Treatment Of Chronic Groin Pain Research Articles

P081 CHRONIC GROIN PAIN IN SPORTSMEN. EVIDENCE-BASED IN EXPERIENCE

Abstract Aim The main objective of this study is to describe and analyze the assessment and treatment of chronic groin pain (CGP) based on the experience collected in 20 years. Material and Methods Descriptive, observational, and retrospective study. It is a multidisciplinary team formed by surgeons, physiotherapists, orthopedists, and imaging specialists. That had developed an assessment, diagnosis, and treatment algorithm for (CGP), which have been implemented for more than 20 years. Follow-up included a record of clinical examination findings, clinical entities diagnosed, ultrasound findings, physiotherapy treatment, operation notes, and postoperative recovery, time to return to sporting activity, and complications. Results In the period between August 2000 and August 2020, we assessed 9996 patients with CGP. (91%) men and (9%) women with a mean age of 30 (SD: 11.21). The most frequently practiced sports were: football (43%), rugby (25%), tennis (12%). The most frequent clinical entities registered were tendinopathies (69%): iliopsoas-pectineus- related (36%) and adductor-related (33%). Tendinopathy sports rehabilitation treatment: (95.7%) presented total recovery in 45 days; 260 patients (4.3%)intra-tissue percutaneous electrolysis was used with favorable recovery. Only 16 patients required tenotomies The ultrasound has been used to detect signs of adductor tendinopathy (92%) and sportsman hernia, but has low sensitivity in iliopsoas-pectineus tendinopathy (21%). Conclusions The algorithm used has proven to be safe and successful. Tendinopathies and Sportsman's hernia are the most common causes of chronic groin pain in sportsmen, presenting together in 82% of the cases. TAPP hernioplasty repair, followed by physical rehabilitation offered excellent results to treat sportsman hernia.

Outcomes Follow Surgical Treatment for Chronic Groin Pain: A Single Center 7-Year Retrospective Analysis

Outcomes Follow Surgical Treatment for Chronic Groin Pain: A Single Center 7-Year Retrospective Analysis

Chronic groin pain in young sportsmen: Algorithm of assessment and treatment

Background: Chronic groin pain (CGP) is a syndrome characterized by pain in the pubic and inguinal-crural regions, resulting in a functional deficit that can lead to severe impairment of different motor tasks. Objective: The main objective of this study is to describe and analyze an algorithm used for the assessment and treatment of chronic groin pain in young sportsmen used for 10 years. Methods: Descriptive, observational, and retrospective study, adapted with recommendations of the STROBE Declaration (Strengthening Reporting of Observational Studies in Epidemiology) for its design. The study was carried out at an Hernia Pathology Center. It is a multidisciplinary team formed by surgeons, physiotherapists, orthopedists, and imaging specialists, with extensive experience in the research field. This team had developed an assessment, diagnosis, and treatment algorithm for CGP which was implemented for more than 15 years. Results: After clinical examination and complementary imaging, 3,858 patients were included to follow the algorithm. A total of 3,289 patients completed the sports physiotherapy and rehabilitation protocol. The most frequent clinical entities registered were tendinopathies: 1,649 iliopsoas-pectineus-related groin pain (42.7%) and 1,522 adductor-related groin pain (39.5%). A total of 569 patients with sportsman’s hernia diagnosis required surgical intervention. There were no intraoperative complications; furthermore, all patients discharging after 6 hours of hospital stay. Conclusions: The assessment, diagnosis, and treatment algorithm used by a multidisciplinary team to treat patients with chronic groin pain has proven to be safe and successful.

Surgical treatment for chronic postoperative inguinal pain-short term outcomes of a specialized center

BackgroundChronic postoperative inguinodynia is a challenging long-term complication after inguinal hernia repair. Surgery may be an option for patients who are refractory to non-operative measures. We aim to evaluate the short-term outcomes of surgical treatment for chronic inguinodynia at our institution. MethodsConsecutive patients undergoing surgical treatment for chronic groin pain were identified in a prospectively maintained database. Outcomes included operative details, intra- and postoperative complications, pain scores, and patient satisfaction. Results29 patients were included in the study. All patients were refractory to multimodal pain management. The median pain score on presentation was 8 (IQR 7–10), and after a median follow-up of 6 months (IQR 4–11), there was a statistically significant reduction in pain scores (median 2, IQR 2–6, p < 0.001). Fifty-five percent of patient were pain free or almost pain free and 93 percent reported they would undergo the same operation again. ConclusionsChronic groin pain is a complex problem with no universal solution. In our experience, surgical treatment significantly decreased short-term pain scores.

Laparoscopic approach for the treatment of chronic groin pain after inguinal hernia repair : Laparoscopic approach for inguinodynia.

Traditional methods of clinical research may not be adequate to improve the value of care for patients with complex medical problems such as chronic pain after inguinal hernia repair. This problem is very complex with many potential factors contributing to the development of this complication. We have implemented a clinical quality improvement (CQI) effort in an attempt to better measure and improve outcomes for patients suffering with chronic groin pain (inguinodynia) after inguinal hernia repair. Between April 2011 and June 2016, there were 93 patients who underwent 94 operations in an attempt to relieve pain (1 patient had two separate unilateral procedures). Patients who had prior laparoscopic inguinal hernia repair (26) had their procedure completed laparoscopically. Patients who had open inguinal hernia repair (68) had a combination of a laparoscopic and open procedure in an attempt to relieve pain. Initiatives to attempt to improve measurement and outcomes during this period included the administration of pre-operative bilateral transversus abdominis plane and intra-operative inguinal nerve blocks using long-acting local anesthetic as a part of a multimodal regimen, the introduction of a low pressure pneumoperitoneum system, and the expansion of a pre-operative questionnaire to assess emotional health pre-operatively. The results included the assessment of how much improvement was achieved after recovery from the operation. Forty-five patients (48%) reported significant improvement, 39 patients (41%) reported moderate improvement, and 10 patients (11%) reported little or no improvement. There were 3 (3%) complications, 13 (11%) hernia recurrences, and 15 patients (13%) developed a new pain in the inguinal region after the initial pain had resolved. The principles of CQI can be applied to a group of patients suffering from chronic pain after inguinal hernia repair. Based on these results additional process improvement ideas will be implemented in an attempt to improve outcomes.

Effect of Interferential Therapy on Chronic Pain After Inguinal Hernioplasty

Introduction: Chronic postoperative pain is strongly related to patient-related factors surgery- related factors. Treatment of chronic groin pain after surgery may be difficult for both the patient and the surgeon and many algorithms have been advocated but none of them has been accepted totally. Interferential Therapy has been used in clinical practice for reducing pain and other symptoms following musculoskeletal injury. This current study was designed to detect the therapeutic efficacy of Interferential Therapy as a method of treatment to reduce chronic post operative pain after inguinal hernia repair. Subjects and Methods: A total of 40 adult male patients were operated upon as inguinal hernioplasty with synthetic mesh repair and their ages were ranged from 30-50 years. Patients were randomly assigned into two equal groups; Group A (Interferential Therapy group) and Group B (Control group). Patients of group A underwent inguinal hernioplasty with synthetic mesh and received the application of interferential therapy over the operative skin incisions in addition they received the routine postoperative analgesia. Regarding the postoperative pain, the assessment approaches were subdivided into 3 main procedures: Visual Analog Scale, prosthesis awareness and physical activity. Results: Total pain score was the sum VAS, prosthesis awareness and physical activity scores. We observed that statistical analysis of total pain scores and the final scores per patient in both groups of this study were statistically significant. Conclusion: Interferential current as a supplement to traditional analgesia in the early postoperative course in hernia repair with mesh seems to be more effective for reducing pain than traditional postoperative analgesia alone. Interferential current therapy is a noninvasive therapy for relief from chronic post-surgical pain. It provides a safe, with minimal side effects and effective alternative to pharmacological approaches to pain control.

Surgical treatment of chronic pain after inguinal hernia repair

Chronic groin pain is defined as pain arising 3-6 months after inguinal hernia repair that can compromise the patient's quality of life. Many articles in the literature report clinical presentation, but there are no well-defined indications and protocols of treatment. Forty-six patients underwent surgical treatment for chronic groin pain that consisted of a simultaneous double approach, anterior and posterior, to the inguinal region, with 44 triple neurectomies and 2 iliohypogastric neurectomies. Ilio-inguinal and ilio-hypogastric nerves were resected by anterior approach, while genitofemoral trunk was resected by a posterior pre-peritoneal approach. Mesh was removed in 24 cases, and mesh and plug were removed in 16 cases. A new mesh repair was performed in 42 cases. All the patients were examined 1 week, 1 month and 1 year postoperatively. In 40 patients, the surgical treatment has obtained good response with improvement or complete resolution of the pain. Two patients referred persistent groin pain different from preoperative and in 4 cases the pain persisted without substantial benefit. Mean VAS value was 7.89 before surgery and 1.89 after surgery. Choice of the adequate therapy of chronic groin pain after inguinal hernia repair is still controversial. Our surgical approach turned out to be a safe and effective procedure. In this way, an accurate exploration of the whole inguinal region can be performed along with the identification of the nerves involved. Anyway in a certain number of cases, the resolution of pain cannot be achieved; this suggests a possible involvement of differences in the single personality and tolerances of pain in the different patients.

Ultrasound guided percutaneous electro-coagulation of ilioinguinal and iliohypogastric nerves for treatment of chronic groin pain

Ultrasound guided percutaneous electro-coagulation of ilioinguinal and iliohypogastric nerves for treatment of chronic groin pain

Surgical treatment of chronic groin pain in athletes.

Conservative treatment of chronic groin pain is prolonged and recurrence is quite common. Coexistence of sports hernia and adductor tendinitis/tendinosis in a single patient is noted in the literature. In our study we evaluated our operative treatment that should enable pain elimination and fast return to sports activities. We performed a prospective study over a six-year period. Ninety-nine (99) patients, all male, with chronic groin pain, resistant to conservative treatment, underwent a surgical procedure. Seventy athletes with sports hernia returned to sports in an average 4.23 weeks (range three-16). Adductor tendinosis symptoms were present in 24 patients (2 %) with sports hernia. Twenty-four patients that had an additional adductor tenotomy performed returned to sports in an average 11.6 weeks (range ten-15). Five patients with isolated adductor tendinosis (7 %) returned to sports in an average 13.4 weeks (range 12-16). All athletes except two (2.8 %) treated for sports hernia were satisfied with the results of treatment and could continue their previous level of activity. Any surgical procedure used for treating chronic groin pain should address the common causes of pain in this region. Adductor tendinosis can be present in up to 24.2 % of cases with sports hernia or may be isolated in 7 % of cases with chronic groin pain and must be treated by tenotomy. Resection of the genital branch of genitofemoral nerve and ilioinguinal nerve neurolysis should also be performed in patients with sports hernia.

Chronic postherniorrhaphy pain following inguinal hernia surgery: Etiology, risk factors, anatomy, and treatment options

Despite recent advances in surgical technique for inguinal hernia repair, chronic groin pain following the surgical repair of an inguinal hernia is not uncommon. Injury to the ilioinguinal, iliohypogastric, or genitofemoral nerves is the most common etiology. Specific risk factors that increase the likelihood of developing chronic groin pain have been identified. Ultrasound-guided peripheral nerve blocks may play an important role in the diagnosis and treatment of chronic groin pain. As in many pain syndromes, early diagnosis and early treatment are crucial. Evidence-based management of chronic groin pain is poorly studied, although cryotherapy and neuromodulation techniques show potential efficacy.

Laparoscopic Triple Neurectomy for Intractable Groin Pain: Technical Report of 3 Cases

Neuropathic groin pain can be a severely debilitating condition. Triple neurectomy of the ilioinguinal, iliohypogastric, and genitofemoral nerves is a viable treatment option. To present our initial experience with the laparoscopic retroperitoneal approach to triple neurectomy. Three patients (33 to 48 years of age) presented with chronic groin pain of 3 to 7 years' duration. The discomfort manifested in the ilioinguinal, iliohypogastric, and genitofemoral nerve distributions and severely affected their lifestyles, resulting in multiple unsuccessful medical and surgical treatments without symptomatic relief. Because the patients failed other modes of treatment, they underwent a laparoscopic retroperitoneal triple neurectomy. Three patients underwent a triple neurectomy from November 2006 to May 2009. All patients reported debilitating chronic groin pain and underwent prior treatments ranging from anesthetic blocks to orchiectomy without lasting relief. The first case illustrates the anatomic variation of the genitofemoral nerve and the importance of transecting both branches for adequate symptomatic relief. The remaining cases demonstrate successful transection of all 3 nerves with significant pain relief at 10 months to 3 years of follow-up. No major complications were encountered. This technique provides several advantages in the treatment of chronic groin pain. The retroperitoneal approach provides a facile method to reach the nerves in 1 stage and provides a dissection field free of previous scars. As a laparoscopic technique, benefits include small incision sites with small scars, less postoperative pain, and shorter hospitalizations and/or same-day discharges with effective relief of groin pain.

Inguinodynia following Lichtenstein tension-free hernia repair: A review

Chronic groin pain (Inguinodynia) following inguinal hernia repair is a significant, though under-reported problem. Mild pain lasting for a few days is common following mesh inguinal hernia repair. However, moderate to severe pain persisting more than 3 mo after inguinal herniorrhaphy should be considered as pathological. The major reasons for chronic groin pain have been identified as neuropathic cause due to inguinal nerve(s) damage or non-neuropathic cause due to mesh or other related factors. The symptom complex of chronic groin pain varies from a dull ache to sharp shooting pain along the distribution of inguinal nerves. Thorough history and meticulous clinical examination should be performed to identify the exact cause of chronic groin pain, as there is no single test to confirm the aetiology behind the pain or to point out the exact nerve involved. Various studies have been performed to look at the difference in chronic groin pain rates with the use of mesh vs non-mesh repair, use of heavyweight vs lightweight mesh and mesh fixation with sutures vs. glue. Though there is no convincing evidence favouring one over the other, lightweight meshes are generally preferred because of their lesser foreign body reaction and better tolerance by the patients. Identification of all three nerves has been shown to be an important factor in reducing chronic groin pain, though there are no well conducted randomised studies to recommend the benefits of nerve excision vs preservation. Both non-surgical and surgical options have been tried for chronic groin pain, with their consequent risks of analgesic side-effects, recurrent pain, recurrent hernia and significant sensory loss. By far the best treatment for chronic groin pain is to avoid bestowing this on the patient by careful intra-operative handling of inguinal structures and better patient counselling pre- and post-herniorraphy.

Successful endoscopic treatment of chronic groin pain in athletes

Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem. From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 +/- 4.5 years; range, 17-36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement. Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation. A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.

Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair

Chronic groin pain is the most common long-term complication after open inguinal hernia repair. Traditional surgical management of the associated neuralgia consists of injection therapy followed by groin exploration, mesh removal, and nerve transection. The resultant hernia defect may be difficult to repair from an anterior approach. We evaluate the outcomes of a combined laparoscopic and open approach for the treatment of chronic groin pain following open inguinal herniorrhaphy. All patients who underwent groin exploration for chronic neuralgia after a prior open inguinal hernia repair were prospectively analyzed. Patient demographics, type of prior hernia repair, and prior nonoperative therapies were recorded. The operation consisted of a standard three trocar laparoscopic transabdominal preperitoneal hernia repair, followed by groin exploration, mesh removal, and nerve transection. Outcome measures included recurrent groin pain, numbness, hernia recurrence, and complications. Twelve patients (11 male and 1 female) with a mean age of 41 years (range 29-51) underwent combined laparoscopic and open treatment for chronic groin pain. Ten patients complained of unilateral neuralgia, one patient had bilateral complaints, and one patient complained of orchalgia. All patients failed at least two attempted percutaneous nerve blocks. Prior repairs included Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1). There were no intraoperative complications or wound infections. With a minimum of 6 weeks follow up, all patients were significantly improved. One patient complained of intermittent minor discomfort that required no further therapy. Two patients had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. A combined laparoscopic and open approach for postherniorrhaphy groin pain results in good to excellent patient satisfaction with no perioperative morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after prior open hernia repair.

Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes.

Eighteen tenotomies of the adductor longus tendon were performed in 16 consecutive male athletes (aged 20 to 42) as treatment for chronic groin pain. The criteria for surgery was a history of long-standing (range, 2.5 to 48 months) and distinct pain at the origin of the adductor longus muscle, refractory to conservative treatment. At followup 35 months (range, 4 to 84) after surgery, all patients were improved or free of symptoms. All but 1 of the athletes returned to the same sport within a mean of 6.6 weeks, and 12 of 16 returned to competitive sports within a mean of 14 weeks after surgery. A majority of the patients (10 of 16) returned to full athletic activity, whereas 5 of 16 performed at a reduced level. One patient discontinued his sports activity due to other causes. In conclusion, when conservative treatment fails, tenotomy of the adductor longus tendon gives good long-term functional results in the treatment of chronic groin pain that is localized at the origin of the adductor longus muscle. A decreased muscle strength was observed in this study and did not seem to influence participation in sports.

Inguinal surgery for debilitating chronic groin pain in athletes

To identify and surgically treat correctable inguinal injuries in athletes with chronic groin pain and to assess the results of surgical treatment. Sixty-four athletes presented between March 1987 and January 1990 for treatment of chronic groin pain in which surgical exploration of the inguinal canal was considered necessary. Follow-up was performed by questionnaire. Patient self-assessment of the success of the operation, including postoperative pain, ability to return to active sport and any further treatment required. Sixty-four athletes were treated, Australian Rules footballers predominated (46/64, 72%). Eight athletes had bilateral groin pain. Fifty-nine (92%) reported an incipient onset of pain. The most common operative finding was of a substantially deranged posterior wall of the inguinal canal which was evident in 61/72 instances (85%). Apparent splitting of the conjoint tendon was found in 19 instances (26%) and previously occult indirect inguinal hernias were discovered in six (8%). Repair of the posterior wall of the inguinal canal was by the standard Bassini repair and Tanner slide or by plication of the transversalis fascia followed by a nylon darn. Follow-up by questionnaire of the 64 athletes revealed that 40 athletes (62.5%) considered themselves cured and had returned to competitive sport. Twenty athletes (31.3%) were partially satisfied with the results of their operation, and also able to return to active sport. Three athletes (4.7%) were dissatisfied with the operative result. One patient was lost to follow-up. The most common finding in athletes with chronic groin pain was a deficiency of the posterior wall of the inguinal canal. Surgical exploration and repair of the posterior wall of the inguinal canal in athletes with chronic debilitating groin pain achieved excellent or good relief of pain in 93.8% of athletes and improved physical performance.