What is the appropriate management and treatment for inguinodynia (groin pain)?

Management of Inguinodynia (Chronic Groin Pain)

For post-herniorraphy inguinodynia, a tailored neurectomy is the most effective treatment, achieving 71% success compared to only 22% with injection therapy, and should be offered after failed conservative management. 1

Initial Assessment and Conservative Management

Pain Assessment

• Patient self-report is critical for comprehensive pain assessment, including clinical examination, pain history, and functional impact 2
• Thorough history and clinical examination are essential, requiring good knowledge of groin nerve distribution 3
• Classify pain as neuropathic (nerve-related) versus non-neuropathic (mesh-related) to guide treatment 3

Early Conservative Approach

• Analgesic management should begin as soon as possible when indicated 2
• Patient education and supported self-management should be implemented from an early stage 2
• Evidence-based assessment and management techniques should guide pain management 2

Common Pitfall: Inguinodynia is defined as pain persisting beyond 3 months after inguinal hernia surgery, so ensure adequate time has elapsed before pursuing aggressive interventions 4

Stepwise Treatment Algorithm

Step 1: Tender Point Infiltration (TPI)

• Perform diagnostic nerve block with local anesthetic to assess response 5, 1
• If >50% pain reduction achieved, proceed with therapeutic TPI using combined lidocaine/corticosteroids/hyaluronic acid injection 1
• Important caveat: TPI achieves only 22% success rate and relief with nerve block does not reliably predict favorable outcomes 5, 1

Step 2: Surgical Neurectomy (Primary Treatment)

A tailored neurectomy should be the preferred definitive treatment for chronic inguinodynia after failed conservative management. 1

Surgical Approach Selection:

• For patients with prior open mesh repair: Combined laparoscopic and open approach with mesh removal plus ilioinguinal or iliohypogastric neurectomy 5, 6
• For patients with prior laparoscopic repair: Complete laparoscopic approach 6

Surgical Technique Details:

• Mesh removal combined with neurectomy achieves 62% good-to-excellent results versus only 50% with mesh removal alone 5
• Tailored neurectomy is 3 times more effective than tender point infiltration (71% vs 22% success) 1
• Average symptom duration before remedial surgery is approximately 12 months 5

Expected Outcomes:

• 60% of patients achieve good-to-excellent results with mesh removal and neurectomy 5
• Median VAS pain score drops from 60 to 14 after neurectomy in crossover patients 1
• Two-thirds of patients on worker's compensation return to work 1

Special Considerations

Laparoscopic Approach Benefits

• For prior laparoscopic repairs, 67% achieve favorable outcomes with laparoscopic remedial surgery 5
• Low-pressure pneumoperitoneum systems may improve outcomes 6
• Bilateral transversus abdominis plane blocks and intra-operative inguinal nerve blocks using long-acting local anesthetic should be administered as part of multimodal pain management 6

Complications and Recurrence

• Major complications after neurectomy are rare 1
• Hernia recurrence occurs in 11% of cases 6
• 13% of patients may develop new pain in the inguinal region after initial pain resolution 6

Treatment Stratagem

The recommended step-up approach is:

1. Conservative management with analgesics and patient education for initial 3-6 months 2
2. Diagnostic nerve block to confirm neuropathic etiology 5, 1
3. Trial of tender point infiltration (1-3 attempts) 1
4. Definitive tailored neurectomy with mesh removal if TPI fails 5, 1

Critical Point: Despite the popularity of mesh repairs, persistent postoperative pain occurs in approximately 11% of patients, and this may become more evident with rising interest in laparoscopic techniques 5, 4

Monitoring and Follow-up

• Assess treatment response using validated pain scales (VAS) with >50% reduction defining success 1
• Improvement in function may be an important reference point beyond pain scores alone 2
• Regular clinical evaluation is recommended, though no universal guidelines exist for follow-up intervals 4