What are the treatment options for anterior groin pain radiating to the lateral aspect with a feeling of hip dislocation after pelvic prolapse surgery?

Post-Pelvic Prolapse Surgery Groin Pain with Hip Instability

This presentation suggests nerve injury or entrapment, most likely involving the lateral femoral cutaneous, ilioinguinal, or iliohypogastric nerves, and requires neurological evaluation with consideration for nerve decompression or resection if conservative management fails.

Clinical Assessment

The pattern of anterior groin pain radiating laterally with a sensation of hip instability following pelvic prolapse surgery is characteristic of nerve injury rather than true hip pathology. Key diagnostic features include:

• Pain distribution: Anterior groin pain extending to the lateral hip/thigh suggests involvement of the lateral femoral cutaneous nerve (LFC), ilioinguinal (II), or iliohypogastric (IH) nerves 1
• Referred symptoms: The sensation of hip "dislocation" is likely referred pain from nerve entrapment rather than actual joint instability, as these nerves can produce symptoms mimicking other pathology 1
• Timing: Post-surgical onset indicates iatrogenic nerve injury during the pelvic prolapse repair 1

Physical examination should focus on identifying the specific nerve(s) involved through palpation of trigger points along the inguinal ligament and assessment of sensory distribution 1.

Initial Management Approach

Conservative Treatment (First-Line)

• Pain control: Neuropathic pain medications (gabapentin or pregabalin) should be initiated as first-line therapy for nerve-related pain
• Physical therapy: Pelvic floor physical therapy may help, though evidence for nerve-specific pain is limited 2
• Trial period: Allow 3-6 months of conservative management before considering surgical intervention 1

Diagnostic Imaging

• Limited role: History and physical examination are typically sufficient to diagnose nerve-related groin pain 1
• Hip imaging: If true hip instability is suspected (which is unlikely given the clinical presentation), plain radiographs can rule out actual hip dislocation 3
• MRI consideration: Only if diagnosis remains unclear or to evaluate for other structural complications from the prolapse surgery 4

Surgical Intervention

If conservative management fails after 3-6 months, surgical treatment targeting the affected nerve(s) achieves excellent pain relief in 68% of patients and functional restoration in 72% 1.

Nerve-Specific Surgical Approach

• Ilioinguinal nerve: Resection provides excellent results in 78% of cases with only 11% poor outcomes 1
• Iliohypogastric nerve: Resection achieves 83% excellent results for both pain relief and functional restoration, with 17% poor outcomes 1
• Lateral femoral cutaneous nerve: Decompression (neurolysis) is the preferred technique, particularly when the nerve is located above or within the inguinal ligament 1
• Genitofemoral nerve: Has the worst outcomes (50% excellent, 25% poor results) and should be approached cautiously 1

Surgical Technique Selection

The choice between neurolysis and nerve resection depends on the specific nerve involved:

• Neurolysis: Reserved for LFC nerve entrapment 1
• Resection: Preferred for II, IH, and GF nerves 1

Important Clinical Pitfalls

Do not assume hip pathology: The sensation of hip "dislocation" is almost certainly referred pain from nerve injury, not actual joint instability. True hip dislocation following pelvic surgery is extraordinarily rare and would present with obvious deformity and inability to bear weight 3.

Avoid premature imaging: Extensive imaging workup is unnecessary and delays appropriate treatment, as the diagnosis is clinical 1.

Recognize multi-nerve involvement: Symptoms may involve more than one nerve simultaneously, requiring comprehensive evaluation of all potential nerve territories 1.

Complications to monitor: Surgical complications include bruising and cautery injury to adjacent nerves, particularly the LFC 1.

Expected Outcomes

With appropriate surgical management targeting the correct nerve(s), patients can expect:

• 68% excellent pain relief overall 1
• 72% restoration of function 1
• Best results with II and IH nerve resection (78-83% excellent outcomes) 1
• Only 10% overall poor results 1

The key to successful treatment is accurate identification of the involved nerve(s) through careful history and physical examination, followed by appropriate conservative management and, if necessary, nerve-specific surgical intervention 1.