How do you treat a patient with extreme inguinal hernia pain?

From the Guidelines

Immediate surgical consultation is essential for patients with extreme inguinal hernia pain, as it may indicate incarceration or strangulation, and emergency surgery is required to prevent tissue death and serious complications. The patient should be evaluated for signs of systemic inflammatory response syndrome (SIRS), such as fever, tachycardia, and leukocytosis, as well as abdominal wall rigidity, which are considered common indicators of strangulated obstruction 1.

For pain management, NSAIDs like ibuprofen (400-600mg every 6 hours) or naproxen (500mg initially, then 250mg every 6-8 hours) can be used, along with acetaminophen (1000mg every 6 hours) for additional relief. Ice packs applied for 15-20 minutes at a time may help reduce swelling and discomfort. However, these measures are only temporary, and urgent surgical consultation is crucial.

In cases where bowel gangrene is suspected, general anesthesia should be preferred, while local anesthesia can be used in emergency inguinal hernia repair in the absence of bowel gangrene (grade 1C recommendation) 1. The definitive treatment for painful inguinal hernias is surgical repair, either through open herniorrhaphy or laparoscopic approaches, which prevent recurrence and complications while providing long-term relief.

Some key factors to consider in the management of extreme inguinal hernia pain include:

• Early detection of complicated abdominal hernias may be the best means of reducing the rate of mortality 1
• The elapsed time from onset to surgery is the most important prognostic factor 1
• Signs of SIRS, contrast-enhanced CT findings, as well as lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation 1
• Local anesthesia can provide effective anesthesia with less postoperative complications for emergency inguinal hernia repair in the absence of bowel gangrene 1

From the FDA Drug Label

Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain. The patient with extreme inguinal hernia pain can be treated with ibuprofen (PO) at a dose of 400 mg every 4 to 6 hours as necessary for relief of pain 2.

• The dose should not exceed 3200 mg total daily dose.
• It is recommended to use the lowest effective dose for the shortest duration consistent with individual patient treatment goals.

From the Research

Treatment Options for Extreme Inguinal Hernia Pain

• The treatment of extreme inguinal hernia pain typically involves a combination of medical and surgical interventions 3, 4, 5.
• For patients with severe pain, surgical repair of the hernia may be necessary, with options including open or laparoscopic techniques 3, 4.
• The choice of surgical technique depends on various factors, including the size and location of the hernia, as well as the patient's overall health and medical history 3, 4.
• In some cases, watchful waiting or conservative management may be recommended for patients with small, minimally symptomatic hernias 3.
• For patients who have already undergone hernia repair and are experiencing chronic pain, a scaled approach to treatment may be recommended, including systemic painkillers, blocks, and surgery as a last resort 5.

Management of Chronic Pain

• Chronic pain following inguinal hernia repair is a common problem, affecting up to 16% of patients 5.
• The optimal management of chronic pain following inguinal hernia surgery should begin with a thorough clinical examination to rule out other causes of chronic pain and to rule out a recurrence 5.
• Treatment strategies for chronic pain may include mesh removal and triple neurectomy, as well as other surgical and non-surgical interventions 5.
• The diagnosis and treatment of chronic pain following inguinal hernia repair should be performed by or discussed with experts in the field 5.

Pain Management Options

• Pre-emptive analgesics, such as intravenous ketorolac or rectal diclofenac, may be used to manage pain following ambulatory inguinal hernia repair 6.
• These medications have been shown to be effective in reducing postoperative pain and improving patient outcomes 6.
• Other pain management options, such as systemic painkillers and blocks, may also be used to manage chronic pain following inguinal hernia repair 5.