classified into nine types according to features of the course and branching pattern of the Rca and li. In three of 67 cases, the pyramidalis muscle had two nerves. Double-innervated pyramidalis muscles received one nerve from a transitional-type Rca (Rcat) and a second nerve derived from one of the superficial Rca (Rcas), li or Rg. The NPy derived from the deep Rca (Rcap; Type 1), Rcat (Type 2) and containing their features as well as the Type 9 (Rcat + li + Rg) reach the muscle from behind. Types 3-8 (not containing features of the Rcap and Rcat) enter the muscle from its surface. The branch that gives off the NPy is determined by the level of segmental origin, with the segmental origin of branches from the Rca (Types 1-4), li (Types 5-6) and Rg (Types 7-9) getting lower in that order. The level of segmental origin of the NPy derived from different Rca becomes lower in the following order: Rcap (Type 1), Rcat (Type 2), Rcas (Type 3), Rcas' (Rcas entering the inguinal canal; Type 4). When the origin of the NPy is from a lower segment, the origin of the boundary nerve (Rcap/Rcas) is also deviated downward. The changes in the NPy are related to the deviation of the entire lumbar plexus.

Perineural Fibrosis of the Paravasal Nerves: A Possible Cause of Orchalgia

Due to the use of prosthetic material in inguinal hernia repair, the recurrence rate has been markedly reduced, and postherniorrhaphy chronic groin pain (inguinodynia) is now the focus of herniologists world-wide. Occasionally, chronic orchalgia occurs in association with groin pain after hernia repair, and it indicates a poor prognosis. In early 2005, while performing a triple neurectomy (i.e. resection of the ilioinguinal nerve, the iliohypogastric nerve, and the inguinal segment of the genital branch of the genitofemoral nerve)1 on a patient with chronic inguinodynia associated with orchalgia and MRI evidence of vas entrapment by a meshoma,2 the patient's vas deferens was found to be completely encircled by the mesh from a previous hernia repair (Fig. 1). Because the patient had undergone a vasectomy, the affected segment of the vas deferens was resected during the triple neurectomy. The patient's chronic groin pain and orchalgia disappeared postoperatively, which was contrary to our experience with other patients with the same symptoms. Histological analysis of the resected vas deferens showed extensive fibrosis and foreign body reaction around the paravasal nerves within the lamina propria (Fig. 2). Figure 1 (Top) MRI image of a meshoma entrapping the vas. (Bottom) Intra-operative photograph of vas entrapped in a meshoma. Figure 2 Foreign body reaction of lamina propria around the vas and paravasal nerves. In five more patients with chronic inguinodynia associated with orchalgia, I resected the lamina propria and the paravasal nerves at the involved segment of the vas deferens during triple neurectomy. In all cases, the orchalgia disappeared postoperatively. The number of patients is too small and follow-up is too short to draw a solid conclusion; however, I wonder whether one of the causes of postvasectomy orchalgia could be perineural fibrosis of the paravasal nerves and whether resection of the lamina propria of the vas during routine vasectomies could prevent paravasal neuropathy as a possible cause of postvasectomy orchalgia.

Influence of Preservation Versus Division of Ilioinguinal, Iliohypogastric, and Genital Nerves During Open Mesh Herniorrhaphy

To evaluate whether the various surgical treatment reserved for ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerves, during open hernia mesh repair, is effective in reducing chronic postoperative pain. Interest in chronic groin pain following herniorrhaphy has escalated, in recent years, due both to treatment and legal implications. However, much debate still exists concerning which treatment to reserve for the 3 inguinal sensory nerves. A multicentric prospective study involving 11 Italian institutions led to the recruitment of 973 cases of hernioplasty. All surgeons were asked to report whether or not each nerve had been identified and preserved or divided. The main endpoint of the study was the evaluation of moderate to severe chronic pain at 6 months and 1 year. Overall, the presence of groin pain at the 6-month and 1-year follow-up was 9.7% and 4.1%, respectively. Pain was mild in 7.9% and moderate to severe in 2.1%, at 6 months, and mild in 3.6% and moderate to severe in 0.5%, at 1 year. Univariate and multivariate analysis showed that lack of identification of nerves is significantly correlated with presence of chronic pain, the risk of developing inguinal pain increasing with the number of nerves not detected. Likewise, division of nerves was clearly correlated with presence of chronic pain. The present findings indicate that identification and preservation of nerves during open inguinal hernia repair reduce chronic incapacitating groin pain and that, in the majority of patients with chronic pain at 6 months, the pain at 1 year is resolved only with conservative or medical treatment.